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Voluntary Medical Male Circumcision (VMMC) for HIV Prevention
As a result, since 2007, the World Health Organisation (WHO) and UNAIDS have recommended voluntary medical male circumcision (VMMC) as a key component of HIV prevention in countries with high HIV prevalence and low levels of male circumcision.
To date, 14 countries in Southern and Eastern Africa have initiated programmes to expand the provision of male circumcision ( Botswana, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe). 2
WHO recommendations for the implementation of VMMC for HIV prevention
Launched in 2009, this massive public health intervention called for 80 percent coverage of male circumcision by 2016 (20.8 million). 3 It was estimated that performing this number of circumcisions would cost $1.5 billion but would lead to savings of $16.5 billion by 2025 due to averted treatment and care costs. It is thought that 80 percent VMMC coverage would prevent up to 3.4 million new HIV infections. 4
Who should VMMC programmes target?
WHO and UNAIDS recommend VMMC programmes in countries where it will have the greatest public health benefit. These include countries with a high HIV prevalence among the general population (over 15 percent) and where the vast majority of men are not circumcised (80 percent). VMMC is also recommended in countries where HIV prevalence is between 3 and 15 percent among the general population where HIV transmission occurs primarily via heterosexual transmission. 5
VMMC is thought to have limited public health benefit if introduced among key affected groups such as sex workers, people who inject drugs and men who have sex with men (MSM). Moreover, there is insufficient evidence that circumcision reduces HIV transmission among MSM. 6
Making VMMC programmes work
Because the male circumcision procedure only partially protects men from HIV transmission, 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; the promotion of safe sex practices and the distribution of condoms as well as their correct and consistent use. 8
Countries are also advised to offer VMMC free of charge or at the lowest possible cost to the client, as per 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 of men and their sexual partners to prevent them developing a false sense of security. 9
UNAIDS and WHO advise that the greatest public health benefit would result from prioritising circumcision for young males (between 12-30 years of age). One study has highlighted the benefits of prioritising male circumcision among adolescents rather than adults:
- 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. 10
In 2010, UNAIDS emphasised the need to reach older men in order to achieve the 80 percent coverage target and to maximise the population-wide prevention benefits of VMMC. 11 The circumcision of newborn babies has also been put forward as a longer-term strategy to combating the HIV epidemic. 12
Scaling up VMMC programmes
It is projected that circumcising 80 percent of all uncircumcised men in countries with high HIV prevalence and low male circumcision by 2015 would avert one in 5 HIV infections by 2025 and have long-term benefits for both men and women. 13 While VMMC programmes have grown dramatically, particularly in the last few years, it is unlikely this goal will be reached.
A number of suggestions have been made in order to accelerate and maximise the impact of VMMC, including:
- promote VMMC as cost-effective in order to secure more funding from donors 14
- allowing VMMC to be performed by nurses and other healthcare workers (task shifting) 15
- VMMC uptake is low among men aged over 25. Programmes need to prioritise sub-populations (e.g. by age, geography etc.) in order to maximise a programmes impact and efficiency 16
- studies need to explore the role of technologies in order to make circumcision more attractive to men. 17 One device called PrePex is discussed below.
In 2013, 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 removed easily after one week. 18
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. 19 In 2014, the device was scaled up in Rwanda and Zimbabwe following pilot studies funded by PEPFAR and the Bill & Melinda Gates Foundation. 20 21
The benefits and challenges of VMMC as an HIV prevention strategy
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. 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.” 22
Male circumcision is one of the oldest and most common surgical procedures worldwide. It is not only undertaken for medical reasons but also religious, cultural and social ones. 24
Indeed, male circumcision is normal practice in many communities. However, many cultures have no tradition of male circumcision, and some are strongly opposed to it. As as a result, acceptance varies greatly across the world. In addition, some men will have personal reasons for rejecting circumcision, even if their culture allows it. 25
Despite this, in Eastern and Southern Africa where nation-wide VMMC has been implemented, high acceptance levels have been reported among men. 26 VMMC has also been received very well by the partners of uncircumcised men. In Nyanza province, Kenya, 77 percent of women preferred that their sexual partner to be circumcised. 27 Likewise, in South Africa, 78 percent of women in the 2011 Youth Sex Survey preferred circumcised men. 28
The effects on risk taking
Because circumcision is mistakenly viewed by some as a fully protective measure against HIV transmission, 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 or visit sex workers more frequently. 29
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. 30
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. 31
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 serious bleeding and damage to the penis. Moreover, if tools are not sterilised properly before each use they can spread HIV. 32
The potential of risk compensation among users of medical interventions such as male circumcision is a concern for many as VMMC continues to be scaled up across much of sub-Saharan Africa. 33 34 In June 2010, 20 deaths were linked to unregulated circumcisions performed by unqualified surgeons in Eastern Cape province, South Africa. 35
Moreover, because newly circumcised men have to wait a few weeks for their wounds to heal before having sex, in the intervening period, HIV-positive men can pass HIV on to their female partners. 36
Preventing the transmission of other sexually transmitted infections (STIs)
Sexually transmitted infections are believed to be more common among uncircumcised men. STIs lead to a greater risk of HIV transmission. 37 Indeed, male circumcision has been shown to reduce the transmission of other sexually transmitted infections.
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 adolescent and adult males. 38
VMMC is very cost-effective
Male circumcision is a one-off procedure therefore unlike antiretroviral treatment, has no on-going costs. Once a man has undergone the procedure, he will benefit from the preventive effect for the rest of his life. 39
Moreover, VMMC is thought to be highly cost-effective as it averts new HIV infections thereby reducing the number of people needing HIV treatment and care. 40 One study from Tanzania reported the average cost of VMMC per person to be $46. Moreover, it was estimated that maintaining current levels of VMMC (88 percent) in Tanzania would equate to savings of roughly $4200 per HIV infection averted between 2010 and 2025. 41
Male circumcision and perceptions of female genital cutting (FGC)
In communities where FGC is practiced and male circumcision for HIV prevention is offered, some incorrectly believe that FGC can also reduce the risk of HIV transmission. 42
FGC has no health benefits and does not protect against HIV. In fact, FGC increases a woman's risk of HIV transmission. 44
Progress made in VMMC for HIV prevention
Since 2008, over 5.8 million male circumcisions have been performed in the 14 priority sub-Saharan African countries. There has been a particularly rapid scaling up of VMMC since 2012 that has seen the number of circumcisions conducted almost double. 45
Despite this shift in pace, it is unlikely that the ambitious target of 20.8 million males circumcised by 2016 will be achieved. Moreover, progress varies significantly across priority countries. For example, Ethiopia and Kenya have reached 57 percent and 63 percent of their VMMC coverage targets respectively. By comparison, Lesotho, Malawi, Namibia, Rwanda and Zimbabwe have not reached 10 percent of their respective targets. 46 A few of the main VMMC programmes are detailed below.
High profile VMMC programmes
Kenya launched its VMMC for HIV prevention programme in 2008. It aimed to conduct 860,000 circumcisions by July 2013 (80 percent coverage). Between 2008 and 2013, the number of annual operations conducted increased dramatically from 8000 to 190,000. 47 The vast majority of these operations were conducted in Nyanza province (80 percent) where nearly half of all uncircumcised men in Kenya live. 48
Overall, the VMMC programme in Kenya has been a success despite coverage falling short of its target. It has been acknowledged that as more young people enter adolescence, there is a greater need to ensure the sustainability of the programme. 49 In recognition of this, the next phases of Kenya's VMMc programme intend to target males under the age of 15 and infants. 50
- South Africa
In 2010, South Africa launched a nationwide VMMC programme that aimed to reach 4.3 million HIV-negative men by 2016 (80 percent coverage). By April 2011, 150,000 VMMCs had been conducted, with one new HIV infection averted for every 5 operations. 51
In contrast to Kenya, South Africa has been much slower in scaling up its provision of VMMC services facing a number of challenges. Whereas the policy of task shifting has allowed the rapid scaling up of antiretroviral treatment in the country, only medical doctors are authorised to perform VMMC. 52
More recently, the scaling up of VMMC services in South Africa has been associated with a reduction in the quality of services including the readiness of facilities and the actual quality of the surgical care provided. 53
In 2009, the Lesotho Demographic and Health Survey found that only 37 percent of men, compared to 66 percent of women, had ever been tested for HIV. In Lesotho, which has one of the world's biggest generalised HIV epidemics, VMMC was viewed primarily as another means of increasing the uptake of HIV testing among men. 54
Lesotho launched its VMMC programme in March 2012 funded by PEPFAR and USAID. Since then, the programme has provided HIV testing and counselling to 97 percent of VMMC clients for HIV. 55 Moreover, by February 2013, the programme had circumcised over 11,000 men with up to 2000 new HIV infections thought to have been averted. 56
- 1. Auvert, B. et al (2005) ' Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial' 2(11):e298
- 2. WHO (2012) ' Voluntary medical male circumcision for HIV prevention'
- 3. PLOS Collections (2014) ' Assessing Voluntary Medical Male Circumcision for HIV Prevention in a Unprecendented Public Health Intervention'
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- 8. WHO & UNAIDS (2007) ' WHO and UNAIDS announce recommendations from expert consultation on male circumcision for HIV prevention'
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- 10. Njeuhmeli Emmanuel, M.D. et al (2014) ' Lessons Learned From Scale-Up of Voluntary Medical Male Circumcision Focusing on Adolescents: Benefits, Challenges, and Potential Opportunities for Linkages With Adolescent HIV, Sexual, and Reproductive Health Services' JAIDS Journal 66:193-199
- 11. UNAIDS (2011) ' Nearly 50% of people who are eligible for antiretroviral therapy now have access to lifesaving treatment'
- 12. Binagwaho, A. et al (2010) ' Male circumcision at different ages in Rwanda: a cost-effectiveness study' PLOS Medicine 7(1)
- 13. Njeuhmeli, E. et al. (2011) ' Voluntary Medical Male Circumcision: Modeling the Impact and Cost of Expanding Male Circumcision for HIV Prevention in Eastern and Southern Africa' PLOS Medicine 8(11)
- 14. Kikaya, V. et al (2014) ' Voluntary Medical Male Circumcision Programs Can Address Low HIV Testing and Counseling Usage and ART Enrollment among Young Men: Lessons from Lesotho' PLOS One 9(5):e83614
- 15. WHO (2010) ' Considerations for implementing models for optimizing the volume and efficiency of male circumcision services'
- 16. Plotkin, M. et al (2013) ' “Man, what took you so long?” Social and individual factors affecting adult attendance at voluntary medical male circumcision services in Tanzania' Global Health: Science and Practice 1(1):108-116
- 17. Sgaier, S.K. et al (2014) ' Achieving the HIV Prevention Impact of Voluntary Medical Male Circumcision: Lessons and Challenges for Managing Programs' 11(5):e10001641
- 18. CIRCLIST (2008, 8 March) ' The PrePex™ device'
- 19. UNAIDS (2013) ' Global Report 2013'
- 20. Ministry of Health (2013, 26 November) ' Rwanda Becomes the First Country to Launch Nationwide Scale-Up of Non-Surgical Adult Male Circumcision to Reduce HIV Infection'
- 21. SHARE (2013, 7 July) ' Zimbabwe: Govt to introduce less painful male circumcision'
- 22. WHO & UNAIDS (2007, 23 February) ' WHO and UNAIDS Secretariat welcome corroborating findings of trials assessing impact of male circumcision on HIV risk'
- 23. IRIN Africa (2008, 31 July) ' SWAZILAND: Circumcision gives men an excuse not to use condoms'
- 24. UNAIDS (2007) ' Male circumcision: global trends and determinants of prevalence, safety and acceptability'
- 25. UNAIDS (2007) ' Male circumcision: global trends and determinants of prevalence, safety and acceptability'
- 26. CDC (2013, 29 November) ' Voluntary Medical Male Circumcision — Southern and Eastern Africa, 2010–2012'
- 27. Carter, M. (2014, 6 June) ' Three-quarters of women interviewed in Kenya's highest prevalence province say they prefer circumcised partners' Aidsmap
- 28. Praekelt Foundation (2011) ' YoungAfricaLive Youth Sex Survey'
- 29. AIDSMEDS (2014, 29 July) ' Male Circumcision Doesn’t Raise Sexual Risk-Taking in Zambia'
- 30. Hewitt, P.C. et al (2014) ' Assessing risk compensation post-male circumcision in Zambia's national program' MOPDC0105 - Poster Discussion Session, AIDS 2014
- 31. SHARE (2013, 2 July) ' Engaging Men in HIV Prevention, Care and Treatment in Lesotho: A Counselor’s Perspective'
- 32. WHO (2012) ' Factors associated with the safety of voluntary medical male circumcision in Nyanza province, Kenya'
- 33. Underhill, K. (2013) ' Study designs for identifying risk compensation behavior among users of biomedical HIV prevention technologies: balancing methodological rigor and research ethics' Social Science and Medicine 94:115-123
- 34. Wamai, R.G. (2011) ' Male circumcision for HIV prevention—current evidence and implementation in sub-Saharan Africa' JAIDS 14:49
- 35. BBC News (2010, 18 June) ' Circumcisions kill 20 boys in South Africa'
- 36. Differding, V. (2007) ' Women may be at heightened risk of HIV infection immediately after male partner is circumcised' Aidsmap
- 37. CDC (2013) ' Male Circumcision'
- 38. Tobian, A.A. et al (2009) ' Male circumcision for the prevention of HSV-2 and HPV infections and syphilis' The New England Journal of Medicine 360(13):1298-1309
- 39. MaleCircumcision.Org (2014) ' Scale-Up of Voluntary Medical Male Circumcision for HIV Prevention in Africa'
- 40. WHO (2012) ' Voluntary medical male circumcision for HIV prevention'
- 41. Menon, V. et al (2014) ' Costs and Impacts of Scaling up Voluntary Medical Male Circumcision in Tanzania' PLOS One 9(5):e83925
- 42. Women's HIV Prevention Tracking Project (2010) ' Making medical male circumcision work for women'
- 43. Women's HIV Prevention Tracking Project (2010) ' Making medical male circumcision work for women'
- 44. Womenshealth.gov (2009) ' Female genital cutting fact sheet'
- 45. UNAIDS (2013) ' Global Report 2013'
- 46. UNAIDS (2013) ' Global Report 2013'
- 47. UNGASS (2014) ' Kenya AIDS Response Progress Report 2014: Progress towards Zero'
- 48. NASCOP (2009) ' Kenya AIDS Indicator Survey 2007: Final Report'
- 49. Galbraith, J.S. et al (2014) ' Status of voluntary medical male circumcision in Kenya: findings from 2 nationally representative surveys in Kenya, 2007 and 2012' JAIDS 66(Supplement 1):37-45
- 50. CDC (2012) ' Progress in Voluntary Medical Male Circumcision Service Provision — Kenya, 2008–2011'
- 51. Njeuhmeli, E. et al (2011) ' Voluntary medical male circumcision: modelling the impact and cost of expanding male circumcision for HIV prevention in eastern and southern Africa' PLOS Medicine 8: e1001132
- 52. Mavhu, W. et al (2014) ' Provider Attitudes toward the Voluntary Medical Male Circumcision Scale-Up in Kenya, South Africa, Tanzania and Zimbabwe' PLOS One 9(5)
- 53. Rech, D. et al (2014) ' Implications of the Fast-Evolving Scale-Up of Adult Voluntary Medical Male Circumcision for Quality of Services in South Africa' PLOS One 9(5)
- 54. USAID (2010) ' Demographic and Health Survey 2009'
- 55. SHARE (2013, 2 July) ' Engaging Men in HIV Prevention, Care and Treatment in Lesotho: A Counselor’s Perspective'
- 56. Jhpiego (2014, 13 January) ' Lesotho Averts 2,000 New HIV Infections: MCHIP-Supported Program Reaches 10,000th Circumcision'
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