PEPFAR’s Best Practices for VMMC Site Operations

A Service Guide for Site Operations

This document provides implementing partners supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) with a collection of the best resources available for sites providing voluntary medical male circumcision (VMMC) for HIV prevention. This version is Edition 2; Edition 1, released in 2013 focused on assisting implementing partners and site staff with opening new VMMC service locations. Edition 1 covered all aspects of the planning, launch, and oversight of daily operations at the site level. Given the maturation of VMMC programs since 2012, Edition 2 focuses on optimizing management of existing service locations, though chapters still remain for those establishing new sites. The primary intended audience for Edition 2 remains site-level staff, with different chapters most relevant to different staff positions.

Achieving an AIDS-free generation will not be possible without including men in HIV prevention, care, and treatment.
Ambassador Deborah L. Birx, MD, U.S. Global AIDS Coordinator

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As in the first edition, the second edition has included new best practices of VMMC service provision from across the 14 priority countries. These have been summarized and placed in the respective chapters. In addition, each chapter is designed as a stand-alone resource covering all aspects of the respective topic, including:

  • Chapter Goals: States the objectives of the chapter
  • What Users Need to Know: Summarizes the most important information and referenced documents with links (online version) or directions (printed version) to the tools/ instruments/resources
  • Frequently Referenced Information: Additional relevant content embedded into the body of the text
  • For Additional Information: Provides additional details on the topic for those that want more
  • Tools, Instruments and Guidance Documents: Lists all the resources referenced in the chapter
  • Case Studies: Provides program examples where applicable
  • References: Lists the manuscripts cited in the chapter.

Message from the U.S. Global AIDS Coordinator

Between 2009 and 2016, PEPFAR supported a cumulative total of 11.7 million voluntary medical male circumcisions (VMMCs) for HIV prevention in the 14 priority countries in East and Southern Africa. This was approximately 56 percent of the 20.9 million circumcisions required to reach 80 percent coverage, as estimated in the Joint Strategic Action Framework 2012–2016. Reaching this goal will avert more than 240,000 HIV infections and will save USD$4,400.00 in HIV treatment costs per HIV infection averted between 2015 and 2025.

The Impact Action Agenda of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR 3.0—Controlling the Epidemic: Delivering on the Promise of an AIDS-free Generation) highlights VMMC as one of the core biomedical prevention interventions, along with condom use, antiretroviral therapy and related diagnostics, and prevention of mother-to-child transmission. PEPFAR 3.0 embodies the push to control the HIV epidemic and realize the goal of an AIDS-free generation; and VMMC is an essential part of that initiative.

The second edition of the PEPFAR Best Practices for VMMC Site Operations updates guidance presented in the 2013 edition. Whereas the first edition focused on setting up VMMC sites, the second edition focuses on establishing and supporting quality VMMC services for HIV prevention at the VMMC site level, reflecting the maturity of the VMMC program and the number of sites already established. This entails solidifying the functionality and efficiency of existing VMMC sites. The document guides PEPFAR implementing partners with proven approaches for providing high-quality VMMC services specifically at the facility or VMMC site level and ensuring successful VMMC scaleup from the site level to the global level. It emphasizes strengthening or enhancing essential linkages among other men’s health services; increasing community-level support and participation; and using data to develop the most cost-effective use of available resources.

Achieving an AIDS-free generation will not be possible without including men in HIV prevention, care, and treatment. Men in sub-Saharan Africa face numerous health risks that have yet to be effectively addressed. HIV risks for men, especially young men, include unprotected sex and alcohol abuse, which are closely tied to cultural concepts that define masculinity, promote risk-taking, and underplay the value of health-seeking behavior. Men’s risks, in turn, affect girls and women, and increase their vulnerability to sexually transmitted infections, including HIV. Addressing men’s HIV risks while bringing them into the wider health care arena could have significant impacts on families, communities, and societies, including indirect benefits to the health of women and girls.

The guidance presented in this manual supports VMMC 2021, as articulated in the policy brief, A Framework for Voluntary Medical Male Circumcision: Effective HIV Prevention and Gateway to Improved Adolescent Boys’ & Men’s Health in Eastern and Southern Africa by 2021. This framework, developed by the World Health Organization and the Joint United Nations Programme on HIV/AIDS, includes VMMC as part of a package of essential interventions to decrease annual new HIV infections to 500,000 by 2021—a 75 percent reduction relative to 2010. These new strategic directions are a follow-on to the Joint Strategic Action Framework 2012–2016.

Specifically, VMMC 2021 seeks to target 27 million men for VMMC as part of integrated sexual and reproductive health services for men—a gateway service to prevent HIV while also welcoming men into the health care arena. viii PEPFAR’S BEST PRACTICES FOR VOLUNTARY MEDICAL MALE CIRCUMCISION SITE OPERATIONS Reaching VMMC 2021 goals will entail not only accelerating the scale-up of VMMC, but also developing new VMMCbased platforms for meeting the sexual and reproductive health needs of men and boys. The expectation is that bringing men the health care they will improve their wellbeing while indirectly benefiting women and girls, thus contributing to the goal of an AIDS-free generation. The DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) Initiative, which targets partners of adolescent girls and young women, is designed to meet this goal. VMMC thus offers an excellent opportunity to bring men into health care, link HIV-positive men to treatment, and expand their access to the full range of clinical services.

The updated manual also reflects PEPFAR’s Phase 3 (PEPFAR 3.0) goals of achieving sustainable control of the HIV epidemic and reaching the globally accepted 90-90-90 goals by 2020. PEPFAR endorses a data-driven, strategic approach that maximizes the effectiveness of investments in HIV interventions; accelerates the scale-up of HIV prevention; and engages all social resources (government, communities, and the private sector) in partnerships to address HIV and improve social wellbeing.

The revision of this manual has been a community enterprise, with input from many experts in the field of VMMC for HIV prevention. PEPFAR particularly acknowledges the contributions and leadership of the VMMC Technical Working Group at the Office of the Global AIDS Coordinator; the unwavering support of the Strengthening High Impact Interventions for an AIDS-free Generation Project; the careful reviews received from PEPFAR and other U.S. Government field offices; and the country-specific case studies contributed by field experts.

PEPFAR implementing partners have a tremendous challenge ahead of them to reach the goal of circumcising 27 million men by 2021. The rewards will be enormous, with millions more lives saved and a tidal shift in HIV incidence and prevalence. PEPFAR encourages implementers at the site service level to use this guidance, which highlights successful approaches and describes key steps in successful implementation of high-quality VMMC services. Our hope is that the manual will serve as a resource for PEPFAR partners as they build on current success in VMMC; support men’s inclusion in health care and health decisions; and contribute to global goals in HIV prevention, treatment, and containment.

Ambassador Deborah L. Birx, MD
U.S. Global AIDS Coordinator