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Assessing Voluntary Medical Male Circumcision for HIV Prevention in a Unprecendented Public Health Intervention

PLOS launches a new collection, Voluntary Medical Male Circumcision for HIV Prevention: Improving Quality, Efficiency, Cost Effectiveness, and Demand for Services during an Accelerated Scale-up, which focuses on the challenges and opportunities of a large scale public health intervention. Dr. Emmanuel Njeuhmeli and Dr. Rhona MacDonald discuss the implementation and outcomes of the program so far.

Voluntary medical male circumcision (VMMC) – a surgical procedure that involves the complete removal of the foreskin by a trained medical professional – has been shown to be effective in the prevention of HIV transmission.

Image Credit: (left) Sgt. Adam Fischman, US Army Africa & (right) Sterling Riber, MFDI for Jhpiego/Tanzania
Image Credit: (left) Sgt. Adam Fischman, US Army Africa & (right) Sterling Riber, MFDI for Jhpiego/Tanzania

In 2007, WHO and the Joint United Nations Programme on HIV /AIDS  recommended that 14 priority countries with high HIV and low male circumcision prevalence in Southern and Eastern Africa consider implementing VMMC as a key intervention in their HIV prevention portfolio.

This massive public health intervention launched in 2009 with support from WHO/UNAIDS calling for 80% coverage of male circumcision by 2016. Although the growth of VMMC programs has dramatically increased over recent years, it appears that the coverage goal will be unattainable by 2016.

This new PLOS Collection focuses on the challenges and opportunities for these programs. Containing a comprehensive PLOS Medicine review, plus 13 original PLOS ONE research articles, the collection provides recommendations to enable a more sustainable and flexible scale-up strategy.

PLOS Medicine Senior Editor Dr. Rhona MacDonald interviewed Dr. Emmanuel Njeuhmeli, Senior Biomedical Prevention Advisor at USAID and key author of the Collection to find out more.

What follows are excerpts from an extended interview which can be found here.


RM: Why is VMMC and scale –up of the programs of such importance?

EN: Circumcised men greatly reduce their risk of acquiring HIV and many other sexually transmitted infections (STIs), such as herpes, syphilis and human papilloma virus (HPV). In addition, female partners of circumcised men also have benefits, including lower rates of cervical cancer (the leading cancer killer among African women) and bacterial vaginosis, a condition that has been associated with pre-term birth.

Scale-up of VMMC is critically important to reduce the future burden of HIV, particularly in high prevalence regions, such as Eastern and Southern Africa. HIV infections are happening every day among uncircumcised men in the region and this can easily be prevented. Each day that this proven prevention method is not brought to scale represents a missed opportunity to bring us closer to reaching an AIDS-free generation.


RM: What progress has been made through the VMMC programs?

EN: On December 1, 2011, President Barack Obama challenged the President’s Emergency Plan for AIDS Relief (PEPFAR) to achieve 4.7 million VMMCs by the end of 2013. PEPFAR programs across the 14 VMMC priority countries in Eastern and Southern Africa had reached approximately 850,000 males over the past four years, and the President’s target called for a four-fold program expansion in half the time. The good news is that PEPFAR has met the President’s target of 4.7 million

Despite our successes to date, we have reached only one-third of the 20.3 million interventions needed to achieve the maximum public health benefit by the end of 2016.


RM: What are the key challenges to implementing VMMC as identified by the articles in the Collection?

EN: There are many. The goals to accelerate scale-up are ambitious and it’s critical that we assure consistent safety and overall quality of services. Furthermore, since being circumcised involves deep-seated values, beliefs, and motivational factors that vary with ethnic, religious, and cultural identities, sensitive approaches are required to ethically and responsibly aid boys and men and entire communities in their consideration of VMMC. Resource and capacity constraints also pose a serious challenge for countries hoping to reach their scale-up goals.


RM: What are the next steps?

EN: We need to increase program efficiency by identifying and prioritizing those most at risk of acquiring HIV. We need to focus on program efficiency and quality at all levels and assures a good match between supply and demand. We need to encourage VMMC programs to further strengthen linkages with ART programs. And, finally we need to strategize for the sustainability phase of the program and finally.

Our work is just beginning.


Please view the Collection here:


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.


Dr. Rhona MacDonald is Senior Editor for PLOS Medicine and PLOS Collections.

Dr. Emmanuel Njeuhmeli is the Senior Biomedical Prevention Advisor in the USAID Office of HIV/AIDS.

  1. Please see the following link for a brief summary, with linked references, of the ethical, legal and methodological flaws with past research informing the present campaign of circumcision-as-HIV-preventative in Africa (which also inform much of the “renewed interest” in circumcision in the English-speaking world), some of the adverse consequences of funding circumcision-as-HIV-preventative in Africa (coercion of men and boys to be circumcised; misdirection of limited medical resources from higher priority areas) and the absence of oversight of organisations promoting and facilitating male circumcision in Africa:

  2. Most specific STIs are not impacted significantly by circumcision status. These include chlamydia, gonorrhea, HSV, and HPV. Syphilis showed mixed results with prevalence studies suggesting intact men were at great risk and incidence studies suggesting the opposite. Intact men appear to be greater risk for GUD while at lower risk for GDS, NSU, genital warts, and the overall risk of any STIs. It is also clear that any positive impact of circumcision on STIs is not seen in general populations. Consequently, the prevention of STIs cannot be rationally interpreted as a benefit of circumcision, and a policy of circumcision for the general population to prevent STIs is not supported by the evidence currently available in the medical literature.

    Cutting genital parts off of men has never been shown to prevent HIV infection in real populations. The US NAVY study shows that there was no STD or HIV advantage to the cut American men. Also, records from the US Veterans Administration shows there is no difference at all in the likelihood of HIV infection between cut and natural men.

    Africa provides similar real world data from the ongoing genital mutilation campaign. In HIV prevalence rate among circumcised males between the ages of 15 and 49 in Zimbabwe is higher than that of the uncircumcised male” after a Bill Gates funded circumcision drive.

    The HPV data cited is not what real population data shows. In the US the number of sexual partners and NOT circumcision status is linked to HPV.

    The idea that cutting the parts off does not affect sexual pleasure is ludicrous. And yet, this has been denied, ignored or downplayed by those that so so want the next generation to also have parts cut off. The parts move, so natural sex is fundamentally different from partial genital sex. The outer skin and inner mucosa (with THOUSANDS of nerves) provides space for an erection. The nerves touch inside the female. This is the sensory input as acute as a fingertip, the nipples or lips.

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