Progress in voluntary medical male circumcision for HIV prevention supported by the US President’s Emergency Plan for AIDS Relief through 2017: longitudinal and recent cross-sectional programme data

ObjectiveThis 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.DesignLongitudinal collection of routine programme data and disaggregations.Setting14 countries in sub-Saharan Africa with low baseline male circumcision coverage, high HIV prevalence and PEPFAR-supported VMMC programmes.ParticipantsClients of PEPFAR-supported VMMC programmes directed at males aged 10 years and above.Main outcome measuresNumbers of circumcisions performed and disaggregations by age band, result of HIV test offer, procedure technique and follow-up visit attendance.ResultsPEPFAR 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.ConclusionsOver 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.

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Urethrocutaneous fistulas after voluntary medical male circumcision for HIV prevention—15 African Countries, 2015–2019

BMC Urology ◽

10.1186/s12894-021-00790-y ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Todd Lucas ◽

Jonas Z. Hines ◽

Julia Samuelson ◽

Timothy Hargreave ◽

Stephanie M. Davis ◽

...

Keyword(s):

Hiv Prevention ◽

Male Circumcision ◽

Odds Ratio ◽

Voluntary Medical Male Circumcision ◽

Emergency Plan ◽

African Countries ◽

Patient Age ◽

Medical Male Circumcision ◽

Urethral Wall ◽

Patient Âgé

Abstract Background Voluntary medical male circumcision (VMMC) is an HIV prevention strategy recommended to partially protect men from heterosexually acquired HIV. From 2015 to 2019, the President’s Emergency Plan for AIDS Relief (PEPFAR) has supported approximately 14.9 million VMMCs in 15 African countries. Urethrocutaneous fistulas, abnormal openings between the urethra and penile skin through which urine can escape, are rare, severe adverse events (AEs) that can occur with VMMC. This analysis describes fistula cases, identifies possible risks and mechanisms of injury, and offers mitigation actions. Methods Demographic and clinical program data were reviewed from all reported fistula cases during 2015 to 2019, descriptive analyses were performed, and an odds ratio was calculated by patient age group. Results In total, 41 fistula cases were reported. Median patient age for fistula cases was 11 years and 40/41 (98%) occurred in patients aged < 15 years. Fistulas were more often reported among patients < 15 compared to ≥ 15 years old (0.61 vs. 0.01 fistulas per 100,000 VMMCs, odds ratio 50.9 (95% confidence interval [CI] = 8.6–2060.0)). Median time from VMMC surgery to appearance of fistula was 20 days (interquartile range (IQR) 14–27). Conclusions Urethral fistulas were significantly more common in patients under age 15 years. Thinner tissue overlying the urethra in immature genitalia may predispose boys to injury. The delay between procedure and symptom onset of 2–3 weeks indicates partial thickness injury or suture violation of the urethral wall as more likely mechanisms of injury than intra-operative urethral transection. This analysis helped to inform PEPFAR’s recent decision to change VMMC eligibility policy in 2020, raising the minimum age to 15 years.

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Scale-Up of Voluntary Medical Male Circumcision Services for HIV Prevention — 12 Countries in Southern and Eastern Africa, 2013–2016

MMWR Morbidity and Mortality Weekly Report ◽

10.15585/mmwr.mm6647a2 ◽

2017 ◽

Vol 66 (47) ◽

pp. 1285-1290 ◽

Cited By ~ 10

Author(s):

Jonas Z. Hines ◽

Onkemetse Conrad Ntsuape ◽

Kananga Malaba ◽

Tiruneh Zegeye ◽

Kennedy Serrem ◽

...

Keyword(s):

Hiv Prevention ◽

Male Circumcision ◽

Scale Up ◽

Eastern Africa ◽

Voluntary Medical Male Circumcision ◽

Medical Male Circumcision

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A review of public health, social and ethical implications of voluntary medical male circumcision programs for HIV prevention in sub-Saharan Africa

International Journal of Impotence Research ◽

10.1038/s41443-021-00484-x ◽

2021 ◽

Author(s):

Winnie Kavulani Luseno ◽

Stuart Rennie ◽

Adam Gilbertson

Keyword(s):

Public Health ◽

Hiv Prevention ◽

Male Circumcision ◽

Sub Saharan Africa ◽

Voluntary Medical Male Circumcision ◽

Medical Male Circumcision ◽

Ethical Implications ◽

Sub Saharan

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Messaging Circumstances and Economic Pressures as Influences on Linkage to Medical Male Circumcision following Community-Based HIV Testing for Men in Rural Southwest Uganda: A Qualitative Study

AIDS Research and Treatment ◽

10.1155/2018/8387436 ◽

2018 ◽

Vol 2018 ◽

pp. 1-7 ◽

Cited By ~ 1

Author(s):

Hannah N. Gilbert ◽

Monique A. Wyatt ◽

Stephen Asiimwe ◽

Bosco Turyamureeba ◽

Elioda Tumwesigye ◽

...

Keyword(s):

Qualitative Study ◽

Hiv Testing ◽

Male Circumcision ◽

Sub Saharan Africa ◽

Voluntary Medical Male Circumcision ◽

Hiv Education ◽

Community Based ◽

Medical Male Circumcision ◽

Demand Creation

Voluntary medical male circumcision (MMC) reduces risk of HIV infection, but uptake remains suboptimal among certain age groups and locations in sub-Saharan Africa. We analysed qualitative data as part of the Linkages Study, a randomized controlled trial to evaluate community-based HIV testing and follow-up as interventions promoting linkage to HIV treatment and prevention in Uganda and South Africa. Fifty-two HIV-negative uncircumcised men participated in the qualitative study. They participated in semistructured individual interviews exploring (a) home HTC experience; (b) responses to test results; (c) efforts to access circumcision services; (d) outcomes of efforts; (e) experiences of follow-up support; and (f) local HIV education and support. Interviews were audio-recorded, translated, transcribed, and summarized into “linkage summaries.” Summaries were analysed inductively to identify the following three thematic experiences shaping men’s circumcision choices: (1) intense relief upon receipt of an unanticipated seronegative diagnosis, (2) the role of peer support in overcoming fear, and (3) anticipation of missed economic productivity. Increased attention to the timing of demand creation activities, to who delivers information about the HIV prevention benefits of MMC, and to the importance of missed income during recovery as a barrier to uptake promises to strengthen and sharpen future MMC demand creation strategies.

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Data triangulation to estimate age-specific coverage of voluntary medical male circumcision for HIV prevention in four Kenyan counties

PLoS ONE ◽

10.1371/journal.pone.0209385 ◽

2018 ◽

Vol 13 (12) ◽

pp. e0209385 ◽

Cited By ~ 3

Author(s):

Katharine Kripke ◽

Marjorie Opuni ◽

Elijah Odoyo-June ◽

Mathews Onyango ◽

Peter Young ◽

...

Keyword(s):

Hiv Prevention ◽

Male Circumcision ◽

Voluntary Medical Male Circumcision ◽

Medical Male Circumcision

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Ethics of pursuing targets in public health: the case of voluntary medical male circumcision for HIV-prevention programs in Kenya

Journal of Medical Ethics ◽

10.1136/medethics-2020-106293 ◽

2020 ◽

pp. medethics-2020-106293

Author(s):

Stuart Rennie ◽

Adam Gilbertson ◽

Denise Hallfors ◽

Winnie K Luseno

Keyword(s):

Public Health ◽

Hiv Prevention ◽

Male Circumcision ◽

Voluntary Medical Male Circumcision ◽

Global Public Health ◽

Medical Male Circumcision ◽

Public Health Initiative ◽

The Many ◽

Global Initiatives ◽

Health Programmes

The use of targets to direct public health programmes, particularly in global initiatives, has become widely accepted and commonplace. This paper is an ethical analysis of the utilisation of targets in global public health using our fieldwork on and experiences with voluntary medical male circumcision (VMMC) initiatives in Kenya. Among the many countries involved in VMMC for HIV prevention, Kenya is considered a success story, its programmes having medically circumcised nearly 2 million men since 2007. We describe ethically problematic practices in Kenyan VMMC programmes revealed by our fieldwork, how the problems are related to the pursuit of targets and discuss possible approaches to their management. Although the establishment and pursuit of targets in public health can have many benefits, assessments of target-driven programmes tend to focus on quantifiable outcomes rather than the processes by which the outcomes are obtained. However, in order to speak more robustly about programmatic ‘success’, and to maintain community trust, it is vital to ethically evaluate how a public health initiative is actually implemented in the pursuit of its targets.

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