In the mid-2000s, male circumcision was found to reduce the female-to-male sexual transmission of HIV by 60%.1
Since 2007, the World Health Organization (WHO) and UNAIDS have recommended voluntary medical male circumcision (VMMC) as a key component of HIV prevention in countries with a high HIV prevalence and low levels of male circumcision.
As a result, to date 14 countries in Southern and Eastern Africa have initiated programmes to expand the provision of male circumcision (Botswana, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe).2
WHO recommendations for the implementation of VMMC
This massive public health intervention called for 80% coverage of male circumcision by 2016 in the 14 priority countries (aiming to reach 20.8 million people).3
It was estimated that performing this number of circumcisions would cost US$1.5 billion but would lead to savings of US$16.5 billion by 2025 due to averted HIV treatment and care costs. 80% VMMC coverage would also prevent up to 3.4 million new HIV infections.4
Who should VMMC programmes target?
The WHO and UNAIDS recommend the implementation of VMMC programmes in countries where they will have the greatest public health benefit.
These include countries with a high HIV prevalence among the general population (over 15%) and where the vast majority of men are not circumcised (80%). VMMC is also recommended in countries where HIV prevalence is between 3% and 15% among the general population where HIV transmission occurs primarily via heterosexual sex.5
VMMC is thought to have a limited public health benefit if introduced among key affected populations such as sex workers, people who inject drugs (sometimes referred to as PWID) and men who have sex with men (sometimes referred to as MSM).6 However, individual men may benefit if they are at a higher risk of heterosexual HIV transmission because they are in a mixed-status relationship.7
Making VMMC programmes work
The male circumcision procedure only partially protects men from HIV transmission.
Therefore it is recommended that VMMC is included as part of a comprehensive HIV prevention strategy which includes HIV testing and counselling; treatment for sexually transmitted infections (STIs); the promotion of safer sex practices and the distribution of condoms as well as their correct and consistent use.8
Providing antiretroviral treatment (ART) to people living with HIV should also be considered to reduce HIV transmission among mixed status couples.9
Countries are also advised to offer VMMC free of charge or at the lowest possible cost to the client, as for other HIV services. Experts have also stressed the need for:
- culturally appropriate strategies
- well-trained practitioners working in sanitary conditions
- informed consent, confidentiality and absence of coercion
- counselling for men and their sexual partners to prevent them developing a false sense of security.10
Maximising public health benefit
UNAIDS and the WHO advise that the greatest public health benefit from VMMC would result from prioritising circumcision for young males (between 12 and 30 years of age).
One study has highlighted the benefits of prioritising male circumcision among adolescents rather than adults. This is because:
- in many places, it is more acceptable both culturally and socially for adolescents to be circumcised than adults
- if performed before becoming sexually active, the benefits of VMMC are long-term for both the individual and wider public health
- if VMMC occurs before an individual starts engaging in sexual relationships there are fewer concerns about sexual abstinence and it allows enough time for the wound to heal.11
In 2010, UNAIDS emphasised the need to reach older men in order to achieve the 80% coverage target and to maximise the population-wide prevention benefits of VMMC.12 The circumcision of newborn babies has also been put forward as a longer-term strategy to combat the HIV epidemic.13
Progress made in VMMC for HIV prevention
Since 2009, over 10 million men have received VMMC services in the priority sub-Saharan African countries.14 In 2014, there was a rapid scale up of VMMC services with 3 million circumcisions performed that year alone.15
Despite this progress, it is unlikely that the ambitious target of 20.8 million circumcisions by 2016 will be reached. Progress also varies significantly across priority countries. For example, Ethiopia and Kenya have exceeded their 80% VMMC coverage targets and in July 2015, Tanzania was in reach of this target. By comparison, Lesotho, Malawi, Namibia, Rwanda and Zimbabwe still have very low coverage – ranging from 6% to 26%.16
The Central African Republic and South Sudan have also been identified as high priority countries in need of VMMC programmes.17 The new UNAIDS Fast-Track strategy demands that an additional 27 million men are circumcised by 2020 on 2014 levels18
A few of the most high profile VMMC programmes are detailed below.
High profile VMMC programmes
Kenya launched its VMMC programme in 2008. It aimed to conduct 860,000 circumcisions by July 2013 (80% coverage).
Between 2008 and 2013, the number of annual operations conducted increased dramatically from 8,000 to 190,000.19 The country fell just short of its target, reaching 800,000 men (71%) but achieved its coverage goal in the Nyanza region where most of the implementation took place.20
The next phase of Kenya’s VMMC strategy aims to see 95% of men aged 15 to 49 years circumcised by 2019. Other key areas of focus include offering age-appropriate services for young infants aged 0 to 60 days and adolescents (10 to 14 years). The country also aims to encourage safer surgical practices among traditionally circumcising communities.21
In 2009, the Lesotho Demographic and Health Survey found that only 37% of men, compared to 66% of women, had ever been tested for HIV. With one of the world's biggest generalised HIV epidemics, VMMC was viewed primarily as another means of increasing HIV testing uptake among men.22
Launched in March 2012, Lesotho’s VMMC programme now performs circumcisions in 18 hospitals and private clinics as well as outreach sites at over 100 health centres. By the end of 2014, nearly 85,000 men received VMMC as part of comprehensive HIV prevention services, with 56% of this number also tested for HIV.23
However, a review conducted in 2013 found that a high percentage were lost to follow-up. To improve the situation, active links to treatment and care were introduced in October 2013, and were expanded in March 2014.24
- CHAPS, Johannesburg, South Africa
In 2010, following successful VMMC trials, the Centre for HIV and AIDS Prevention Studies (CHAPS) was established in Orange Farm, a township outside Johannesburg, to contribute to the roll-out of South Africa’s national VMMC programme.25
However, at this time, the healthcare system was still coping with the rapid expansion of ART and a chronic shortage of health workers. To ensure the expansion of the programme, CHAPS and the National Department of Health selected private sector clinics in high priority areas and trained private providers to deliver free VMMC.26
To date, CHAPS has trained and partnered with 12 private practitioners. Between 2012 and 2015, nearly 250,000 circumcisions were performed by CHAPS, with private practitioners accounting for 60,000 of this total.27
Due to its success, CHAPS has supported the launch of a similar programme in Swaziland and provided advice to partners of Namibia’s VMMC programme.28
Scaling up VMMC programmes
A number of suggestions have been made in order to accelerate and maximise the impact of VMMC, including:
- promoting VMMC as cost-effective in order to secure more funding from donors29
- allowing VMMC to be performed by nurses and other healthcare workers (task shifting)30
- prioritising sub-populations (for example by age or geography) in order to maximise a programme's impact and efficiency, for example men over the age of 2531
- exploring the role of technologies in order to make circumcision more attractive to men.32 One device called PrePex is discussed below.
In 2013, the WHO approved the first adult circumcision device for use in low-resource settings called Prepex.
PrePex is an elastic ring device that requires no injected local anaesthetic and can be placed and removed by trained mid-level healthcare workers. It works by stopping the flow of blood to the foreskin due to the compressive force of the elastic ring. Eventually the foreskin tissue dies and can be easily removed after one week.33 It is hoped that the device will accelerate the scale up of VMMC in low-income countries and relieve the demands placed on the limited number of healthcare workers.34
In April 2014, the device was introduced in Zimbabwe as an alternative to surgery. In a study of 500 men who had undergone a PrePex circumcision, 93% said they would recommend it to their peers. More than 12,000 men in the country are thought to have benefitted from PrePex since its introduction.35
Innovations such as this can play a key role in helping priority countries circumcise an additional 27 million men by 2020.36
Increasing uptake of VMMC programmes
Community mobilisers and peer education
Using members of the community to provide one-on-one messaging to potential VMMC clients has been one of the most effective strategies. It allows men who are thinking about the procedure to ask questions in private.37
In Kenya, the Impact Research and Development Organisation has produced a toolkit to support counsellors to provide tailored information to the individual’s stage in the decision-making process. In Malawi, satisfied clients have been employed as community mobilisers.38
Counselling women on the benefits of VMMC is recognised as important in increasing uptake in most priority countries. Kenya has gone a step further by using married women to educate other women and couples about VMMC in women’s groups, antenatal clinics and other healthcare settings.39
In Tanzania, radio spots and print materials tailored to different regions feature the voices of “satisfied customers” and local health experts.40 Another programme has used geographic information systems (GIS) to map VMMC activities in order to identify areas to increase awareness among unreached populations.41
The benefits and challenges of VMMC
VMMC is cost-effective
Male circumcision is a one-off procedure and therefore, unlike ART, has no ongoing costs. Once a man has undergone the procedure, he will benefit from the preventive effect for the rest of his life.44
VMMC is also cost-effective as it averts new HIV infections, thereby reducing the number of people needing HIV treatment and care.45 The WHO estimates that US$16.5 billion could be saved in HIV treatment and care costs by 2025 if coverage targets are met.
At the country level, one study from Tanzania reported the average cost of VMMC per person to be $46. It was also estimated that maintaining current levels of VMMC (88%) in the country would equate to savings of roughly $4,200 per HIV infection averted between 2010 and 2025.46
While male circumcision has been found to reduce the female-to-male sexual transmission of HIV, circumcised men can still become infected with HIV, and if HIV-positive, can infect others. The WHO makes it clear that:
"Male circumcision should never replace other known effective prevention methods and should always be considered as part of a comprehensive prevention package, which includes correct and consistent use of male or female condoms, reduction in the number of sexual partners, delaying the onset of sexual relations, and HIV testing and counselling." 47
In some places, it has been reported that circumcision is mistakenly viewed as providing complete protection from HIV and a viable alternative to more effective forms of protection such as condoms.48
Male circumcision is one of the oldest and most common surgical procedures worldwide. It is not only undertaken for medical reasons but also for religious, cultural and social ones.49
In Eastern and Southern Africa where nationwide VMMC has been scaled up, high acceptance levels have been reported among men.50
VMMC has also been very well received by the partners of newly circumcised men. In Nyanza province, Kenya, 77% of women preferred their sexual partner to be circumcised.51 Likewise, in South Africa, 78% of women in the 2011 Youth Sex Survey preferred circumcised men.52
While male circumcision is normal practice in many communities, many cultures have no tradition of male circumcision, and some are strongly opposed to it. For example, studies of traditionally non-circumcising communities have found that older married men do not consider themselves at risk of acquiring HIV and view circumcision as more appropriate for younger men.53
In these settings, some argue that promoting circumcision as a modern medical procedure rather than as a cultural process, may increase uptake.54
The effects on risk taking
Circumcision is mistakenly viewed by some as a fully protective measure against HIV transmission, and there are concerns that men who have been circumcised may be more inclined to engage in risky behaviours. For example, they may stop using condoms.55
However, to date, no significant links have been made between the provision of VMMC and a decline in condom use. One study from Zambia showed a marginal increase in the prevalence of risky behaviour following the implementation of VMMC. However, the same study also reported more protective behaviours among other circumcised men.56
In some places (such as Lesotho), VMMC acts as a critical gateway to HIV testing, treatment and care. As a result, men can learn their HIV status and reduce the risk of onwards transmission to others.57
Hazards of the procedure
Unlike other HIV prevention methods, male circumcision requires medical intervention. To carry out the procedure safely requires the right level of training and resources. Poorly performed male circumcision can lead to bleeding and damage to the penis. Moreover, if tools are not sterilised properly before each use, they can transmit HIV.58
The potential risk involved in medical interventions such as male circumcision is a concern for some as VMMC continues to be scaled up across much of sub-Saharan Africa.59 60 In June 2010, 20 deaths were linked to unregulated circumcisions performed by unqualified surgeons in Eastern Cape province, South Africa.61
Moreover, because newly circumcised men have to wait a few weeks for their wounds to heal before having sex, they are at greater risk of HIV infection from an HIV-positive partner if they don't abstain.62
Preventing the transmission of STIs
Sexually transmitted infections are believed to be more common among uncircumcised men and lead to a greater risk of HIV transmission.63 Male circumcision has been shown to reduce the transmission of other STIs
For example, a trial conducted in Rakai, Uganda, found that in addition to reducing the incidence of HIV infection, male circumcision also reduced the incidence of herpes simplex virus type 2 (HSV-2) and the prevalence of human papillomavirus (HPV) among adolescents and adult males.64
Male circumcision and perceptions of female genital mutilation (FGM)
In communities where FGM is practiced and VMMC is offered, some incorrectly believe that FGM can also reduce the risk of HIV transmission.65
One survey of 494 women from communities in Kenya, Namibia, South Africa, Swaziland and Uganda found that almost one in four thought FGM could protect women from HIV.66
FGM has no health benefits and does not protect against HIV. In fact, FGM increases a woman's risk of HIV transmission.67
Photo credit: Photo by Gil Eilam/CC BY-NC-ND 2.0
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