As part of our special coverage of the Voluntary Medical Male Circumcision collection, I recently sat down with Emmanuel Njeuhmeli, a public health physician who was heavily involved with the VMMC initiative. For those interested in a career in public health, and in infectious disease epidemiology, his perspective is enlightening.
1: Hi Emmanuel, and thank you for taking the time to speak with us. To start, could you tell me a little about yourself?
I am a public health physician holding a medical degree and two master’s degrees, one in public health and the other in business administration. I have been involved with HIV/AIDS prevention, care and treatment program design, coordination, implementation, monitoring, and evaluation since 1998 in various countries, mostly in Central, West, Eastern and Southern Africa. I have been involved with the scale-up of Voluntary Medical Male Circumcision (VMMC) since November 2008.
2: How did you get involved with USAID? How long have you been there?
After graduating from medical school, I was involved with both public health and clinical medicine for several years, mostly implementing HIV/AIDS prevention, care and treatment in the field in several countries. I decided to go back to school and get a Master of Public Health degree (MPH) and an MBA to be able to work at a more strategic planning level, building on my skills and experience gained in the field. I have been with USAID since November 2008 as Senior Biomedical Prevention Advisor. In this position, I am the Agency technical lead for providing support to priorities countries in Southern and Eastern Africa to introduce and accelerate the scale-up of VMMC. During these years, I have also been Co Chair of the PEPFAR Male Circumcision Technical Working Group (ed note: PEPFAR = United States President’s Emergency Plan for AIDS Relief).
3: Why male circumcision? That’s not usually an approach you hear about when you consider HIV reduction strategies.
There is a biological explanation for why circumcised men have lower rates of infection with HIV and several other sexually transmitted infections. Studies have shown that the foreskin contains many immune system target cells, for example Langerhans cells. Like other immune cells, they have an affinity for foreign bodies including HIV. In addition, the warm, moist area under the foreskin promotes the growth of bacteria, particularly anaerobic bacteria, which are associated with inflammation and may recruit additional immune cells to the area, further increasing vulnerability to HIV infection. The foreskin is also a delicate mucosal tissue that is more vulnerable to micro-tears and other breaks in the skin than is the tougher, more keratinized skin of the circumcised penis. Finally, uncircumcised men have higher rates of other STIs, which we know are a risk factor for HIV acquisition.
4: How long has this project been in the pipeline?
The scientific papers summarizing the results of the three clinical trials were published in 2005 (South Africa) and 2007 (Kenya and Uganda). In March 2007, the World Health Organization and the Joint United Nations Program on HIV/AIDS (UNAIDS) issued a recommendation that countries with high HIV prevalence and low male circumcision rates should add VMMC to their prevention programming. Following this recommendation, many countries in the East and Southern Africa region began the process of adding VMMC to their HIV prevention programs, and shortly after that, PEPFAR and the Bill and Melinda Gates Foundation (BMGF) made resources available to support the scale-up of VMMC, engaging implementing partners to support Ministries of Health in the priority countries. In December 2011, global partners including UNAIDS, PEPFAR, WHO, BMGF, the World Bank, in consultation with the priority countries, launched a five- year action framework to further accelerate the scale-up of VMMC. The papers included in this PLOS collection summarize many of the lessons learned during the accelerated scale up, during which time nearly 6 million men and adolescent boys have been reached with comprehensive VMMC services. This includes risk reduction counseling, HIV testing and linkage to care if necessary, STI screening and treatment and condom provision and promotion.
5: What was the hardest part of doing this project?
Introducing a new health product or service is never easy, but scaling up VMMC seemed particularly daunting at the outset because the task involved providing millions of surgeries – in countries with an acute shortage of healthcare workers and very limited surgical capacity – to a population (young men) that typically has very little interaction with the health system.
To be honest, many people doubted that it could be done at all, let alone safely. What these papers demonstrate is that it is indeed possible to rapidly scale up safe and high quality services, even in resource constrained settings. The VMMC community has worked hard to document our lessons learned so that others working in the HIV response and in other critical health areas can learn from our experiences.
6. What has the reaction been “on the ground”? Have people bought into the project or has it been a very slow process?
Overall the VMMC scale-up has been very successful, although progress has been greater in some countries than in others, largely due to differences in demand for the service. At present, all 14 countries have embraced the HIV prevention potential of VMMC and are moving forward with the scale-up. We find that in many settings, HIV prevention program managers and frontline healthcare workers embrace the opportunity afforded by VMMC, which is different from many other prevention strategies in that a relatively brief interaction with the health system will provide a man a lifetime of partial protection. This is not to say that it has been easy; male circumcision is closely associated with culture and religion in many African countries, and it has been very important to involve community and religious leaders, including traditional and political leaders, so that people understand that VMMC is about promoting health rather than changing one’s culture, ethnicity or religion. Adolescents have been early adopters of VMMC and in some cases have encouraged adults in their communities to examine their stance on medical male circumcision.
7: What could the future public health implications be of your work?
My work over the past six years has focused on the introduction of VMMC as a new HIV prevention intervention, and subsequently, acceleration of the scale-up of VMMC in priority countries in Eastern and Southern Africa. VMMC was recommended in March 2007 by WHO and UNAIDS for countries with high HIV prevalence and low male circumcision prevalence as part of their HIV prevention portfolio.
Scaling up VMMC would avert millions of HIV infections, saving lives and significantly decreasing the future investments needed to provide HIV treatment. Modeling studies have shown that a combination approach of scaling up both VMMC and HIV treatment would have the largest impact on the epidemic and would be more cost-effective than scaling up treatment alone. VMMC is one of the most effective and cost-effective HIV prevention approaches currently available.
In 2011, we published results from mathematical modeling we did in collaboration with UNAIDS demonstrating that countries in Southern and Eastern Africa have the opportunity to avert potentially close to 3.4 million new HIV infections in the next 15 years and generate a potential cost savings of $16.5 billion in treatment costs if VMMC is scaled up. We also demonstrated that while the intervention focuses on males, the benefits are for both males and females. In a country like Zimbabwe, for example, scaling up VMMC alone could potentially avert up to 42% of new HIV infections that would have occurred otherwise. The faster the program can be brought to scale, the higher the impact will be, so any day or month that passes without this intervention being scaled up is a missed opportunity.
8: What advice do you have for future public health professionals who are interested in field work?
Public health is a noble profession that allows us to save people’s lives millions at a time with our work. With adequate resources, one is able to identify health issues faced by specific populations, look for evidence in terms of what interventions can be implemented to overcome those issues, design the interventions and implement them efficiently. It is rewarding when you evaluate the work done and you can translate that work into numbers of lives saved.
My advice for any young public health professional is to gain experience in the field. They need to understand the population they intend to support and there is only one way to do that besides looking at the data, and that is to involve the community from the beginning in the solutions that are meant to address their health issues. Community buy-in is key in implementing any public health program. The knowledge and experience you acquire while consulting with community stakeholders is invaluable.
We’d like to thank Emmanuel Njeuhmeli for offering his time and insight for this interview. For those interested in learning more, the PLOS open access VMMC collection can be found here: Voluntary Medical Male Circumcision (VMMC) for HIV Prevention: Improving Quality, Efficiency, Cost Effectiveness, and Demand for Services during an Accelerated Scale-up.