Voluntary Medical Male Circumcision (VMMC) – a cost-effective HIV prevention measure in eastern and southern Africa: a UNAIDS and PEPFAR collection

Today PLoS Medicine is delighted to announce the publication of a sponsored Collection, in conjunction with the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the United States President’s Emergency Plan for AIDS Relief (PEPFAR)Voluntary Medical Male Circumcision for HIV Prevention: The Cost, Impact, and Challenges of Accelerated Scale-Up in Southern and Eastern Africa.

The Collection comprises four reviews and five research articles, and highlights how scaling up voluntary medical male circumcision (VMMC) for HIV prevention in eastern and southern Africa can help prevent HIV, not only at the individual level but also at the community and population level, as well as leading to substantial cost savings for countries due to averted treatment and care costs. Two of the research articles are published in PLoS ONE; the remaining seven articles are published in PLoS Medicine on 29th November 2011. They can be accessed from the PLoS Medicine VMMC Collection page; the table of contents is also included below.

The first article by Catherine Hankins of UNAIDS, Steven Forsythe of The Futures Institute, and Emmanuel Njeuhmeli of PEPFAR/USAID, offers an introduction to the cost, impact and challenges of accelerated scaling up and lays out the rationale for the Collection. The remaining eight papers focus on the various factors that have important roles in effective program expansion of VMMC, including data for decision making, policy and programmatic frameworks, logistics, demand creation, human resources, and translating research into services.

The potential cost savings of scale-up are clear. An initial investment of US$1.5 billion between 2011 and 2015 to achieve 80% coverage of VMMC services in 14 priority countries in southern and eastern Africa, and thereafter US$0.5 billion between 2016 and 2025 to maintain coverage of 80%, could result in net savings of US$16.5 billion between 2011 and 2025. However, as the articles in the Collection show, strong political leadership, country ownership, and stakeholder engagement, along with effective demand creation, community mobilization and human resource deployment, are essential for effectively expanding and maintaining VMMC programs.

All 9 articles were peer-reviewed, revised and considered in depth by the editorial team, and subjected to all the usual PLoS Medicine or PLoS ONE editorial processes. We would like to thank the numerous peer reviewers for their detailed critiques, which helped to shape the articles, and we would also like to thank the authors for their patience in making appropriate revisions to these reviews. In particular we would like to Stephanie Sansom, guest academic editor, who read all the articles and provided critical feedback and reviewer advice to the editorial team. A special thank you goes to Emmanuel Njeuhmeli of PEPFAR/USAID who served as the main editorial contact for the articles in this Collection.

A question-and-answer Twitter expert session [#VMMC@USAIDGH] will be held on December 19 2011, from 1pm-2pm EST, with Emmanuel Njeuhmeli, Senior Biomedical Prevention Advisor of the Office of HIV/AIDS/USAID Washington, Co-Chair PEPFAR, Male Circumcision Technical Working Group, and an author on several of the articles in the Collection. In regard to this Collection Dr. Njeuhmeli comments:

“The collaboration that led to the findings in the PLoS Collection is a true testament to what international partners can accomplish when they work together and do so effectively to support country strategy for HIV Prevention. I can say with confidence this collaboration has played a major role in moving the needle on VMMC and HIV prevention. This Collection represents extensive collaboration between Ministries of Health, WHO, UNAIDS, PEPFAR and implementing partners to document and share with policy makers and program implementers the estimated cost and potential impact of scaling up voluntary medical male circumcision (VMMC) services in southern and eastern Africa. The papers included in this Collection document the enormous potential of VMMC to alter the course of the epidemic. They also describe the way that country programs have successfully navigated human resource, demand generation and other challenges in an effort to rapidly scale up comprehensive VMMC services.”

Collection Table of Contents :

1)       Voluntary Medical Male Circumcision: An Introduction to the Cost, Impact, and Challenges of Accelerated Scaling Up

2)       Voluntary Medical Male Circumcision: Modeling the Impact and Cost of Expanding Male Circumcision for HIV Prevention in Eastern and Southern Africa

3)       Voluntary Medical Male Circumcision: A Framework Analysis of Policy and Program Implementation in Eastern and Southern Africa

4)       Voluntary Medical Male Circumcision: A Cross-Sectional Study Comparing Circumcision Self-Report and Physical Examination Findings in Lesotho

5)       Voluntary Medical Male Circumcision: Logistics, Commodities, and Waste Management Requirements for Scale-Up of Services

6)       Voluntary Medical Male Circumcision: A Qualitative Study Exploring the Challenges of Costing Demand Creation in Eastern and Southern Africa

7)       Voluntary Medical Male Circumcision: Strategies for Meeting the Human Resource Needs of Scale-Up in Southern and Eastern Africa

8)       Voluntary Medical Male Circumcision: Translating Research into the Rapid Expansion of Services in Kenya, 2008–2011

9)      Voluntary Medical Male Circumcision: Matching Demand and Supply with Quality and Efficiency in a High-Volume Campaign in Iringa Region, Tanzania

Disclaimer: The views expressed in the VMMC collection are those of the authors and do not necessarily reflect the official policy or position of the U.S. Government and UNAIDS. The collection was produced with support from the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the United States President’s Emergency Plan for AIDS Relief (PEPFAR). The PLoS Medicine editors have sole editorial responsibility for the content of this collection.

Image Credit: PEPFAR Male Circumcision Technical Working Group

Permission to use the CCAL license granted by the PEPFAR Male Circumcision Technical Working Group.

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One Response to Voluntary Medical Male Circumcision (VMMC) – a cost-effective HIV prevention measure in eastern and southern Africa: a UNAIDS and PEPFAR collection

  1. Hugh7 says:

    Circumcision has been heavily promoted and the “up to 60% reduction” factoid treated like gospel, but it needs some context. Circumcision comes with a great deal of cultural baggage, and has been promoted for a mind-boggling variety of reasons so that, intermingled with its religious and cultural contexts, it has been described as a cure looking for a disease, an intervention in serch of an excuse. Promoted across the English-speaking world more than 100 years ago as prevention and “cure” – but most effectively as punishment – for masturbation (which was misleadingly called “moral hygiene” and so inevitably morphed into claims about real hygiene), it remains culturally embedded in the USA, so that circumcised men become fiercely defensive of their own condition, some so much that they want to make it uriiversal. This important bias needs to be carefully factored out of claims that it is beneficial.

    The claim that circumcision has any effect on HIV/AIDS (let alone the “up to 60% factoid”) still rests on the very tiny and shaky basis of 73 circumcised men who did not get infected in less than two years, after a total of 5,400 men were circumcised in the three randomised trials (and 64 of them did get it). 137 non-circumcised men were infected, and that difference is the whole “proof”. Contacts were not traced so we don’t even know which, if any of them were infected by women or even by sex. 703 men dropped out, 327 of them circumcised, their HIV status unknown. No attempt was made to compensate for the dramatic effect the performance and results of a painful and marking operation might have on behaviour in the experimental group, but not the control group. So there are many reasons other than circumcision the infection of the 73 may have been delayed (not prevented).

    A Cochrane Review before the three trials found unsufficient evidence to recommend circumcision, and a second one looked only at those three trials, so the case for mass circumcision is inadequate.

    A study in Uganda (Wawer et al., Lancet 374:9685, 229-37) started to find that circumcising men increases the risk to women (who are already at greater risk), but they cut that one short for no good reason before it could be confirmed.

    In 10 of 18 countries for which USAID has figures, more of the circumcised men have HIV than the non-circumcised. In Malaysia, 60% of the population is Muslim (the only circumcised people in that country) but 72% of HIV cases are Muslim. Shouldn’t that at least be explained before blundering on with mass circumcision programmes?

    There is no evidence whatever that infant circumcision has any effect on HIV, and genital cutting of minors raises serious human rights issues, yet circumcision advocates want to blend that into the mix indiscriminately – apparently because men are refusing to have it done to them.

    It is clear that soon we will hear “success stories” about circumcision that won’t mention the intensive counselling, provision of condoms and general consciousness-raising that will go with the operation. Like the nail in Nail Soup, circumcision will get all the credit.

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