Title

Making the impossible possible: Progress in scale-up of voluntary medical male circumcision for HIV prevention supported by the United States President's emergency plan for AIDS relief through 2017

Presenter

Carlos Toledo

Authors

C. Toledo¹, S. Davis², J. Hines², M. Habel², L. Hinkle², K. Izenour², A. Thomas³, V. Kiggundu⁴, C. Cooney⁵, D.H. Watt⁵

Institutions

¹US Centers for Disease Control and Prevention (CDC), Atlanta, United States, ²US CDC, Atlanta, United States, ³DoD HIV/AIDS Prevention Program, Defense Health Agency, US Department of Defense, San Diego, United States, ⁴USAID, Washington, DC, United States, ⁵Office of the U.S. Global AIDS Coordinator and Health Diplomacy, US Department of State, Washington, DC, United States

Background: Voluntary medical male circumcision (VMMC), which offers men with lifelong partial protection from HIV and other sexually transmitted infections (STIs), has become a cornerstone of the global HIV prevention portfolio through support by national and global programs, such as PEPFAR. VMMC was introduced in 14 southern and eastern African countries, which scaled-up services progressively between 2007 and 2011. Since then, the PEPFAR program has experienced rapid growth and is contributing to epidemic control in these countries.
Description: All PEPFAR-supported programs report key metrics, including total VMMCs performed and disaggregations of client age range, technique, HIV test results, and post-operative follow-up. These indicators provide an overview of accomplishments and key characteristics of the program.
Lessons learned: From 2007 through 2017, 15.2 million VMMCs were performed with PEPFAR support (Figure 1); representing over 80% of global procedures performed. 2010-2014, annual performance approximately doubled each year. After temporarily slowing of performance during 2015-2016, 2017 represented the highest single year of VMMCs performed since program inception, contributing nearly one-fourth (22%) of all PEPFAR-supported circumcisions performed to date.
In 2017, 48% of VMMC clients were between the ages of 15-29 years, a priority age group for immediate impact on HIV incidence. Over twenty-four thousand clients tested positive for HIV at VMMC sites. Device-based techniques constituted a minority of circumcisions, except in Rwanda where they dominated (53%). Post-operative follow-up rates were over 80% overall, ranging from between 60% in South Africa to 100% in Rwanda.
Conclusions/Next steps: VMMC has undergone an historic scale-up within global health, enabled by dedicated resources, targets setting, leadership, rapid expansion of surgical skills and responsibilities to non-physicians, and public outreach campaigns. Models estimate that the VMMCs conducted through 2016 will avert at least 500,000 infections by the end of 2030. VMMC has also helped prevent HIV and STIs among women. The PEPFAR program''s achievements demonstrate the feasibility of rapid expansion of circumcision, but global strategy must continue evolving to maximize impact, achieve revised UNAIDS targets including circumcising 27 million men during 2016-2020, maintain safety, and meet broader UNAIDS and PEPFAR objectives.

[Cumulative Number of PEPFAR-Supported Voluntary Medical Male Circumcisions by Country, 2009-2017]

Download the e-Poster