Dr Rhona MacDonald, Senior Editor at PLOS Medicine posed the following questions to Emmanuel Njeuhmeli, Senior Biomedical Prevention Advisor at the US Agency for International Development and lead author of the new PLOS Collection: Voluntary Medical Male Circumcision for HIV Prevention: Improving Quality, Efficiency, Cost Effectiveness, and Demand for Services during an Accelerated Scale-up.
RM: What is Voluntary Medical Male Circumcision and why is it so important?
EN: Voluntary medical male circumcision (VMMC) is a surgical procedure that involves the complete removal of the foreskin by a trained medical professional. Studies show that VMMC reduces female to male HIV transmission by approximately 60 percent. In 2007, WHO and UNAIDS recommended that 14 countries in Southern and Eastern Africa with high HIV and low male circumcision prevalence consider including VMMC as a key intervention in their HIV prevention portfolio. Mathematical modelling suggests circumcising 80 percent of the male population between the ages of 15-49 in these countries and sustaining this level of coverage to avert 3.36 million HIV infections among men and women in the next 15 years.
VMMC involves a one-time procedure and offers men life-long benefits, including greatly reducing 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. VMMC should be offered as part of a comprehensive package of HIV and reproductive health services. This includes education, HIV testing, counselling and linkages to care and treatment, provision of condoms and screening and treatment for STIs. Because it is only partially protective, men who are circumcised are strongly encouraged to use other precautions to reduce their risk of HIV exposure, including using condoms and reducing their number of sexual partners.
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 since the 2011 PLOS Collection and this latest work?
EN: The first collection was published in November 2011 just before the December launch of the WHO-UNAIDS Joint Strategic Action Framework for Acceleration of the Scale-up of VMMC. 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 VMMCs by doubling its reach year after year. In FY2011, it performed 880,000 VMMCs. In FY2012, it performed 1.7 million VMMCs and in FY2013, it performed 2.8 million VMMCs. To date, the East and Southern Africa regional VMMC program has achieved more than 6 million VMMCs with the support of multiple donors and national resources. This achievement is a testament to the collaborative efforts of policymakers, donors, community leaders, civil society groups and many others who saw the value in a proactive approach to health. Their efforts have improved lives and prevented incalculable human suffering.
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.
The progress has taught program implementers a great deal about the supply and demand associated with scaling up VMMC to improve quality and efficiency. The initial collection provided the evidence that eventually led to significant increases in funding for VMMC programs as well as the prioritization of VMMC as one of three essential interventions needed to achieve an AIDS-free generation.
RM: Can you tell us about the key themes of the Collection?
EN: The PLOS Collection, Voluntary Medical Male Circumcision for HIV Prevention: Improving Quality, Efficiency, Cost Effectiveness, and Demand for Services During an Accelerated Scale-up, includes 13 research papers and an overview of key findings, best practices, challenges and recommendations from several priority countries experiencing high-volume VMMC services. The collection addresses the following themes and a host of other practical concerns faced by governments, donors, and program implementers: quality of services, efficiency, cost effectiveness and demand creation.
Sixty-seven co-authors have contributed to the development and publication of these manuscripts, including experts from country Ministries of Health as well as international donors such as the Bill and Melinda Gates Foundation and PEPFAR implementing agencies and partners.
RM: What are the challenges to implementing the VMMC program 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. Currently, the Joint Strategic Action Framework sets an ambitious goal to circumcise 20.3 million men by 2016
(2012–2016) across 14 African countries.
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. While, as the studies show at a broad level, the program is increasing its outputs each year, the current growth rate of the program is not sufficient to reach the goal of 80 percent coverage by 2016. Resource and capacity constraints pose a serious challenge for countries hoping to reach their scale-up goals.
RM: What would you consider to be the main messages that need to be learned from the scale-up of the program?
EN: The collection shows how systematic, evidence-based management of programs and a dynamic culture of learning can help meet the challenges of VMMC scale-up. Let me elaborate these key points.
It is possible to maintain and even improve service quality, especially surgical performance, as VMMC is scaled up. But, improved provider training is needed to strengthen quality of pre and postoperative care and infection control. It is possible for VMMC programs to increase the number of men who learn their HIV status and enroll in HIV care and treatment with effective referral systems between VMMC and ART services.
Personnel and consumables are VMMC’s largest expenses, but costs may be reduced as programs scale up and economies of scale are achieved and by improving service efficiency. Under-utilization of service capacity increases unit costs more than any other variable, highlighting the importance of predictable demand and nimble service platforms so that sites are consistently performing as close to capacity as possible. Responsible public-sector pricing strategies for new VMMC devices have the potential to reduce overall unit costs, and further discounts should be negotiated as procurement volumes increase.
Messaging must be tailored to generate demand among specific age groups and to cultural norms of diverse communities. Men aged 25 and above are generally less inclined to undergo VMMC. Studies suggest the need to go beyond HIV-prevention messaging and include additional VMMC benefits, such as hygiene, aesthetics, attractiveness to partners, peer group norms, leadership, modernity, and benefits to women.
Countries vary in their surgical efficiency levels. Task sharing, bundling of surgical instruments, and electrocautery are associated with improved surgical efficiency. Surgical quality need not be compromised by measures to reduce operating time.
RM: Finally, what will the next steps be for the program and who needs to do what?
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 including HIV testing, care and treatment for men, a group that has been under served by ART programs in the region.
We need to explore the role that technologies, especially devices, can play in accelerating scale-up.
We need to rethink demand creation through market segmentation and insights from other disciplines to better encourage VMMC participation.
We need to gather and use standardized, high-quality data for program management and decision-making.
We need to provide technical assistance to governments for strengthening management and coordination of programs at national, provincial and district levels.
And, finally we need to strategize for the sustainability phase of the program and finally.
Our work is just beginning.
Please view the full 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.