Voluntary Medical Male Circumcision


I. Definition of the Prevention Area

Voluntary medical male circumcision (VMMC) is the surgical complete removal of the foreskin of the penis. While conducted for a number of reasons, evidence from recent clinical trials has shown that medical male circumcision can significantly reduce (but not eliminate) men's risk of acquiring HIV through heterosexual vaginal sex. The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) supports VMMC performed by qualified and well-equipped professionals, and with the client's informed consent. VMMC is part of a comprehensive HIV prevention strategy that is defined by the World Health Organization (WHO) to include screening and treatment of sexually transmitted infections (STIs), promotion of sexual partner reduction, correct and consistent male and female condom use, HIV testing and counseling, and active referral of HIV-positive clients to care and treatment.

II. Epidemiological Justification for the Prevention Area

The results of three randomized controlled clinical trials conducted from 2005 to 2007 in Kenya, South Africa, and Uganda confirmed that VMMC provided by well-trained health professionals in properly equipped settings is safe and has the potential to reduce men's risk of acquiring HIV from their female partners. The combined data from the trials led WHO and the Joint UN Programme on HIV/AIDS (UNAIDS) to strongly recommend VMMC as a new HIV prevention tool with an estimated protective effect around 60 percent. Recent data from the long-term follow-up of the Kenya and Uganda cohorts and a population-level impact evaluation done in South Africa show that the protective effect of VMMC is more than 60 percent and could be around 70 percent. Additional studies have demonstrated that circumcision also reduces men's risk of infection with some STIs.

Scientists have demonstrated plausible biological connections between HIV infection and lack of circumcision. The tissue of the internal foreskin contains Langerhans and other cells that are targeted by HIV when the virus first enters the body. In addition, tears to the mucosal layer of the internal foreskin may increase vulnerability to HIV infection, as well as other STIs. Circumcision removes the internal foreskin, and the penis head develops extra layers of skin after the procedure, thereby eliminating the mucosal layer and reducing the number of Langerhans cells. Some studies also theorize that circumcision changes the bacterial environment of the penis in a way that reduces the risk of HIV infection.

Male circumcision has a direct and lifelong impact on health by reducing a circumcised man's risk of being infected with HIV. Mathematical modeling hypothesizes that male circumcision has an additional indirect benefit to women because as more men are circumcised, fewer men acquire HIV. Estimates done by PEPFAR and UNAIDS have further shown that VMMC will have the highest impact on HIV when the majority of men are circumcised within the shortest possible time.

In areas with high HIV prevalence, it is estimated that scaling up VMMC to reach 80 percent coverage of men aged 15 to 49 years old in five years could avert up to 3.4 million new HIV infections in eastern and southern Africa, or 22 percent of all new infections in the region. In Zimbabwe, it is estimated that only four circumcisions will avert one HIV infection. Programs should target adolescent (10 to 14 years old) and adult (15 to 49 years old) men during this catch-up scale-up period as these age groups are at greatest risk of being infected through sexual transmission. Providing VMMC to prevent HIV among these cohorts will have the greatest and most immediate impact on the spread of HIV.

As VMMC protects against HIV acquisition rather than HIV transmission, circumcision for HIV-infected men is not recommended. Furthermore, there is inconclusive data that circumcision provides protection against HIV infection for men who have sex with men and for men who practice unprotected anal intercourse.

III. Core Programmatic Components

VMMC must be integrated into a comprehensive HIV prevention program, because both circumcised and uncircumcised males remain at risk of HIV infection if they have unprotected sexual intercourse. The WHO's minimum package of VMMC services includes HIV testing and counseling, STI screening and treatment, risk reduction counseling and education that explains the procedure and obtains informed consent, promotion and provision of male and female condoms, and surgical and clinical care that includes preoperative assessments and postoperative review and counseling. In addition, communication activities are key to generate demand; to educate clients, partners, and communities on the benefits and disadvantages of VMMC; and to promote safe healing and sustain safer sexual behaviors.

Historically, VMMC programs have tended to focus heavily on development and scale-up of clinical services, with demand creation activities carried out on a more informal basis. There is increasing acknowledgment that VMMC communication interventions should draw on lessons learned in sexual behavior change communication for other health behaviors including use of proven processes to design, implement, and evaluate communication activities. Demand creation for VMMC should 1) include development of a comprehensive national or subnational communication strategy; 2) target a range of well-segmented primary and secondary audiences, including health care providers and traditional leaders; 3) communicate complex subject matter in simple and audience-appropriate terms; and 4) ensure proper timing and sequencing of messages. Although efforts to date have focused heavily on interpersonal communication and small group community mobilization, mass media promotion may become increasingly important as services are scaled up and latent demand is fulfilled.

Because adult male circumcision is a one-time surgical procedure, rapid scale-up will require an intensive, short-term investment of human resources, logistical capacity, and funding. It also requires creative solutions to ensure the efficiency and quality of VMMC services. When scaling up VMMC, community engagement is critical to ensure that local leaders accept VMMC services and that clients receive correct information. Country experience has also demonstrated the importance of communication with women and girls, who may be the partners or caretakers of men who are circumcised.

IV. Current Status of Implementation Experience

WHO and UNAIDS have identified 13 eastern and southern African countries with high rates of HIV prevalence and low rates of male circumcision; it is in these 13 countries where VMMC should be taken to scale as quickly and as safely as possible. PEPFAR is also supporting the Gambela region of Ethiopia to promote VMMC.

Within these priority countries, governments and implementers have progressed at different paces to develop policies and guidelines to support and implement VMMC programming. In late 2008, Kenya began implementing its national VMMC program with a goal of circumcising 860,000 men. Nyanza province in Kenya is the only province with a male circumcision prevalence of less than 80 percent, and it will take 377,000 circumcisions in Nyanza province alone to reach 80 percent coverage between 2009 and 2013. Since late 2008, Kenya has circumcised approximately 290,000 men (mainly in Nyanza province) to reach 61.5 percent coverage (as compared to the number of men aged 15 to 49 years old that need to be circumcised to reach 80 percent coverage) using a combination of task shifting, innovative models for service delivery, and intensive communication efforts. Government leadership, a documented implementation strategy, and program flexibility have been key factors in Kenya's rapid scale-up of VMMC. Kenya has ensured adequate skilled practitioners by training clinical officers and nurses to provide circumcision services. In 2009, Kenya's month-long campaign performed more than 1,200 circumcisions a day, reduced the cost per procedure by 56 percent ($86 vs. $39 per procedure), and maintained quality service provision.

Additional countries that began implementing VMMC in 2008 include South Africa, Zambia, and Swaziland, which by the end of 2010 had circumcised a total of 145,475 (3.4 percent coverage), 81,849 (4.2 percent coverage), and 24,315 (13.3 percent coverage) men, respectively. In 2009, Tanzania adopted VMMC as an important component of its HIV prevention strategy with a target of reaching 2.8 million uncircumcised men within the next three years. By the end of 2010, Tanzania had circumcised a total of 29,443 men (2.1 percent coverage). In mid-2010, Tanzania implemented a campaign approach to rapidly expand VMMC services in the Iringa region and performed 10,352 circumcisions over a six-week period. Strategies adopted by the campaign to generate demand included broad dissemination of messages focused on the provision of free VMMC services by trained practitioners and on the efficacy of VMMC for HIV prevention. Clinical efficiency was improved through the use of multiple beds in an assembly line, task shifting, and task sharing. Tanzania's experiences suggest that concentrated campaign-style efforts to deliver high-volume VMMC can be implemented without compromising quality or client safety, and provide a model for matching supply to existing demand for VMMC.

As VMMC programs roll-out in different contexts, programs must be sensitive and responsive to VMMC's impact on traditional ideas of manhood and on perceptions of sexual pleasure. Programs must also monitor the possible negative impacts of VMMC on women, including their ability to negotiate safer sex.

In the long-term, priority countries will transition from adult and adolescent circumcision to neonatal circumcision. New policies and guidelines will be needed to integrate neonatal circumcision into existing health programs.

What we know

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Putting it into practice

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Tools and Curricula

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2012 International AIDS Conference

A number of VMMC abstracts were presented at the 2012 International AIDS Conference. Here are a few:

Implementation of VMMC Efficiency Elements in Four Sub-Saharan Countries: Service Delivery Methods and Provider Attitudes

Bertrand, J., Rech, D., Njeuhmeli, E., et al. XIX International AIDS Conference (2012). Abstract MOPDE010.

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Determinants of VMMC Provider Burnout in Four Sub-Saharan Countries

Bertrand, J., Rech, D., Njeuhmeli, E., et al. XIX International AIDS Conference (2012). Abstract MOPDE0102 (poster discussion).

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pdf View Slides outside link (PDF, 2.1 MB)

Service Delivery Trends in Kenya's Voluntary Medical Male Circumcision Scale-Up from 2008-2011

Mwandi, Z., Ochieng, A., Grund, J., et al. XIX International AIDS Conference (2012). Abstract MOPDE0104.

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Male Circumcision in Swaziland: Demographics, Behaviours and HIV Prevalence

Reed, J.B., Mirira, M., Grund, J., et al. XIX International AIDS Conference (2012). Abstract MOPDE0105.

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A Comparative Analysis of Two High-Volume Male Medical Circumcision (MMC) Operational Models with Similar Service Delivery Outcomes in Different Settings within Gauteng and KwaZulu-Natal Provinces in South Africa: Urban Centre for HIV/AIDS Prevention Study

Soboil, N., Cockburn, J., Rech, D., et al. XIX International AIDS Conference (2012). Abstract MOPDE0106.

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We Too Are Shareholders: Why Women Must Be Meaningfully Involved in the Rollout of Medical Male Circumcision in Africa

Agot, K., Ohaga, S., Ayieko, B., et al. XIX International AIDS Conference (2012). Abstract MOPDE0107.

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Population-Level Impact of Male Circumcision on HIV Incidence: Rakai, Uganda

Gray, R., Kigozi, G., Serwadda, D., et al. Conference on Retroviruses and Opportunistic Infections (2012). Paper 36.

The authors of this study assessed male circumcision uptake and the population-level impact on HIV incidence in Rakai, Uganda. The oral abstract was presented at the Conference on Retroviruses and Opportunistic Infections in 2012.

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Zimbabwe HIV Prevention E-Toolkit

K4Health (2012).

The toolkit offers a selection of different materials including research papers, books, training materials, and behavior change communication materials across the spectrum of HIV prevention topics. Readers can access materials and resources on behavior change communication, condom use, family planning and HIV service integration, male circumcision, multiple and concurrent partners, prevention of mother-to-child transmission, and voluntary counseling and testing.

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AVAC, Global Advocacy for HIV Prevention

AVAC (2013).

The website offers the latest news on the past, present, or ongoing status of biomedical HIV prevention research studies. Readers can review summary tables from various HIV prevention clinical trials, search information on prevention trails, see what is new on the site this month, and review the user's guide for help in using the site. The site offers information about the following biomedical prevention trials: microbicides, pre-exposure prophylaxis (PrEP), treatment as prevention, and vaccines.

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Clearinghouse on Male Circumcision for HIV Prevention

WHO, UNAIDS, AIDS Vaccine Advocacy Coalition, and FHI (undated).

This website is a comprehensive resource for people seeking information on male circumcision (MC) for HIV prevention. It was developed to provide "evidence-based guidance, information and resources to support the delivery of safe male circumcision services in countries that choose to scale up male circumcision as one component of comprehensive HIV prevention services." Information is categorized by research findings, advocacy, policies and programs, and training. Readers can also browse through publications, browse site content by topic, or search through a resource database. Materials can be immediately downloaded, including training manuals, planning tools, and situation analysis toolkits.

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C-Change: Communication for Change

fhi360  (undated).

This website contains communication toolkits, including one on male circumcision (MC). Developed for audiences in Nyanza province, Kenya, the toolkit contains all of the communication materials used to promote MC in the province. Readers can download a communication guide, community dialogue cards, a flip chart for counselors to use, posters about health and MC, a video, and other materials that can be adapted for a comprehensive MC communication campaign in other settings.

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Southern and Eastern Africa Region Male Circumcision Communication Meeting: A Joint UNAIDS & PEPFAR Sponsored Meeting

Bertrand, J. T., Evanson, L., et al. (2010).

The rapid roll-out of male circumcision (MC) programming is crucial to halting the further spread of the HIV epidemic in countries with generalized epidemics and low rates of MC. This is an urgent public health challenge; if the 14 target countries reach 80 percent coverage by 2015, an estimated 4 million adult infections will be averted. Modeling indicates that reaching these targets faster will avert even more new infections than a gradual scale-up. Creating demand for adolescent and adult MC is essential to the success of scale-up. To consolidate learning and to advance MC communication, the Male Circumcision Technical Working Group for the U.S. President's Emergency Plan for AIDS Relief and the Joint UN Programme on HIV/AIDS organized the first regional meeting on MC communication on September 22 to 24, 2010. Held in Durban, South Africa, the three-day meeting brought together 117 health professionals from 14 countries in eastern and southern Africa and international experts from Europe and North America. The meeting aimed to advance knowledge and to share promising experiences and communication materials for adolescent and adult MC in three key areas: demand creation, client counseling, and advocacy. The program provided participants with an overview of current work in MC communication and fostered interactive and in-depth discussion of key issues in small group settings.

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In It to Save Lives: Scaling Up Voluntary Medical Male Circumcision for HIV Prevention for Maximum Public Health Impact

AIDSTAR-One, U.S. President's Emergency Plan for AIDS Relief. (2011).

In this 15-minute film, award-winning filmmaker Lisa Russell tells the story of how governments in Kenya and Swaziland have embraced voluntary medical male circumcision (VMMC) for HIV prevention to turn the tide of the epidemic in their countries. Produced by AIDSTAR-One, the film features interviews with a variety of experts, policymakers, and implementers, and shows that VMMC programs can be replicated and expanded to reach the critical mass needed for maximum public health impact.

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Manual for early infant male circumcision under local anaesthesia

WHO, Jhpiego, 2011.

This manual builds on the World Health Organization's Manual for male circumcision under local anaesthesia and focuses entirely on early infant male circumcision. It has been developed by WHO in collaboration with Jhpiego to help providers and programme managers deliver high-quality safe infant male circumcision services for the purposes of HIV prevention and other health benefits. It draws from experiences with service provision in Africa, the Eastern Mediterranean and developed countries and was reviewed by actual and potential providers of male circumcision services representing a range of health care and cultural settings where demand for male circumcision services is high.

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Medical Male Circumcision as HIV Prevention: Follow the Evidence: The Case for Aggressive Scale Up

Center for Global Health Policy, 2010

This report first reviews the epidemiologic evidence of the effectiveness in male circumcision (MC) in reducing heterosexual HIV transmission. In the second section, the authors present a strategy for scaling up MC services in priority areas, identifying criteria for using MC as a way to reduce HIV rates, what clinical services are needed, and how MC can have a synergistic effect on HIV when it is part of a package of HIV prevention interventions. Lastly, the document provides data on how this one-time, low-cost, cost-effective intervention has the potential to avert a significant number of HIV infections. The authors argue that the evidence presents a compelling argument for rapid scale-up of MC programs in HIV endemic areas.

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Male Circumcision

US Agency for International Development, 2010

This webpage provides a concise overview of the US Agency for International Development's (USAID) position on voluntary medical male circumcision (MC) as part of a comprehensive package of HIV prevention programs and services. The page also briefly summarizes USAID's assistance for implementing MC in southern and eastern Africa.

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USAID Technical Issue Brief: Medical Male Circumcision and HIV Prevention

US Agency for International Development, 2010

This four-page brief describes the US Agency for International Development's (USAID) voluntary medical male circumcision (MC) activities as part of the US President's Emergency Plan for AIDS Relief. In addition to containing background information on MC, readers can learn about ensuring adequate supplies of MC kits, providing services, and costing and impact summaries. A case study from Swaziland provides an overview of an accelerated saturation initiative.

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PEPFAR External Quality Assurance Tools


PEPFAR Site Operational Guidance