Voluntary medical male circumcision for HIV prevention: an unprecendented public health intervention
With new HIV infections in Sub-Saharan Africa occurring at a rate of 2.3 million each year, a new PLOS Collection, featuring original research published in PLOS Medicine and PLOS ONE, presents interim results from a public health campaign applying a longstanding method - voluntary medical male circumcision (VMMC) - performed by health care practitioners in low resource settings to prevent new infections in men ages 15-49. Since WHO and UNAIDS issued recommendations in 2007, this program has been scaled-up with an ongoing, largely US-funded program in 14 countries in Eastern and Southern Africa, the epicenter of the global epidemic with over 16 million people currently living with HIV and where new HIV infection rates are highest.
In 2005, PLOS Medicine published the first randomized controlled intervention demonstrating a 60% reduction in HIV infections over a two-year period among a trial population of 3,274 young South African men who received a voluntary medical circumcision to assess the effectiveness of VMMC as a means of reducing the rate of sexual transmission from female sexual partners.
This level of risk reduction against contracting the AIDS virus was considered to be equivalent to what a vaccine of high efficacy would have achieved. The new PLOS Collection, Voluntary Medical Male Circumcision for HIV Prevention: Improving Quality, Efficiency, Cost Effectiveness, and Demand for Services during an Accelerated Scale-up, documents the translation of this subsequently amplified evidence base into a program to circumcise 20.3 million Sub-Saharan men by 2016. Based on modelling studies, published by PLOS Medicine in 2011, if this number of circumcisions is achieved by 2016, authors predicted 3.4 million new HIV infections will be prevented, saving the lives of thousands of men, women and children, and averting approximately $16.5 billion in medical treatment costs over 15 years.
"In 2008, when this program first started, there was skepticism about whether health systems could deliver a high volume of services and still keep the quality of services high," said Emmanuel Njeuhmeli, Senior Biomedical HIV Prevention Advisor at the U.S. Agency for International Development (USAID). "This collection provides evidence from four African countries that safe, high-quality VMMC can be implemented and sustained at scale. No one could have imagined that a surgical intervention could be rolled out in this way; yet, as of today, countries have done more than six million medical male circumcisions, averting thousands of new HIV infections."
The 13 research papers and overview contained in this new PLOS Collection examine lessons learned from the scaled-up VMMC program since 2008. Research papers focus on programs in Kenya, South Africa, Tanzania, Zimbabwe and Lesotho, identifying strengths and challenges in key program areas, including demand creation, the quality of surgical services, operational efficiencies, data collection and cost controls. Of particular concern to researchers is the program's relative lack of success reaching men over age 25, health-worker burnout and the outstanding need for substantial additional funding from other nations and sponsors to meet the VMMC program's completion and long-term sustainability goals.
Dr Rhona MacDonald, Senior Editor and Collection Editor at PLOS Medicine says: "This Collection shows that at a time of constrained international resources to fight HIV/AIDS, voluntary medical male circumcision offers the advantage of its relatively low cost and one-time action to achieve continuous benefits over other prevention methods, such as pre-exposure prophylaxis and preventative Antiretroviral Therapy (ART)."
The question of demand creation is addressed in several collection papers in which authors determine factors impacting uptake of VMMC by men over the age of 25 who live in countries with ongoing HIV epidemics and low levels of male circumcision. Researchers found that the most effective outreach was not the effectiveness of VMMC in decreasing an individual's risk of contracting HIV (as well as HPV and other STDs) but rather alternative influential factors, such as hygiene, attractiveness to partners, peer group norms and modernity.
The VMMC program faces challenges at multiple levels that will have to be overcome to achieve the ambitious targets, such as maintaining quality of services while rapidly scaling up, generating demand for services, and resource and capacity constraints. In order to accelerate scale-up and impact the Collection authors recommend increasing program efficiency by identifying and prioritizing those most at risk of acquiring HIV, focusing on program efficiency and quality at all levels, matching supply with demand, and exploring the role that technologies, especially devices, can play in scale up, among other recommendations.
What has been achieved in a relatively short period of time is remarkable and could hold lessons for other public health interventions as well.This Collection is a joint collaboration between PLOS and the U.S. President's Emergency Plan for AIDS Relief (through the U.S. Agency for International Development, the Centers for Disease Control and Prevention, and the Department of Defense), the Bill & Melinda Gates Foundation, PEPFAR implementing partners, and the Ministries of Health in Kenya, Tanzania, Zimbabwe, and South Africa.
Key Findings From The Collection
Quality of Services
It is possible to maintain and even improve service quality, especially surgical performance, as VMMC is scaled up, but improved provider training is needed to strengthen quality of pre- and post-operative care and infection control.
Personnel and consumables are the largest cost drivers, but costs may be reduced as programs scale up and economies of scale are achieved, as well as by improving service efficiency. Under utilization of service capacity increases unit costs more than any other variable, highlighting the importance of predictable demand and nimble service platforms so that sites are consistently performing as close to capacity as possible. Responsible public-sector pricing strategies for devices have the potential to reduce overall unit costs, and further discounts should be negotiated as procurement volumes increase.
Messaging must be tailored to different age groups and to the cultural norms of different communities. Men aged 25 and above are less motivated to undergo VMMC. Studies suggest that we need to go beyond simple HIV messaging and present VMMC in terms of hygiene, appearance, attractiveness to partners, peer group norms, and modernity.
Adoption of various elements of surgical efficiency is variable between countries studied. Task sharing, bundling of surgical instruments, and electrocautery are associated with surgical efficiency outcomes, and surgical quality need not be compromised by measures to reduce operating time.