A paper authored by Reed, J., Njeuhmeli, E., Thomas, A., et al. has been published in the JAIDS journal. It outlines the background to the development of Voluntary Medical Male Circumcision (VMMC) as part of a comprehensive HIV prevention package and moves on to discuss some of the challenges being faced in programme scale-up. In it the authors note that President Obama has committed PEPFAR to provide funding and technical support to help 13 countries in Africa to achieve 4.7m procedures by 2014. This in itself is a step towards a previously set target of 20.8m VMMCs by 2015.
The WHO formally recommended VMMC as part of its HIV prevention strategy in 2007. Between October 2009 and March 2012, PEPFAR has supported the delivery of 901,900 VMMCs at a cost of more than $250m. This financial support has been alongside more than $140m from the Bill and Melinda Gates Foundation since 2001.
The 901,900 represents just 4.3% of the overall 2015 target. The paper shows relative performance across all 13 countries. Kenya, so far, has shown most progress in overall numbers performed (295,800) and also in progress towards meeting its national target (34%). Uganda follows 2nd, having so far performed 149,400 VMMCs, but this is just 3.5% of its 4.2m national target.
Clearly these National programmes need to be scaled-up if the 2014 and 2015 targets are to be achieved:
The authors discuss a number of issues that need to be managed if scale-up is to be achieved.
VMMC is a one-time, relatively low-cost, quick and effective intervention. Protection against HIV infection can be more than 60% and such protection is permanent; the procedure does not need to be repeated again and again, nor does it rely on user adherence. Modelling shows that if we can reach a significant prevalence rate of male circumcision (80%) then millions of new infections could be averted, saving billions of dollars in the cost of future care and treatment; but these benefits take some years to accrue and health care professionals may prefer to use scarce resources on other health interventions that are more immediate and in which the benefits are more easily, more quickly, seen.
There is an interesting note that perhaps some countries have already seen the ‘early adopters’ with the implication that reaching these early numbers has been relatively easy. In the next phase as countries seek to scale-up the programmes there will need to be a greater emphasis on community engagement and mobilisation to ensure that not just the targeted numbers are achieved, but that we also focus more on the most at risk groups.
Two other matters will be essential for successful scale-up:
- Acceptance at Policy level that VMMC can be task-shifted to lower credentialed, specifically trained staff
- Inclusion of non-surgical (device) methodology, with full WHO approval and agreed funding support from PEPFAR and other donors.
Studies are currently on-going in a number of the 13 countries to evaluate both of these innovations.
Reed, J.B. et al., 2012. Voluntary Medical Male Circumcision : An HIV Prevention Priority for PEPFAR. JAIDS, 60(August), pp.88–95. Available at: http://bit.ly/Pcq8QP
[Accessed August 22, 2012].