Definition of the Prevention Area
Voluntary medical male circumcision (VMMC) is the complete removal of the foreskin of the penis by surgical means. Though VMMC may be conducted for a number of reasons, evidence from three 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 provision of VMMC by qualified, well-equipped professionals, and with the client’s informed consent. To ensure that VMMC is provided as part of a comprehensive HIV prevention strategy, the World Health Organization (WHO) recommends that a minimum package of services should be available in all facilities providing male circumcision. This package includes HIV testing and counseling, screening and syndromic treatment of sexually transmitted infections (STIs) where required; provision and promotion of male and female condoms; and counseling on risk reduction, safer sex, and male circumcision (removal of the foreskin, surgically or using a device) performed as described in the Manual for Male Circumcision under Local Anesthesia (WHO, Joint United Nations Programme on HIV/AIDS (UNAIDS), and Jhpiego 2009).
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 can reduce men’s risk of acquiring HIV from their female partners. The combined data from the trials led WHO and UNAIDS to strongly recommend VMMC as a new HIV prevention tool with an estimated protective effect of around 60 percent. Additional data from the long-term follow-up of the Kenya and Uganda cohorts and a population-level impact evaluation done in South Africa showed that the protective effect of VMMC is more than 60 percent, and could be around 70 percent; this level of protection was confirmed in a 2012 meta-analysis (Lei 2015). Other follow-up studies over five years indicated that VMMC's effectiveness can be sustained over a longer term (Gray 2012; Mehta 2013); and a cross-sectional survey in South Africa suggested that VMMC reduces the risk of HIV acquisition by between 57 percent and 61 percent (Auvert 2013).
In addition to reducing the risk of HIV acquisition among circumcised men, VMMC provides other health benefits to both men and to women. Evidence shows that VMMC reduces incidence of some STIs, particularly ulcerative STIs, including chancroid, herpes, and syphilis, as well as balanitis, phimosis, and penile cancer.
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. Tears to the mucosal layer of the internal foreskin may increase vulnerability to HIV infection, as well as other STIs. Circumcision removes the 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. One of the primary benefits of VMMC for female partners is its association with a reduction in penile human papillomavirus (HPV), which is associated with cervical cancer in female partners (Wawer 2011). As more men are circumcised, women’s likelihood of sexual exposure to HIV decreases, along with their risk of HIV infection. The indirect protection for women is substantial, and modeling at a level of 80 percent circumcision coverage shows that an approximately equal number of HIV infections will be averted in women as in men after 15 years (Njeuhmeli 2011).
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 could avert up to 3.4 million new HIV infections in Eastern and Southern Africa within five years (22% of all new infections in the region). The 11.7 million VMMC procedures conducted to date are projected to avert 335,000 HIV infections by 2025 (WHO Brief 2016). In Zimbabwe, it is estimated that only four circumcisions will avert one HIV infection. Programs should target boys (10 to 14 years old) and adult men (15 to 49 years old) during this catch-up and scale-up period, since 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. In the longer term, priority countries will transition from adult and adolescent circumcision to neonatal circumcision.
Though VMMC protects against HIV acquisition rather than HIV transmission, the 2007 WHO guidelines acknowledge that HIV-positive men should not be denied VMMC, since this may increase stigma or encourage them to have untrained providers conduct the procedure. HIV status does not seem to affect adverse events, complications, or wound healing (Kigozi 2014). VMMC in HIV-positive men who have not taken antiretroviral therapy has not been shown to lead to an increase in viral load or viral shedding over the long term, though viral shedding does increase prior to wound healing (Odoyo-June 2013). VMMC should not be withheld from healthy HIV-positive males, but HIV testing should be offered and encouraged to all men. HIV-positive men who wish to be circumcised need to be counseled, so that they understand that male circumcision will not lower the risk of transmitting HIV to their sexual partners; that circumcision will not reverse their own HIV status; and that resuming unprotected sex before full wound healing will increase the risk of HIV transmission. Men—and women—should be educated about the importance of not resuming sex until six weeks after the procedure and the wound is fully healed (Hewett 2012). Data are inconclusive as to whether 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. Communication activities are an important component of demand generation. These activities are key to educating clients, partners, and communities on the benefits and disadvantages of VMMC, and reinforcing the importance of safe healing and sustaining safer sexual behaviors.
VMMC programs have increasingly incorporated demand creation activities within development and scale-up of clinical services. Communication activities have expanded beyond small group community mobilization and interpersonal communication to broader campaigns using mass media such as radio, TV, billboards, and posters (Hatzold 2014). Assessments of demand creation initiatives have generated practical tools, such as case studies and templates for communication with diverse audiences, including men at risk of HIV, women, and other key community members who may influence men's decisions.
VMMC policies and programs have required an intensive, short-term investment of human resources, logistical capacity, and funding. A range of creative solutions have been implemented and evaluated in an effort to improve the efficiency and quality of VMMC services. Engaging stakeholders is critical to ensure that local leaders understand and support VMMC, and that clients and other community members receive correct information about partial effectiveness, healing, and other critical aspects of VMMC’s benefits and limitations. Engaging women and girls is also important, and is a growing aspect of outreach in some programs.
A wide range of technical guidelines, toolkits, and training materials is available to support VMMC activities. Guidance and didactic materials are available on program planning, adverse events, site operations, VMMC with use of local anesthesia for adults and infants, optimizing volume and efficiency, legal and regulatory issues, and scale-up, among other topics.
Current Status of Implementation Experience
WHO and UNAIDS identified 14 countries in Eastern and Southern Africa with high rates of HIV prevalence and low rates of male circumcision; and recommended that VMMC should be taken to scale as quickly and as safely as possible in these settings. From 2008–2015, nearly 11.7 million cumulative VMMCs were performed for HIV prevention in the 14 priority countries, more than 60 percent of them in the prime target population of males aged 15 years and older. The two main targets of VMMC 2021 align with the UNAIDS fast track goals: first, that by 2021, 90 percent of males ages 10- to 29 years will have been circumcised in priority settings in sub-Saharan Africa; and second, that 90 percent of 10- to 29-year-old males will have accessed health services tailored to their needs.
Priority countries, governments, and implementers have progressed at different paces. However, most countries now include national policies or guidance on VMMC among national HIV prevention strategies, as well as plans and tools to guide implementation, monitoring, and evaluation. Rollout of VMMC services has also varied between and within countries. Some countries have met, and even exceeded, VMMC targets. For example, in 2015, Ethiopia, Kenya, and Tanzania surpassed the targets set in 2011, whereas Mozambique, South Africa, Uganda, and Zambia all attained 50 percent of the targeted cumulative number of VMMCs. The number of VMMCs performed increased between 2014 and 2015 in five countries (Kenya, Malawi, Namibia, South Africa and Swaziland), but decreased during the same period in all other priority countries.
WHO notes that these decreases have occurred against a backdrop of 2.5 million men being circumcised in just three years, and that these circumcisions can be attributed to both availability of services and demand for them. Programs need to develop new approaches to understand and build on men's varying motivations to be circumcised (aside from early adopters). Based on the current status of VMMC implementation experiences and results, PEPFAR is recommending that national programs prioritize clients aged 15–29 years for immediate impact, and aim for 80 percent coverage in that group over a very short time.
Monitoring and evaluation of program implementation has generated a substantial evidence base that has informed program planning, implementation, and scale-up. Use of multiple beds in an assembly line, task shifting, and task sharing have been shown to improve clinical efficiency. Modeling suggests that task shifting and task sharing are key drivers of efficiency as VMMC programs scale up, given that personnel costs are the highest component of cost (Bollinger 2014). Program assessments in Kenya, South Africa, Tanzania, and Zimbabwe showed that while safe, high-quality VMMC services could be delivered and sustained at scale, quality varied across service settings during rapid expansion, and not all met readiness and quality standards. (Rech 2014; Jennings 2014).
Countries are also using different service modalities and technologies to expand access. From 2009–2012, activities to increase VMMC uptake in Tanzania and Zimbabwe included fixed, outreach and mobile services as well as campaigns. In Tanzania, most clients receiving VMMC during campaigns were 10–14 years old, while most in routine services were older than 15. In Zimbabwe, almost twice as many clients received VMMC during mobile campaigns (64%) as during routine services (36%) (Ashengo 2014). Tanzania successfully used geographic information systems to plan where to locate VMMC campaigns and mobile services (Mahler 2015).
The 2013 WHO guidelines on the use of non-surgical devices indicate that they are safe, efficacious, and acceptable for men aged 18 years and older when they are used by health care providers, and where surgical backup and skills are available. The guidelines also outline program considerations, and have helped expand use of these devices, which are intended to make VMMC more cost-effective, safer, and easier to implement, while requiring a shorter recovery time.
To reduce the risk of tetanus during VMMC, WHO mandated a dual protection approach that includes clean wound care and vaccination with tetanus toxoid-containing vaccine, to ensure that all patients are adequately protected against tetanus before circumcision (WHO Informal Consultation on Tetanus and Voluntary Medical Male Cicumcision, 2015).
Information on acceptability, including perceptions of VMMC in relation to traditional ideas of manhood and its effects on sexual pleasure, have helped VMMC programs and communication campaigns to be sensitive and responsive to these issues. Women and men in Kenya viewed VMMC as both hygienic and effective for HIV prevention, and this is a main motivator (Riess 2014). A study in Zimbabwe on barriers and motivators to uptake indicated that demand creation messages should be tailored to different ages; address men’s fear of pain; and emphasize benefits aside from HIV prevention, such as improved hygiene and sexual appeal. It also recommended promoting VMMC among women, who influence men’s decisions (Hatzold 2014). Community members in a traditionally non-circumcising community in Kenya echoed these perceptions, and also associated VMMC with modernity (MacIntyre 2014). Some women in Kisumu, Kenya maintained that circumcised partners increased their sexual satisfaction (Riess 2014).
Despite initial concerns, there has been little evidence of greater sexual risk-taking among men who have been circumcised (Gray 2012, Mattson 2008; Westercamp 2014). Several studies did show that a portion of clients will resume sex early, and that programs must continue to reinforce the importance of abstinence until wounds are completely healed (Hewett 2012; Kigozi 2014; Odoyo-June 2013). Programs must also monitor the possible negative impacts of VMMC on women, including their ability to negotiate safer sex.