Male Circumcision Part 1: How It Can Get Us Closer to an “AIDS-Free Generation”

This week the Public Health Perspectives blog team offers a total of five posts highlighting and interpreting findings in an important new PLOS research collection, Voluntary Medical Male Circumcision (VMMC) for HIV Prevention: Improving Quality, Efficiency, Cost Effectiveness, and Demand for Services during an Accelerated Scale-up. This research documents the work of global health doctors and public health workers toiling in the epicenter of the global epidemic – SubSaharan Africa – where over 16 million people currently live with HIV and where new HIV infection rates are highest. It also presents some surprising and enlightening results from surveys of VMMC clients and prospective clients, men and women with the most at stake in the battle against HIV-AIDS.

Circumcision clinic

Bapong Health Centre, Bapong, North West, South Africa Credit: Gaph Phatedi, CHAPS

The following introductory post includes some background on voluntary medical male circumcision (VMMC) with reporting by Public Health Perspectives bloggers Atif Kukaswadia,  Beth Skwarecki and Lindsay Kobayashi. In the course of the week, each PHP  team member will publish a separate post, incorporating interviews with collection authors, to examine individual papers and themes in the research.

We hope you’ll get involved with our PLOS-wide discussion on the important topic of HIV-AIDS prevention by reading the collection papers, offering comments on blog posts, posting on the PLOS Facebook page, or tweeting to the collection hashtags #MaleCirc  and #PLOSVMMC2014.


How Voluntary Medical Male Circumcision Can Get Us Closer to an AIDS-free Generation

There’s still no vaccine for HIV, but it’s not for lack of trying. Thirty-seven trials are ongoing right now, according to the International AIDS Vaccine Initiative. If one were to prove even partially effective, it would be a major boon to public health: even a halfway effective vaccine, given to a fraction of its target population, could still save millions of lives in Africa. There, 1 in every 20 adults is living with HIV, and over 17 million children have lost one or both parents to AIDS.

Rather than waiting for the long-promised vaccine, public health agencies across the African continent, with major assistance from the US and other donors, are rolling out an intervention that trials have shown is almost as effective: circumcision for men.

First things first, what is VMMC and how does it prevent HIV infection?

Circumcision is the surgical removal of the foreskin on a male’s penis. In uncircumcised men, the area under the foreskin can be more vulnerable to infection by the HIV virus (and to other STIs including gonorrhoea and syphilis), due to its microenvironment. In the first decade of this century, epidemiological studies and randomised clinical trials have provided consistent and compelling evidence that male circumcision helps to prevent HIV transmission. As a result, the WHO and UNAIDS have been recommending since 2007 that voluntary medical male circumcision as an important strategy for HIV prevention, particularly in settings with high HIV prevalence and low levels of male circumcision, where the public health benefits will be maximized.

Because the skin cells under the foreskin are particularly vulnerable to HIV infection, circumcision reduces a man’s chance of being infected by 60%. (That’s about the same success rate as last winter’s flu shot). It’s not a complete solution to the AIDS epidemic, since it does nothing for male-to-female transmission; and because it’s only partially effective, condoms are still crucial. But safe sex messages have obviously fallen short. Circumcision is promising because it’s a one-time action: a few minutes in the operating room, and you’re (partially) protected for life.

The PLOS VMMC Collection assesses ongoing efforts in 14 countries in Eastern and Southern Africa to scale up voluntary medical male circumcision (VMMC) programmes to prevent HIV transmission. These countries are Botswana, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe.

Containing a comprehensive PLOS Medicine review, plus 13 original PLOS ONE research articles, the collection authors recommend increasing program efficiency and by identifying and prioritizing those most at risk of acquiring HIV, matching supply with demand and focusing on quality at all levels.

Because of its proven effectiveness when studied in multiple randomized, controlled clinical trials, male circumcision could be used almost like a vaccine to help prevent HIV. Based on modelling studies published in PLOS Medicine in 2011, if 80% of men aged 15 to 49 in these countries underwent circumcision, about 3.4 million new HIV infections would be prevented and US$16.5 billion in averted HIV-related costs would be saved.

In the resource-poor countries involved in the VMMC campaign, these savings would go a long way in supporting other forms of health infrastructure, not to mention the millions of human lives saved.

Today, voluntary medical male circumcision is designed to be part of a comprehensive package for HIV/AIDS treatment — one that includes treatment and counselling, screening, condom promotion and health education.

Some countries in southern Africa show low rates of HIV testing, and enrollment in Antiretroviral Therapy (ART) treatment is even lower. In countries such as Lesotho and Zimbabwe, voluntary medical male circumcision services are seen as an effective strategy to attract men to HIV testing and counselling and link them to continuing care and treatment, since early diagnosis of HIV and treatment initiation at higher CD4 counts improves outcomes and reduces HIV transmission.

The Multiplied Benefits of VMMC for Men and Women

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.

Iringa campaign vmmc

Clients line up in Iringa, Tanzania to receive circumcision services; Credit: Jhpiego/Tanzania

In some parts of Africa, men are lining up to be circumcised—over 2 million in 2013, bringing the total since 2007 to around 6 million. However, in certain countries, particularly among rural people and those over the age of 25, slow uptake of VMMC is a concern to local and international health agencies. Reflecting this on-the-ground reality, several papers in the collection probe the causes and potential solutions to the challenge of “demand creation.”


Emmanuel Njeuhmeli, Senior Biomedical Prevention Advisor at the US Agency for International Development and lead author of the collection, “on the ground” during the VMMC campaign.

The importance of documenting lessons learned thus far in the VMMC program implementation was discussed by Emmanuel Njeuhmeli, Senior Biomedical Prevention Advisor at the US Agency for International Development and lead author of the collection, in an interview posted  on the PLOS Speaking of Medicine blog:

“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.”

We invite you to stay with us throughout the week to learn more. Also posting today is an in-depth interview with Emmanuel Njeuhmeli about the program he oversees in 14 countries — and how researchers documented its progress and remaining challenges in the new PLOS VMMC Collection.

Read other posts in this series:

Male Circumcision Part 2: His Choice and Her Influence

Male Circumcision Part 3: Why Some Men are Resisting the Next Best Thing to an AIDS Vaccine 

Male Circumcision Part 4: Public Health is a Noble Profession

Male Circumcision Part 5: Measuring Health Provider Burnout 


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