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PEPFAR has funded 15m circumcisions in sub-Saharan Africa

PEPFAR (the US President’s Emergency Fund for AIDS Relief) has supported the voluntary medical male circumcisions (VMMC) of 15,269,720 men and boys in 14 countries in sub-Saharan Africa, in the eleven years to 2017, according to a study. The World Health Organisation estimates that PEPFAR supported 84% of all VMMCs in the 14 countries.

Research conducted over ten years ago showed that circumcising men reduces their lifetime HIV risk by between 60 and 70%. According to mathematical modelling, the 14.5m circumcisions performed up to the end of 2016 will result in 500,000 fewer HIV infections by 2030.

From 2010 to 2013, the annual number of circumcisions approximately doubled each year, reaching 2.79 million in 2014. Figures dropped slightly in 2015 and 2016, before reaching 3.38 million in 2017, the highest annual total to date. Over half (54%) of all PEPFAR-supported circumcisions were performed in 2015-2017.

The researchers at the division of global HIV and TB, HIV prevention branch, voluntary medical male circumcision team, US Centres for Disease Control and Prevention, Atlanta, President’s Emergency Plan for AIDS Relief, Office of the US Global AIDS Coordinator and Health Diplomacy, Washington, the US Department of Defence HIV/AIDS Prevention Programme (DHAPP), Naval Health Research Centre, San Diego, California, the US Agency for International Development, Global Health Bureau and the Office of HIV/AIDS, Prevention, Care and Treatment division, Washington, describe this as “a scale-up of historic proportions within global health, comparable with the scale-up of HIV treatment.”

Programme size varied considerably by country, varying from 3.62m performed in Uganda to 66,410 in Ethiopia. This is partly related to country population size but is also due to their HIV epidemiology; for instance, only two high-prevalence provinces in Ethiopia are covered.

The programme originally prioritised men and teenage boys aged 15-29, as it was reasoned that this was the peak age for sexual debut and activity. An unforseen development is that although 48% of VMMCs in 2017 were performed on males of this age, almost as many – 45% – were performed on boys aged 10-14. This proportion has increased slightly in the last few years.

It is not certain why the average age is younger than envisaged, but reasons suggested by the writers include reluctance in older males to abstain from sex for the six-week healing period, perception of low risk in men with established partners, the cost of losing wages during recovery, and fear of being suspected of infidelity. While circumcision in younger boys will still result in a reduction in their risk of HIV once they start having sex, the prevention benefit of the programme will be delayed.

Testing for HIV before the procedure is encouraged in the PEPFAR VMMC programme but not mandatory – 8% of males who underwent VMMC did not test and this proportion has stayed steady, but was considerably more common in Lesotho (50%), Namibia, Ethiopia and South Africa (20%). Only 1% of those who tested were HIV-positive – much lower than the HIV-positivity among the general male population aged 15-49 in the 14 countries of 5.5%, mostly due to the young age of VMMC attendees.

The proportion of men who attended follow-up appointments within 14 days of their VMMC procedure was generally good and improved from 72% in 2015 to 84% in 2017. Individual country rates ranged from 100% in Rwanda to 59% in South Africa.

There were significant declines in the number of VMMCs performed in Uganda and Rwanda between 2014 and 2016. This was largely due to a cluster of cases of tetanus occurring in VMMC recipients in Uganda. The situation was resolved by 2017 (in Uganda, by making tetanus vaccination mandatory before VMMC). In that year VMMCs in Uganda doubled relative to the previous year and in Rwanda they more than tripled. As Uganda has the largest PEPFAR VMMC programme, these events had an impact on the overall PEPFAR figures.

The writers of the paper say that the VMMC programme has had benefits over and above reducing the lifetime risk of HIV infection to heterosexual men by roughly two-thirds. As well as offering protection from some other STIs, it “has connected them with additional HIV and other health services through testing, STI screening, and referrals for other health conditions.” Men who are circumcised are also less likely to pass on HIV and some other STIs to women.

In addition, the VMMC programme has involved engaging young men, a traditionally hard-to-recruit population, in the idea of protecting themselves for HIV. Its approach, which has included appeals to traditionally masculine ideas of strength and responsibility, may help in reaching men who need to be targeted by other prevention methods such as pre-exposure prophylaxis (PrEP).

Abstract
Objective: This article provides an overview and interpretation of the performance of the US President’s Emergency Plan for AIDS Relief’s (PEPFAR’s) male circumcision programme which has supported the majority of voluntary medical male circumcisions (VMMCs) performed for HIV prevention, from its 2007 inception to 2017, and client characteristics in 2017.
Design: Longitudinal collection of routine programme data and disaggregations.
Setting 14 countries in sub-Saharan Africa with low baseline male circumcision coverage, high HIV prevalence and PEPFAR-supported VMMC programmes.
Participants: Clients of PEPFAR-supported VMMC programmes directed at males aged 10 years and above.
Main outcome measures: Numbers of circumcisions performed and disaggregations by age band, result of HIV test offer, procedure technique and follow-up visit attendance.
Results: PEPFAR supported a total of 15 269 720 circumcisions in 14 countries in Southern and Eastern Africa. In 2017, 45% of clients were under 15 years of age, 8% had unknown HIV status, 1% of those tested were HIV+ and 84% returned for a follow-up visit within 14 days of circumcision.
Conclusions: Over 15 million VMMCs have been supported by PEPFAR since 2007. VMMC continues to attract primarily young clients. The non-trivial proportion of clients not testing for HIV is expected, and may be reassuring that testing is not being presented as mandatory for access to circumcision, or in some cases reflect test kit stockouts or recent testing elsewhere. While VMMC is extremely safe, achieving the highest possible follow-up rates for early diagnosis and intervention on complications is crucial, and programmes continue to work to raise follow-up rates. The VMMC programme has achieved rapid scale-up but continues to face challenges, and new approaches may be needed to achieve the new Joint United Nations Programme on HIV/AIDS goal of 27 million additional circumcisions through 2020.

Authors
Stephanie M Davis, Jonas Z Hines, Melissa Habel, Jonathan M Grund, Renee Ridzon, Brittney Baack, Jonathan Davitte, Anne Thomas, Valerian Kiggundu, Naomi Boc, Paran Pordell, Caroline Cooney, Irum Zaidi, Carlos Toledo

[link url="http://www.aidsmap.com/PEPFAR-funded-15-million-medical-male-circumcisions-between-2007-and-2017/page/3343169/"]Aidsmap material[/link]
[link url="https://bmjopen.bmj.com/content/8/8/e021835"]BMJ Open abstract[/link]

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