Assessing Voluntary Medical Male Circumcision for HIV Prevention in a Unprecendented Public Health Intervention

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PLOS launches a new collection, Voluntary Medical Male Circumcision for HIV Prevention: Improving Quality, Efficiency, Cost Effectiveness, and Demand for Services during an Accelerated Scale-up, which focuses on the challenges and opportunities of a large scale public health intervention. Dr. Emmanuel Njeuhmeli and Dr. Rhona MacDonald discuss the implementation and outcomes of the program so far.

Voluntary medical male circumcision (VMMC) – a surgical procedure that involves the complete removal of the foreskin by a trained medical professional – has been shown to be effective in the prevention of HIV transmission.

Image Credit: (left) Sgt. Adam Fischman, US Army Africa & (right) Sterling Riber, MFDI for Jhpiego/Tanzania

Image Credit: (left) Sgt. Adam Fischman, US Army Africa & (right) Sterling Riber, MFDI for Jhpiego/Tanzania

In 2007, WHO and the Joint United Nations Programme on HIV /AIDS  recommended that 14 priority countries with high HIV and low male circumcision prevalence in Southern and Eastern Africa consider implementing VMMC as a key intervention in their HIV prevention portfolio.

This massive public health intervention launched in 2009 with support from WHO/UNAIDS calling for 80% coverage of male circumcision by 2016. Although the growth of VMMC programs has dramatically increased over recent years, it appears that the coverage goal will be unattainable by 2016.

This new PLOS Collection focuses on the challenges and opportunities for these programs. Containing a comprehensive PLOS Medicine review, plus 13 original PLOS ONE research articles, the collection provides recommendations to enable a more sustainable and flexible scale-up strategy.

PLOS Medicine Senior Editor Dr. Rhona MacDonald interviewed Dr. Emmanuel Njeuhmeli, Senior Biomedical Prevention Advisor at USAID and key author of the Collection to find out more.

What follows are excerpts from an extended interview which can be found here.

 

RM: Why is VMMC and scale –up of the programs of such importance?

EN: Circumcised men greatly reduce their risk of acquiring HIV and many other sexually transmitted infections (STIs), such as herpes, syphilis and human papilloma virus (HPV). In addition, female partners of circumcised men also have benefits, including lower rates of cervical cancer (the leading cancer killer among African women) and bacterial vaginosis, a condition that has been associated with pre-term birth.

Scale-up of VMMC is critically important to reduce the future burden of HIV, particularly in high prevalence regions, such as Eastern and Southern Africa. HIV infections are happening every day among uncircumcised men in the region and this can easily be prevented. Each day that this proven prevention method is not brought to scale represents a missed opportunity to bring us closer to reaching an AIDS-free generation.

 

RM: What progress has been made through the VMMC programs?

EN: On December 1, 2011, President Barack Obama challenged the President’s Emergency Plan for AIDS Relief (PEPFAR) to achieve 4.7 million VMMCs by the end of 2013. PEPFAR programs across the 14 VMMC priority countries in Eastern and Southern Africa had reached approximately 850,000 males over the past four years, and the President’s target called for a four-fold program expansion in half the time. The good news is that PEPFAR has met the President’s target of 4.7 million

Despite our successes to date, we have reached only one-third of the 20.3 million interventions needed to achieve the maximum public health benefit by the end of 2016.

 

RM: What are the key challenges to implementing VMMC as identified by the articles in the Collection?

EN: There are many. The goals to accelerate scale-up are ambitious and it’s critical that we assure consistent safety and overall quality of services. Furthermore, since being circumcised involves deep-seated values, beliefs, and motivational factors that vary with ethnic, religious, and cultural identities, sensitive approaches are required to ethically and responsibly aid boys and men and entire communities in their consideration of VMMC. Resource and capacity constraints also pose a serious challenge for countries hoping to reach their scale-up goals.

 

RM: What are the next steps?

EN: We need to increase program efficiency by identifying and prioritizing those most at risk of acquiring HIV. We need to focus on program efficiency and quality at all levels and assures a good match between supply and demand. We need to encourage VMMC programs to further strengthen linkages with ART programs. And, finally we need to strategize for the sustainability phase of the program and finally.

Our work is just beginning.

 

Please view the Collection here: www.ploscollections.org/VMMC2014

 

This Collection is a joint collaboration between PLOS and the U.S. President’s Emergency Plan for AIDS Relief (through the U.S. Agency for International Development, the Centers for Disease Control and Prevention, and the Department of Defense), the Bill & Melinda Gates Foundation, PEPFAR implementing partners, and the Ministries of Health in Kenya, Tanzania, Zimbabwe, and South Africa.

 

Dr. Rhona MacDonald is Senior Editor for PLOS Medicine and PLOS Collections.

Dr. Emmanuel Njeuhmeli is the Senior Biomedical Prevention Advisor in the USAID Office of HIV/AIDS.

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