Understanding the Evolving Role of Voluntary Medical Male Circumcision as a Public Health Strategy in Eastern and Southern Africa: Opportunities and Challenges

Abstract

Purpose of review: Voluntary male medical circumcision (VMMC) has been a cornerstone of HIV prevention in Eastern and Southern Africa (ESA) and is credited in part for declines in HIV incidence seen in recent years. However, these HIV incidence declines change VMMC cost-effectiveness and how it varies across populations.

Recent findings: Mathematical models project continued cost-effectiveness of VMMC in much of ESA despite HIV incidence declines. A key data gap is how demand generation cost differs across age groups and over time as VMMC coverage increases. Additionally, VMMC models usually neglect non-HIV effects of VMMC, such as prevention of other sexually transmitted infections and medical adverse events. While small compared to HIV effects in the short term, these could become important as HIV incidence declines. Evidence to date supports prioritizing VMMC in ESA despite falling HIV incidence. Updated modeling methodologies will become necessary if HIV incidence reaches low levels.

Keywords: Cost-effectiveness; HIV prevention; Male circumcision; Mathematical modeling; Sexually transmitted infections; Sub-Saharan Africa.

Fig. 1

Association between cost per HIV infection averted by VMMC and a HIV incidence or bunit cost of VMMC. Unit costs and costs per infection averted were obtained from a study by Kripke et al. [••] which used direct costs and modeled impact of VMMCs performed over 2010–2025 for each country except for Kenya where only the Nyanza region was included. Incidence was obtained at the national level from UNAIDS [81] and for Nyanza from three published estimates [13, 82, 83]