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.
In this study, the control group of a large randomized trial of male circumcision was offered the procedure after the original trial had closed, and four out of five accepted. The men were then followed up for over two years, and HIV incidence between the circumcised and uncircumcised participants was compared. In this group, HIV incidence was 0.53/100 person-years among the circumcised men and 1.65/100 person-years among those uncircumcised, which was almost identical to the outcome of the trial. Potential demographic confounders and sexual behavior traits such as condom use, number of partners, and alcohol use with sex were comparable in both the circumcised and uncircumcised controls, and any changes to sexual behavior during the course of the study were similar in both groups. Although both the circumcised and uncircumcised men reduced their use of condoms, the circumcised group did not do so more frequently.
Adult male circumcision (AMC) holds promise as an effective HIV prevention strategy, but detailed communication strategies are required to ensure that communities have an accurate understanding of what it is and the extent of HIV prevention it can confer, according to this paper. The authors conducted a cross-sectional survey and genital examination of almost 1,200 men aged 15 to 49 from Orange Farm, South Africa. Clinical examination revealed that almost half of the men who self-reported being circumcised had intact foreskins. One in five of respondents mistakenly believed that AMC fully protects men against HIV. The incidence of HIV infection was considerably lower among circumcised men, the study found, and among the 860 men who self-reported being uncircumcised who were offered AMC, over 80 percent said they would have the procedure if it was free and performed by a doctor.
The cost of not scaling up efforts to implement voluntary male medical circumcision (VMMC) is now too high to ignore, according to this introduction to a series of articles on the costs and impact of VMMC as HIV prevention. If $1.5 billion is spent between 2011 and 2015 in 13 countries where VMMC is a priority in order to attain 80 percent coverage, future cost savings can reach $16.6 billion, by freeing up resources that would otherwise be used to provide antiretroviral treatment. Successful scale-up of VMMC relies on national-level factors such as strong political will and engagement of stakeholders, but it also requires community-level action in demand creation, mobilization, and deployment of human resources, the paper states.
This study used the Male Circumcision: Decision Makers' Program Planning Tool to predict both the cost and impact of scaling up voluntary male medical circumcision (VMMC) in 13 countries in eastern and southern Africa where VMMC is considered a priority (Botswana, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe, and Nyanza province in Kenya). The calculations were based on epidemiologic and demographic data from each of the countries, and the cost of each procedure, which ranged from $65 to $95, was calculated according to World Health Organization supply-side models for optimal volume and efficiency. To attain 80 percent coverage in these countries requires over 20 million circumcisions between 2011 and 2015, and 8.4 million more in the subsequent decade to maintain coverage at that level. Modeling shows that if coverage at this level could be achieved, it would avert more than 3.3 million new HIV infections, with cost savings on care and treatment of $16.5 billion.
Self-reported male circumcision (MC) may not be an accurate measure of actual circumcision rates, according to this paper. Of 312 men aged 18 to 25 who applied to join the Lesotho Defence Force, 241 agreed to complete a survey and undergo physical examination. Although 64 men reported being circumcised, physical examination showed that only half were completely circumcised, a quarter were partially circumcised, and a quarter were not circumcised at all. Men who reported being circumcised by traditional circumcisers during the process of initiation were seven times more likely to report MC that physical examination showed was not complete. The low accuracy of self-reported circumcision could explain why data from the Lesotho Demographic and Health Surveys appear to contradict the findings of three clinical trials in support of MC as a means of HIV prevention. The authors recommend that service delivery and cost estimates for MC programs should be guided by data from physical examinations, and medical MC campaigns must include education about what constitutes complete circumcision.
This paper adds further support to the call for extensive scale-up of voluntary medical male circumcision (VMMC) by showing that the protective effects of the procedure to prevent HIV transmission extend for at least 54 months. The study followed up on the randomized controlled trial of over 2,800 men aged 18 to 24 years from Kisumu, Kenya, who were either offered immediate or delayed VMMC. The trial showed VMMC conferred 60 percent protection against HIV transmission. After the trial was unblinded, all the participants were offered immediate circumcision. Among the controls, those who did and did not choose VMMC had similar profiles in terms of age and number of sexual partners at baseline. The number of seroconversions among circumcised and non-circumcised trial participants during the follow-up period confirmed the level of protective effect found in the original trial, allaying fears that the protection may reduce over time.
This article is the first to note circumcision's protective effect in male-to-female transmission. Using data from various studies in eastern and southern Africa, the authors assert circumcision confers a 46 percent reduction in male-to-female HIV transmission. The authors go on to posit that the impact of circumcision on HIV prevention is greater than originally estimated. These projections show a significant increase in infections averted by male circumcision: overall infections averted increased by 40 percent, which includes a doubling of infections averted among women. The authors also note that the increased risk during wound healing does not have a statistically significant impact at a population level.
Because male circumcision (MC) reduces the risk of HIV infection among heterosexual men, it also provides long-term, indirect protection to women. In this systematic review and meta-analysis, the authors looked at 19 epidemiological studies covering 11 populations, including one randomized controlled trial and six longitudinal studies to see what direct effect on HIV risk in women MC may have. The latter seven studies indicated that there was little evidence of a direct protective effect of MC against women becoming infected with HIV. It would require a randomized controlled trial of 10,000 serodiscordant couples to generate more definitive data, a task that is not logistically practicable. The authors recommend that with the scale-up of MC in high-prevalence settings, the maximum benefits for both men and women would be gained by integrating MC with other prevention strategies, and they urge rigorous monitoring for potential adverse effects for women.
Observational studies suggest that male circumcision (MC) may reduce transmission of high-risk human papillomavirus (HR HPV) strains, which can cause cervical cancer. This is the first randomized controlled trial to assess whether MC is protective against HR HPV. Over 1,200 men ages 18-24 in the Orange Farm township near Johannesburg provided urethral swab specimens 21 months after being randomized to the circumcision or control arm. HR HPV prevalence was 40% lower among men who had been circumcised, compared to those who had not been circumcised. Furthermore, HR HPV prevalence was significantly lower among the circumcised men. Study limitations include a lack of HR HPV testing prior to study inclusion (which can underestimate the true effect of MC), inability to blind the participants to the intervention (which can lead to changes in behavior), and urethral specimens (which are likely to miss HPV infection). Despite these limitations, this study provides additional evidence that MC can help reduce cervical cancer in developing countries.
Using the female partners of men enrolled in a male circumcision (MC) study, researchers investigated whether MC has an effect on their rates of bacterial vaginosis (BV), trichomonas vaginalis, and symptomatic genital ulcer disease. This study only included women who were not infected with HIV, nor whose partners were infected with HIV. Participants in the intervention arm had husbands who were randomized to immediate circumcision, while those in the control arm had husbands with delayed circumcision. Data were collected via interviews, and self-collected vaginal swabs provided samples for testing for BV and trichomonas. Compared to baseline data, one year after enrollment in the trial, women in the intervention arm had lower rates of BV, trichomonas, and self-reported genital ulcer disease than those in the control arm. The reduction of such infections among the partners of circumcised men was 18%, 45%, and 22%, respectively. Despite higher rates of BV among controls and more reported sexual partners among controls, the researchers believe these results are valid. Since reproductive tract infections can heighten the risk of HIV acquisition, MC can help reduce both primary and secondary HIV transmission among women.
This study assessed whether about 1,000 18-24 year-old men in Kisumu, Kenya in a male circumcision (MC) randomized, controlled trial adopted risky sexual behaviors after being circumcised. Participants were counseled that research about MC's protective effect against HIV was inconclusive. This study included a comprehensive, 18-point scale that was validated with serologic text results for sexually transmitted infections. Detailed sexual histories were collected at baseline, 6 months, and 12 months after randomization, with individualized HIV risk reduction counseling taking place at this time. The researchers found that sexual risk behaviors decreased one year after being randomized to either MC or to control. There was no difference between circumcised and uncircumcised men after one year of follow up in sexual risk propensity, or incidence of gonorrhea, chlamydia, and trichomoniasis. While this study indicates risk compensation may not be an issue with MC, study participants had risk reduction counseling and the support of a clinical trial--counseling and support that will be difficult to replicate when MC becomes widely available. Furthermore, changes in sexual behavior may take place more than one year after MC.
As epidemiologic data mounted regarding the effectiveness of male circumcision (MC) in reducing heterosexual HIV transmission, acceptability of MC becomes a pressing question. As such, these researchers reviewed studies on the acceptability of MC among traditionally non-circumcising areas of sub-Saharan Africa. Thirteen studies met the inclusion criteria, representing nine countries. While willingness of uncircumcised men to become circumcised varied considerably, at least half of men in the studies "appear to be receptive, if not eager, to become circumcised." Cost, fear of pain, and concern for safety were the three most consistent barriers to acceptability of MC. Furthermore, in every study Africans equated circumcision with improved hygiene. There is a widespread belief that circumcision leads to fewer sexually transmitted infections. Some studies indicated that circumcision was becoming an issue of personal choice rather than ethnic identity. The authors concluded that "acceptability of MC is likely to be high enough to have a significant impact on HIV prevalence in these communities." Because existing acceptability studies are consistent in support for MC, the authors recommend moving into pilot interventions for MC without the need for further acceptability studies.
Researchers stopped this study prior to completing because the positive results among study participants in the intervention arm were clear during interim analyses: male circumcision (MC) was protective of HIV infection. Nearly 2,800 men aged 18-24 in Kisumu, Kenya were randomized to immediate circumcision or delayed circumcision at 24 months. Researchers provided HIV counseling and testing, genital examination, and asked participants about their sexual activity; collected blood and urine for sexually transmitted infection (STI) testing, and used a comprehensive questionnaire about sexual function and HIV risk behaviors. Individual risk reduction counseling took place with every visit, free condoms were given to participants, those with STIs were treated and counseling, and those testing positive for HIV were referred to free HIV treatment and care along with a post-test counseling and support group. When the study was halted, MC had a protective effect of 53% compared to the control arm, which increased to 60% when the analysis was statistically adjusted. Men in both study arms reported a reduction in HIV sexual risk behaviors. Uncircumcised men reported decreasing rates of having two or more sex partners over the study period, while this percentage remained stable after month 6 for men who had been circumcised. Furthermore, men with MC were more likely to have unprotected sexual intercourse with any partner in the previous 6 months and less likely to use condoms consistently at 24 months of follow up. The researchers attribute this difference to "increases in safer sexual practices in the control group rather than to riskier behavior patterns in the circumcision group, indicating that risk compensation did not occur" during the study.
This study confirmed the results of the first randomized, controlled trial clearly indicating a protective effect of male circumcision (MC) on HIV acquisition among men. As with the other studies, this one was also stopped early when interim analysis showed a benefit in the intervention arm. Among nearly 5,000 men in Rakai, Uganda, who were enrolled in the study, men who had been circumcised were 51% to 60% less likely to become infected with HIV than the uncircumcised men. (The protective effect varies due to the type of analysis.) This study also shows high acceptability of MC, with 80% of the controls completing 24 months of follow up agreeing to MC. There was no difference in the sexual behavior of the two study arms, which may have been a result of the "intensive health education provided during the trial to minimize risk compensation." Moderate to severe adverse events were similar to those found in other studies, at about 4%. The authors conclude that while the epidemiological evidence shows a clear benefit of MC, studies that are stopped early could overestimate effectiveness of an intervention. They recommend that long-term surveillance take place to assess the effect of MC on HIV prevalence, and whether any risk compensation takes place.
This landmark study was the first randomized, controlled trial to confirm the results of observations studies: that male circumcision (MC) reduced the rate of heterosexual HIV transmission. In fact, this protection was evident partway through the trial, and this was stopped early. Among 3,274 HIV-negative men aged 18-24 in Orange Farm, South Africa, those who had been circumcised were 60% less likely to be infected with HIV than those who had not been circumcised over an 18-month period. This level of protection was evident when using statistical techniques to control for other factors, such as condom use and non-marital sexual partnerships. Because the trial was stopped early, the long-term protective effects of MC on HIV acquisition are unknown. Furthermore, the men who had been circumcised were more likely to have risky sexual behaviors than uncircumcised men, raising concerns about behavioral disinhibition among circumcised men.
This review focused specifically on research available through 1999 on male-to-female transmission of HIV in sub-Saharan Africa. The authors included 28 observational studies from eight countries in their analysis, including studies among the general populations and high-risk populations. When the data were pooled, circumcision reduced the risk of HIV infection by about one-half compared to non-circumcised men. Those at high risk of HIV tended to experience a greater protective effect of the procedure, although men in the general population also experience a significant protective effect. Despite the limitations of observational studies, the authors concluded that compelling evidence exists for additional studies on "the, acceptability, feasibility, and safety of introducing male circumcision as an HIV prevention strategy in high prevalence areas where men are not traditionally circumcised."
In this qualitative study, the authors say that early infant male circumcision (EIMC) is safer and more cost-effective than adult circumcision and find that barriers related to perceptions of safety and low levels of knowledge about male circumcision--rather than individual beliefs--are more likely to impede EIMC uptake. In a 2009 survey, 60 percent of Zimbabwean women and 58 percent of men reported a willingness to have their sons circumcised. The study found similar acceptability rates but low levels of knowledge about the procedure. The authors encourage the creation of community awareness and mobilization campaigns aimed at women as well as men to spread information on male circumcision beyond clinics. They also underscore the importance of understanding cultural and religious beliefs attached to male circumcision among certain groups and of involving religious and traditional leaders in EIMC campaigns. Finally, they stress that, although fathers often learn about EIMC from mothers (who themselves learn about the procedure at health centers), it's important to provide information directly to fathers in workplaces and beer halls. Concerns for the child's safety, such as the belief that a newborn's penis is "too fragile" to undergo circumcision, must also be addressed. The authors encourage the use of quality assurance methods to ensure a cosmetically acceptable result and to prevent adverse effects. They also encourage increased education for nurses and midwives to improve their ability to safely perform EIMC skills.
Male circumcision (MC) can provide protection from HIV over an extended period, according to a follow-on study that examined long-term effectiveness data from a trial in Rakai, Uganda--one of the three completed randomized controlled trials that proved the efficacy of MC for HIV prevention in men. The Uganda trial, involving 4,996 HIV-negative uncircumcised men aged 15 to 49, was closed early on December 12, 2006, after it demonstrated the efficacy of MC. Subsequently, 4,145 HIV-negative men were enrolled in a post-trial surveillance study that ended December 15, 2010. According to the authors, there were no statistically significant differences in socio-demographic characteristics or sexual risk between men who accepted circumcision and those who remained uncircumcised. Moreover, the authors found no significant risk compensation or increased risk behavior following circumcision. Analysis of the findings of the follow-on trial showed that MC's high effectiveness (adjusted effectiveness of 73 percent) was maintained for slightly less than five years. These results are similar to those from a recent study in Kenya, which found efficacy rates of 64 percent over 4.5 years following the closure of a comparable MC trial. The results also mirror observational studies demonstrating reduced HIV incidence among adult men who had been circumcised during infancy or childhood.
Approximately 25 percent of men who have undergone medical male circumcision in Zambia reported resuming sex prior to full healing of their wounds. This observational study, focusing on early resumption of sexual behavior following circumcision, included 225 men aged 15 to 29. Men undergoing circumcision are generally counseled to avoid sexual activity until six weeks post-circumcision. Of the men in the study, most (82 percent) reported at least one unprotected sex act before the end of the six-week recovery period, and close to 40 percent reported having sex with multiple partners. Using a regression model, the authors calculated that of the 61,000 men circumcised in one year, early resumption of sex leads to 69 additional HIV infections (32 in men and 37 in women), while circumcision averts 230 HIV infections in one year, predominantly among men. The authors caution that an increase of only 5 percent in early resumption of sex (from 25 to 30 percent) may lead to more new HIV infections in women than HIV infections averted overall. They associate early resumption of sex after circumcision with reported risky sexual behavior just prior to circumcision and with a reported higher number of lifetime sexual partners. The authors recommend targeting counseling at men who are identified as engaging in sexual behavior that puts them at high risk of acquiring HIV infection as well as investigating the costs and impact of interventions to drive down sexual behavior in the wound-healing period, particularly interventions targeting women.
This article discusses lessons learned in Kenya's voluntary medical male circumcision scale up and assesses VMMC services in 16 government health facilities in Kenya' Nyanza Province. The paper focuses on the ways that challenges were overcome at national and local levels. The article is designed to share lessons with other VMMC programs in Africa.
The human resources aspect of scale-up of voluntary medical male circumcision (VMMC) in eastern and southern Africa is the focus of this paper. It identifies ways to overcome the shortage of health professionals in countries where VMMC has been identified as a priority intervention. Based on a review of the literature and of a VMMC program, the authors describe various measures: task management strategies, surgical and non-surgical efficiencies, short-term redeployment of staff from other parts of the public sector, and recruitment of underutilized health workers such as those who have recently qualified or retired, as well as medical volunteers from overseas. They highlight examples from existing campaigns, such as relocating public sector staff in Tanzania, training nurses to conduct VMMC surgery in Kenya, and finding ways to utilize untapped nursing resources in Swaziland, to show how innovative approaches can overcome human resources shortages.
The experience of Kenya, where approximately 290,000 men have undergone voluntary medical male circumcision (VMMC) since 2008, serves as a model for VMMC scale-up in other countries, according to this paper. Two crucial factors are the Government of Kenya's leadership in prioritizing VMMC in the country's HIV prevention efforts and the adoption of a strategy targeting 80 percent circumcision of all uncircumcised men by 2012. Widespread support for VMMC is attributed to the government's prompt and ongoing engagement with politicians, community leaders, and civil society organizations. The implementation of VMMC programs has been characterized by innovation and flexibility, which has also contributed to their success, the paper states.
This paper describes Tanzania's experience in running a high-volume voluntary medical male circumcision (VMMC) campaign in which over 10,300 men were circumcised in six weeks. The number of procedures was 72 percent higher than the target, with less than 1 percent of cases encountering an adverse event and almost universal HIV testing throughout the campaign. Such good results were achieved by implementing measures to improve clinical efficiency, such as using the forceps-guided circumcision method and enabling surgical teams to operate on an assembly line of patients. Community-based client preparation and mobilization were crucial to stimulating demand for the procedure. Tanzania's example shows that VMMC can be scaled up to high volume without adversely affecting service quality, the paper concludes.
This study looked at voluntary medical male circumcision (VMMC) demand creation with two key issues in mind: the main elements of a demand creation campaign and the impact of challenges to demand creation on the overall cost. The authors conducted qualitative interviews with seven experts who had experience in managing VMMC demand creation budgets and offering technical assistance to government VMMC programs. Given the diversity of views among informants, demand creation should be tailored to specific country contexts, the authors found. Costing exercises depend on individual country and program variations, as well as the extent and quality of programs. The authors also note the lack of data on what factors prompt eligible men to make the decision to go for VMMC. The paper offers a seven-step process for VMMC cost estimation based on key assumptions, but calls for more research into the identification and costing of core components of a VMMC demand creation program.
This paper looks at the differing degrees of progress in scaling up male medical circumcision (MMC) programs in countries in eastern and southern Africa where MMC is considered a priority. It categorized the countries according to how quickly they adopted MMC policies after the World Health Organization and the Joint UN Programme on HIV/AIDS issued recommendations for scale-up in 2007, and assessed the volume of MMCs conducted from 2008 to 2010. Among the countries considered early adopters, only Kenya is approaching the recommended 80 percent target coverage, having achieved over 60 percent coverage by the end of 2010. Overall, coverage was only 3 percent of the target, at 550,000 MMCs. The study found potential predictors of early adoption include having a national policy and focal person, as well as running a pilot program and developing an operational strategy. However, early adoption alone is not predictive of rapid scale-up of MMC--it also requires sustained leadership and country ownership, the authors conclude.
Costing estimates for the implementation of voluntary medical male circumcision (VMMC) programs should include the cost contribution of the supply chain and waste management as these can account for a significant proportion of total costs, according to this paper. The standard list of commodities for scale-up of a VMMC program that was developed by U.S. President's Emergency Plan for AIDS Relief programs in collaboration with the World Health Organization and the Joint UN Programme on HIV/AIDS was used in the process of program planning for a VMMC campaign in Swaziland that targeted 152,000 VMMCs in one year. Once the researchers added the cost of the supply chain and waste management, as well as commodities for HIV counseling and testing and treatment of sexually transmitted infections, they found that these items almost doubled the total cost, adding approximately $60 to the bill per circumcision.
This project focused on identifying whether it is possible to implement a large-scale, high-quality adult male circumcision (MC) program in settings with high HIV prevalence, low levels of MC, and low incomes. Prior to rolling out adult MC services, the researchers took care to consult with the local community in Orange Farm township in South Africa. Surveys showed a high level of support from the community for the project, and a willingness among adult males to obtain MC. The project set up a high-volume surgery room in an existing facility, trained teams of providers, procured necessary equipment, and began dedicated communication and outreach activities to bring clients in for MC. They performed 14,011 procedures over nearly two years, with minimal adverse events. Participant and community satisfaction levels were high. While this project demonstrated the feasibility of providing high-quality, large-scale MC, only 28% of men seeking MC obtained HIV testing and counseling. One point of concern, however, was that only two-thirds of the men returned for their follow-up visit.
To safely implement male circumcision (MC) where the potential impact is great, programs must have skilled providers. This study in Rakai, Uganda followed a team of six newly-trained MC providers over 3,000 circumcisions to identify when they reached full clinical competency in the procedure. All providers received two or more weeks of training by an urologist; none had previously performed adult MC. Training included preoperative preparation and aseptic technique, local anesthesia, the sleeve circumcision procedure, suturing, hemostasis, and management of surgical emergencies and adverse events. The trainees performed 15-20 supervised circumcisions during training. It took providers an average of 40 minutes to complete one procedure during their first 80-100 circumcisions. As provider competency increased, this time declined to between 20 and 25 minutes. Similarly, moderate to severe adverse events (requiring treatment or surgical intervention) occurred in nearly 9% of the first 20 procedures, declined to 4% for the next 20 to 99 procedures, then leveled off to 2%. The authors conclude that newly-trained clinicians should perform their first 35-40 procedures under supervision while they gain competency in the procedure to minimize adverse events.
This statement and recommendations follow an expert review of newly-published evidence on the effectiveness of male circumcision (MC) for HIV prevention. A wide range of stakeholders attended, including researchers, women's health advocates, government representatives, and members of civil society. The group agreed that the evidence on the effectiveness of MC for HIV prevention was "compelling," and provided a number of policy and program recommendations resulting from the research. Topics addressed span epidemiologic, communication, cultural, human rights, and gender issue, among others. These conclusions and recommendations can help guide policy makers and program managers as they move from MC research to program implementation, roll out, and scale up.
Male circumcision in clinical trials demonstrated a reduction of between 50 and 60 percent in HIV acquisition. As male circumcision scales up in many countries, national strategies will most likely recommend infant circumcision. This study, conducted between September 2009 and November 2011 and involving 1,239 babies that received infant male circumcision (IMC), reports on type and severity of adverse events (AE) within an IMC intervention in Kenya. Data came from two sources--one a case/control IMC study and the other derived from routine monitoring of IMC services. In the study reported here, median age for IMC was four days, and 96 percent of post-operative reviews took place within seven days. The total AE rate was 1.5 percent, with most AE occurring in infants one month or older (3.5 percent). AE did not differ depending on provider type or experience level. Almost all parents (96 percent) reported being very satisfied with the experience. The study demonstrates that IMC can be highly successful and safe in developing countries where circumcision is not predominantly practiced.
The authors report on a prospective, randomized, controlled trial in Rwanda comparing procedure and recovery times for circumcision via the nonsurgical PrePex male circumcision device and the dorsal-slit surgical method. Of 217 subjects aged 21 to 54, 144 were randomized to the PrePex arm and 73 to the surgical arm. Mean procedure time for the PrePex arm was 3.1 minutes, significantly shorter (p < 0.0001) than the mean procedure time, 15.4 minutes, for the surgical circumcision arm, with no adverse events reported for the PrePex device. On the other hand, mean healing time was longer for individuals in the PrePex arm (31 days) than for those in the surgical circumcision arm (23 days). In addition to a shorter procedure time, say the authors, PrePex has other important advantages for resource-constrained settings: it is bloodless, does not require anesthesia or a sterile setting, and can be carried out by nonsurgeons, such as nurses. The authors suggest that these results favor nonsurgical circumcision methods for Rwanda, which has launched a two-year campaign to circumcise two million men but has only 21 surgeons in the entire country.
This systematic review assessed the safety of medical male circumcision (MC) by non-physician providers (nurses, midwives, surgical aides, and clinical officers). The authors found task shifting of MC to trained non-physician providers in a supportive environment does not increase the frequency of adverse effects and is thus very different from MC performed by untrained or minimally trained lay providers with little or no supervision or supportive equipment. The authors, who reviewed 25,000 procedures carried out by trained non-physicians, found rates of adverse events similar to MC conducted by doctors or specialists, including urologists and surgeons. According to the authors, the quality of training and supervision and the availability of safe equipment are more likely to affect MC safety than the cadre of health professional conducting the procedure. Another safety factor is the number of circumcisions performed; one study found that adverse events averaged 3.8 percent for the first 100 procedures by trained personnel, but fell to 0.7 percent after 400 procedures. The authors also found that practitioners with more experience with MC require less time to perform it and encourage further research into the cost-effectiveness of task-shifting for MC, particularly since some men seeking MC turn to informal providers to avoid charges, often resulting in adverse effects. More research is also needed to understand other factors that may contribute to safety, including the length and duration of training, the availability of supportive medical materials, providers' experience and skill set, and reporting of adverse events.
This three-hour e-learning course uses reviews the evidence about the protective effect of male circumcision (MC) on HIV transmission and presents available data on the acceptability and safety of MC. It also addresses program and policy issues, such as implementation challenges, and provides policy and program guidance. Developed for health policy makers and program managers, this module focuses primarily on the public health issues related to MC. The course presents information on providing MC in both high- and low-prevalence settings. Modules include key information on commodities and supply chain management; counseling, communication, and demand generation; and the cost and impact of expanding MC on HIV incidence.
Indicators are needed to measure how an intervention or program is achieving its goals. This guide developed indicators related to creating demand for male circumcision (MC), generating supply for MC, and maximizing safer sexual behavior. When used, they can help provide feedback for managing MC programs. They developed targeted indicators for indicators for advocacy that include a strong policy component, and behavior/social change. Each indicator has a detailed description, including what the indicator is intended to measure, recommended frequency of reporting, measurement tools needed, how the data will be collected, numerators, denominators, and how the indicator can be interpreted. Countries can choose to add specific indicators to their programs, or adapt them for use.
This report outlines various considerations and options for organizing adult MMC surgical services in order to improve the efficiency and service volume while assuring a safe service of high quality. It is a guide for both program managers involved in setting up or strengthening MC services, and funders and policymakers who need to make decisions about the costing and financing of MC services.
Volunteer medical personnel can help respond to short-term demand for medical services that local personnel do not have the skill to perform, or the infrastructure to support demand. They also build long-term capacity in training local staff during their efforts. This guide provides information on how medical volunteers can help bring male circumcision (MC) services to scale for policy makers, program managers, professional associations and the volunteers themselves. In addition to laying out the objectives of the MC volunteer program, this document describes the roles and responsibilities of all parties involved: coordinating bodies, professional associations, implementing agencies, ministries of health, service delivery sites, and volunteers.
This report summarizes the findings of a meeting on traditional male circumcision (MC), which brought together those involved in both traditional and medical MC in eastern, southern, and western Africa, as well as policymakers, government officials, and UN and non-government agency representatives and researchers. The aim was to increase understanding of traditional MC practices, promote best practice for collaboration between the health sector and traditional circumcisers, and examine ways for traditional MC to contribute to HIV prevention. It covers the challenges of improving communication between the medical community and traditional male circumcisers, improving the safety of traditional MC and building links between medical and traditional MC, each with country examples and summaries of discussions by the relevant working groups during the meeting. Individual country follow-up plans are included in the report.
This report documents what took place during a meeting among organizations working with the President's Emergency Plan for AIDS Relief (PEPFAR) to promote and provide male circumcision (MC) as an appropriate HIV prevention strategy in certain country contexts. The first day of the meeting focused on sharing experiences, lessons learned, and challenges to implementing MC service delivery programs in the field. The second day focused on commodity and procurement issues that present a challenge to scaling up MC services. The report recommends how to improve the supply chain in order to support rapid scale-up of MC activities. In addition, meeting participants reached consensus on an essential MC kit. The report includes three lists of possible MC commodities options.
This tool is comprised of a series of spreadsheets and a manual explaining their use in estimating the costs and impact of scaling up male circumcision (MC) services. Costing information is calculated by delivery mode based on locally derived information about staff time and salaries, supplies, equipment, and shared facility and staff costs. Users can also estimate the impact of MC on a country's HIV epidemic, including net cost per averted HIV infection. By varying coverage levels and speed of scale-up, users can examine the cost and impact of different scenarios. This tool was used to model the cost and impact of scaling up MC services in 14 eastern and southern African countries.
A situation analysis is crucial to developing safe male circumcision (MC) services. Such an analysis can help program planners (1) understand the determinants and scale of MC practices, (2) assess current capacity to perform safe MC, and (3) understand whether community support exists for MC. This toolkit contains six tools that can be used to obtain a situation analysis from which to build a successful MC program. These tools include guided desk review, key informant interviews, stakeholders' meetings, focus groups, service availability, feedback and action.
This tool can be used to assess the quality of male circumcision (MC) services, guide setting up services, and improve existing services. In addition to measuring a site's progress towards meeting standards, it can be used for certification or accreditation. It first outlines how the toolkit should be used, how often assessments should take place, and what should be done with the findings. The toolkit contains extensive checklists that can be used to assess everything from infection prevention and control to the surgical procedures taking place, counseling, and managing adverse events.
This document was written to provide programmatic operational guidance to countries that want to implement and scale up male circumcision (MC) services. These recommendations can help programs bring MC services to scale safely, efficiently, and effectively. The guide contains 10 essential components for operationalizing MC services such as human resource development and social change communication. For each of these 10 components, readers can find a summary of key issues, key actions for consideration, and key tools and guidelines that can be accessed on the Internet. There are also vignettes from different country experiences launching MC efforts thus far.
Male circumcision (MC) programs for HIV prevention have distinct human rights, ethical, and legal implications. This document contains guidance for decision-makers, program planners, and health care providers. State responsibilities that are outlined include protection and promotion of human rights; developing a legal, regulatory and policy framework; protecting and promoting the rights of the child; ensuring access to accurate information; protecting women in the context of MC; and progressively expanding access to voluntary MC services. Responsibilities of health care providers include ensuring: safety, non-discrimination in access to services, voluntary and informed consent, and respecting confidentiality. The document includes considerations related to infant, child, adolescent, adult MC, as well as special considerations to women. It is meant to be used with the companion document, UNAIDS Legal and Regulatory Self-Assessment Tool for Male Circumcision in Sub-Saharan Africa.
This tool can help countries "gauge how well the existing legal and regulatory framework is supporting male circumcision (MC) service scale-up for HIV prevention and indicate what changes may be required." It is informed by health and human rights standards in international and domestic law, and reflects UNAIDS guidance on safe, voluntary, informed MC. The tool contains information on how to use it, the mix of skills and backgrounds needed for the assessment team, and provides users ways to assess MC availability, acceptability, education and counseling, how children and women are affected, and issues related to access and informed consent, among other topics. It is meant to be used with the document Safe, Voluntary, Informed Male Circumcision and Comprehensive HIV Prevention Programming: Guidance for Decision-makers on Human Rights, Ethical and Legal Considerations.
This comprehensive manual describes the safest and most practical methods for male circumcision (MC) in resource-limited settings. It starts by describing the benefits and risks of MC, and how MC can be linked to other sexual and reproductive health services. The bulk of the manual provides technical guidance on the MC procedure, detailing the knowledge, skills, and attitudes providers need to safely provide different procedures. Containing multiple photos and drawings, sample consent forms, information sheets for clients, stock cards, adverse event forms that manual is an excellent training tool. In addition, the manual contains a chapter on counseling and client and obtaining informed consent for MC, infection prevention, managing complications, and running a MC service.
The implementation report provides details on the effort of Jerusalem's Operation Abraham Collaborative and St. Mary's Catholic Mission Hospital, in KwaZulu-Natal, South Africa, to roll out a medical male circumcision (MC) intervention in South Africa. Challenges and solutions are discussed. Preparing the facility was the first step in implementation, and floor plans and photos are provided. The project goal was to circumcise 50 or more men a day; therefore, an efficient patient flow had to be established. Training hospital and clinical staff on MC was the next step; a daily training schedule illustrates how this worked for the program, which trained 19 medical doctors, 53 nurses, 11 administrative personnel, and 3 counselors between August 2010 and December 2011. Educating the clients through preoperative group and individual counseling is another key program component. Measures for quality assurance and sustainability are included. Finally, program details for participating hospitals are provided.
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.
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).
View Slides (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.
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.
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.
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.
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.
Zimbabwe HIV Prevention E-Toolkit
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.
AVAC, Global Advocacy for HIV Prevention
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.
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.
C-Change: Communication for Change
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.
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.
View Report (PDF, 834 KB)
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.
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.
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.
View Full Text (PDF, 953 KB)
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.
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.
View Full Text (PDF, 278 KB)
PEPFAR External Quality Assurance Tools
PEPFAR Site Operational Guidance