Achieving the HIV prevention impact of voluntary medical male circumcision: lessons and challenges for managing programs

Abstract

Voluntary medical male circumcision (VMMC) is capable of reducing the risk of sexual transmission of HIV from females to males by approximately 60%. In 2007, the WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommended making VMMC part of a comprehensive HIV prevention package in countries with a generalized HIV epidemic and low rates of male circumcision. Modeling studies undertaken in 2009-2011 estimated that circumcising 80% of adult males in 14 priority countries in Eastern and Southern Africa within five years, and sustaining coverage levels thereafter, could avert 3.4 million HIV infections within 15 years and save US$16.5 billion in treatment costs. In response, WHO/UNAIDS launched the Joint Strategic Action Framework for accelerating the scale-up of VMMC for HIV prevention in Southern and Eastern Africa, calling for 80% coverage of adult male circumcision by 2016. While VMMC programs have grown dramatically since inception, they appear unlikely to reach this goal. This review provides an overview of findings from the PLOS Collection "Voluntary Medical Male Circumcision for HIV Prevention: Improving Quality, Efficiency, Cost Effectiveness, and Demand for Services during an Accelerated Scale-up." The use of devices for VMMC is also explored. We propose emphasizing management solutions to help VMMC programs in the priority countries achieve the desired impact of averting the greatest possible number of HIV infections. Our recommendations include advocating for prioritization and funding of VMMC, increasing strategic targeting to achieve the goal of reducing HIV incidence, focusing on programmatic efficiency, exploring the role of new technologies, rethinking demand creation, strengthening data use for decision-making, improving governments' program management capacity, strategizing for sustainability, and maintaining a flexible scale-up strategy informed by a strong monitoring, learning, and evaluation platform.

Figure 1. Timeline and key milestones of the voluntary medical male circumcision program in 14 priority countries.

6 million circumcisions listed in 2013 is an estimate by PEPFAR and the Bill & Melinda Gates Foundation. RCTs, randomized controlled trials; TWG, technical working group; TAG, technical advisory group; MOVE, Models for Optimizing the Volume and Efficiency of MC services.

Figure 2. Scale-up of voluntary medical male circumcision program and coverage in 14 priority countries, aggregate, 2008–2013.

Number of circumcisions completed each year in millions. Source of 2008–2012 data is the WHO 2012 VMMC report . 2013 numbers have been estimated using data from PEPFAR and the Bill & Melinda Gates Foundation. *CAGR, compound annual growth rate, calculated based on the average proportional growth each year. CAGR (t₀,t_n)  =  (V(t_n)/V(t₀))^{1/(tn − to)} −1, where V(t₀) is the start value and V(t_n) is the finish value and t_n − t₀ is the number of years.

Figure 3. Scale-up of voluntary medical male circumcision program and coverage in 14 priority countries, 2008–2012.

Totals reflect progress through 2012. Percentage figures represent the achieved proportion of the target of 80% coverage among males ages 15–49, but totals include circumcisions done for all age groups, regardless of the age-range target. Data obtained from WHO 2012 VMMC report .

Figure 4. Scale-up of voluntary medical male circumcision program and coverage in 14 priority countries: growth scenarios, 2008−2016.

Source of 2008–2012 data is the WHO 2012 VMMC report ; 2013 figures are estimates, and 2014–2016 figures are projections. In the “no growth” scenario, the program continues to perform the same numbers of circumcisions each year as in 2013. In the “current growth” scenario, the program continues the trend of historical growth rate.

Figure 5. Enabling factors and levers to achieve scale and impact for the voluntary medical male circumcision program.

Strong enabling factors of leadership, policy, and financing are needed to accelerate and maximize the impact of scale-up of the VMMC program. The levers for scale—government management capacity, use of data for decision-making, and technologies—are needed to match supply and demand.