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.
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.
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.
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.