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

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

• Lesotho

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.

PrePex

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

Media involvement

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

In Kenya, journalists have been trained to report accurately on the science behind VMMC, while Zambia has incorporated key VMMC messages into radio magazine broadcasts. 42 43