Scale-Up of Voluntary Medical Male Circumcision Services for HIV Prevention — 12 Countries in Southern and Eastern Africa, 2013–2016

Jonas Z. Hines, MD; Onkemetse Conrad Ntsuape; Kananga Malaba, MD; Tiruneh Zegeye, MD; Kennedy Serrem, MD; Elijah Odoyo-June, PhD; Rose Kolola Nyirenda, MSc; Wezi Msungama, MPH; Kondwani Nkanaunena, MS; Jotamo Come, MD; Marcos Canda, MS; Herminio Nhaguiombe, MS; Ella K. Shihepo, MPH; Brigitte L.T. Zemburuka; Gram Mutandi, MBChB; Emmanuel Yoboka, MD; André H. Mbayiha, MD; Hilda Maringa; Alfred Bere, PhD; J. Joseph Lawrence, MPH; Gissenge J.I. Lija, MD; Daimon Simbeye, MPH; Kokuhumbya Kazaura, DDS; Ramadhani S. Mwiru, MD; Stella Alamo Talisuna, PhD; Joseph Lubwama, MD; Geoffrey Kabuye, MD; James Exnobert Zulu, MBChB; Omega Chituwo, MBChB; Maybin Mumba, MSc; Sinokuthemba Xaba, MSc; John Mandisarisa, PhD; Brittney N. Baack, MPH; Lawrence Hinkle, MSPH; Jonathan M. Grund, MPH; Stephanie M. Davis, MD; Carlos Toledo, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2017;66(47):1285-1290. 

In This Article

Abstract and Introduction

Introduction

Countries in Southern and Eastern Africa have the highest prevalence of human immunodeficiency virus (HIV) infection in the world; in 2015, 52% (approximately 19 million) of all persons living with HIV infection resided in these two regions.* Voluntary medical male circumcision (VMMC) reduces the risk for heterosexually acquired HIV infection among males by approximately 60%.[1] As such, it is an essential component of the Joint United Nations Programme on HIV/AIDS (UNAIDS) strategy for ending acquired immunodeficiency syndrome (AIDS) by 2030.[2] Substantial progress toward achieving VMMC targets has been made in the 10 years since the World Health Organization (WHO) and UNAIDS recommended scale-up of VMMC for HIV prevention in 14 Southern and Eastern African countries with generalized HIV epidemics and low male circumcision prevalence.[3] This has been enabled in part by nearly $2 billion in cumulative funding through the President's Emergency Plan for AIDS Relief (PEPFAR), administered through multiple U.S. governmental agencies, including CDC, which has supported nearly half of all PEPFAR-supported VMMCs to date. Approximately 14.5 million VMMCs were performed globally during 2008–2016, which represented 70% of the original target of 20.8 million VMMCs in males aged 15–49 years through 2016.[4] Despite falling short of the target, these VMMCs are projected to avert 500,000 HIV infections by the end of 2030.[4] However, UNAIDS has estimated an additional 27 million VMMCs need to be performed by 2021 to meet the Fast Track targets.[2] This report updates a previous report covering the period 2010–2012, when VMMC implementing partners supported by CDC performed approximately 1 million VMMCs in nine countries.[5] During 2013–2016, these implementing partners performed nearly 5 million VMMCs in 12 countries. Meeting the global target will require redoubling current efforts and introducing novel strategies that increase demand among subgroups of males who have historically been reluctant to undergo VMMC.

CDC supports national ministries of health to provide VMMC services for HIV prevention in 12 priority countries: Botswana, Ethiopia, Kenya, Malawi, Mozambique, Namibia, Rwanda, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe.§ The VMMC service package includes male circumcision, offer of HIV testing services and linkage to care and treatment for men testing HIV positive, HIV risk reduction education, condom provision, and screening and treatment or referral for sexually transmitted infections.[3] Circumcisions are performed under local anesthesia by trained clinicians (clinical officers and nurses in most countries). All VMMC clients provide informed consent; consenting for minors adheres to national standards.

CDC-supported VMMC programs reported program data on key indicators. Data were reported in accordance with the fiscal year October 1–September 30. Data were drawn from site-level VMMC client registers, collected by VMMC implementing partners, and reported to PEPFAR and CDC. The primary indicator was the total number of VMMCs performed; disaggregated indicators included VMMC method (conventional surgical circumcision or device-based circumcision), client age group, HIV test results among VMMC clients tested at VMMC sites, and attendance at postoperative follow-up visits within 14 days.

During 2013–2014, client age was reported as <15 or ≥15 years; during 2015–2016, age was categorized as <15 years, 15–29 years, and ≥30 years. HIV prevalence was calculated by dividing the number of males that tested positive for HIV infection by the number undergoing HIV testing services at VMMC sites. In this report, disaggregated indicators were excluded from multi-country analyses if the sum of values in the disaggregated indicator was <85% or >100% of the total number of VMMCs reported for a given year.

During 2013–2016, CDC supported 4,859,948 VMMCs in 12 Southern and Eastern African countries (Table 1). The annual number of VMMCs increased during 2013–2015. In 2016, 181,737 (13.4%) fewer VMMCs were performed than in 2015. In multi-country analyses, the proportion of VMMC clients aged <15 years increased each year during 2013–2016, from 31.7% in 2013 to 47.6% in 2016 (Table 2). Conversely, the proportion of VMMC clients aged 15–29 years declined from 48.4% in 2015 to 45.6% in 2016. During 2013–2016, circumcision devices were used in 42,520 (1.1%) of the VMMCs.

Data from multi-country analyses indicated that, during 2013–2016, 89.3% of VMMC clients participated in HIV testing services, and among those tested, the percentage of clients who tested positive ranged from 0.8% to 1.3% (at the country level, the percentage testing positive ranged from <0.1% to 4.4%) (Table 2). All VMMC clients were advised to return for a postoperative assessment; overall, 71.9% returned to the circumcising site within 14 days of surgery.

*http://aidsinfo.unaids.org/.
In 2015, the prevalence of HIV infection among all persons (male and female) aged 15–49 years in the 14 priority VMMC countries was as follows: Botswana (22.2%), Ethiopia (not available), Kenya (5.9%), Lesotho (22.7%), Malawi (9.1%), Mozambique (10.5%), Namibia (13.3%), Rwanda (2.9%), South Africa (19.2%), Swaziland (28.8%), Tanzania (4.7%), Uganda (7.1%), Zambia (12.9%), and Zimbabwe (14.7%).
§CDC support includes hiring of clinical staff members to provide VMMCs, conducting training and quality assurance assessments, providing technical assistance, and procurement of VMMC supplies, medications, and instruments.

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