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Voluntary Medical Male Circumcision — Southern and Eastern Africa, 2010–2012

Sub-Saharan Africa bears the greatest global burden of human immunodeficiency virus (HIV) infection; 70% (25.0 million) of all persons living with HIV reside in this region (1). Voluntary medical male circumcision (VMMC) has been shown to reduce the risk for heterosexually acquired HIV among men by approximately 60% in three randomized controlled trials (2–5). Further studies found that the protection from HIV acquisition conferred by VMMC was sustained for 6 years following surgery (6,7). In 2007, the World Health Organization (WHO) and Joint United Nations Programme on HIV/AIDS (UNAIDS) recommended that 14 countries with generalized HIV epidemics (i.e., where >1% of the population is HIV-positive) and low male circumcision prevalence* prioritize scale-up of VMMC for HIV prevention (8). On December 1, 2011 (World AIDS Day), funding through the President's Emergency Plan for AIDS Relief (PEPFAR) was announced to support >4.7 million VMMCs over the next 2 years. This report presents the results of VMMC scale-up in nine countries where national ministries of health and CDC are implementing VMMC services for HIV prevention: Botswana, Kenya, Malawi, Mozambique, Namibia, South Africa, Tanzania, Uganda, and Zambia. During October 2009–September 2012,§ a total of 1,924,792 VMMCs were performed in 14 countries using PEPFAR funding provided through U.S. government agencies; of this total, 1,020,424 were conducted at approximately 1,600 CDC-supported VMMC sites: 137,096 VMMCs in 2010, 347,724 in 2011, and 535,604 in 2012.** Continued program monitoring and quality assurance activities are required to ensure that CDC-supported country programs meet World AIDS Day targets for VMMC.

Data were collected from VMMC client medical forms and country-specific data collection and summarization tools from CDC-supported sites. These data include only VMMCs for HIV prevention, performed under local anesthesia in medical settings by trained clinicians in southern and eastern Africa. All VMMC clients provided informed consent, or assent with permission from a parent or guardian for those aged <18 years. If clinicians determine that a client aged <15 years understands the information provided and is able to cooperate with VMMC under local anesthesia, then surgery can be performed, as long as assent and permission is provided. Data from approximately 1,600 CDC-supported sites were pooled by CDC country offices from local VMMC implementing partners and used to generate summary statistics. Multicountry analyses were conducted to document VMMC progress by examination of data for VMMCs performed, client age, HIV testing and counseling (HTC) acceptance and results, postoperative reviews, and postoperative moderate and severe adverse events (AEs) from 2010–2012. Moderate and severe AEs (e.g., excessive bleeding, infection, swelling, or wound disruption) were classified by type and severity according to PEPFAR's indicator guidance.†† Some countries use AE definitions that vary slightly from country to country. Annual data were not available from all countries (Table 1).

During 2010–2012, approximately 1,020,424 males were circumcised at CDC-supported sites in the nine countries. The total number of VMMCs has increased each year: 137,096 VMMCs performed in 2010 (seven countries), 347,724 in 2011 (eight countries), and 535,604 in 2012 (nine countries). CDC-supported VMMC programs in Kenya and Uganda performed the most VMMCs during these years: 386,752 and 205,812, respectively (Table 1).

Of the countries reporting data on HTC for VMMC clients (n = 533,143), 86.5% (461,323) of VMMC clients accepted HTC during 2010–2012. Among clients accepting HTC, 2.4% (10,933) tested HIV-positive and were referred to care and treatment services (Table 2). HTC acceptance among VMMC clients varied during this period but remained high: 84.1% in 2010 (four countries), 95.4% in 2011 (five countries), and 83.8% in 2012 (eight countries).

All VMMC clients are advised to return to a health facility for postoperative assessment. Of the countries reporting data on postoperative visits of VMMC clients (n = 614,478), a total of 359,881 clients (58.6%) returned for assessment at the circumcising site within 14 days of surgery. Postoperative follow-up rates have been inconsistent at 75.7% (three countries), 50.0% (five countries), and 64.8% (seven countries) for 2010, 2011, and 2012, respectively. Among all clients returning for postoperative follow-up review within 14 days, the overall postoperative moderate or severe AE rate was low (0.8%), and within acceptable rates for minor surgery. The proportion of clients experiencing a moderate or severe AE has declined from 1.7% in 2010 (three countries) to 0.9% in 2011 (five countries) and 0.8% in 2012 (six countries) (Table 2).

For 986,392 (96.7%) VMMC clients with age reported, the proportion of clients aged ≥15 years increased during 2010–2012. In 2010, the proportion of clients aged ≥15 years was 67.0% (89,280) (six countries), increasing to 78.7% (272,038) (eight countries) in 2011 and 79.4% (400,560) (eight countries) in 2012. The proportion of VMMC clients aged ≥25 years has increased from 0.1% (70) in 2010 (one country), 3.0% (10,249) in 2011 (five countries), and 6.0% (30,553) in 2012 (six countries) (Table 3).

Reported by

Mpho Dorothy Seretse, Ministry of Health, Botswana. Peter Cherutich, MBChB, National AIDS and STI Control Programme, Kenya. Amon Nkhata, Ministry of Health—HIV and AIDS Dept, Malawi. Jotamo Come, MD, Ministry of Health, Mozambique. Epafras Anyolo, Ministry of Health and Social Svcs, Namibia. Goitsemodimo Collen Bonnecwe, National Dept of Health, South Africa. Gissenge J.I. Lija, MD, Ministry of Health and Social Welfare—National AIDS Control Program, Tanzania. Alex Opio, PhD, Ministry of Health, Uganda. Bushimbwa Tambatamba Chapula, MD, Ministry of Community Development, Mother and Child Health, Zambia. Robert Manda, MBChB, (CDC Botswana); Samuel Mwalili, PhD, (CDC Kenya); Beth A. Tippett Barr, DrPH, (CDC Malawi); Beverley Cummings, MPH, (CDC Mozambique); Gram Mutandi, MBChB, MPH, (CDC Namibia); Carlos Toledo, PhD, (CDC South Africa); Kokuhumbya J. Kazaura, DDS, (CDC Tanzania); Monica Dea, MS, MPH, (CDC Uganda); Jonas Mwale, MD, (CDC Zambia); Jonathan Grund, MA, MPH, Naomi Bock, MD, Div of Global HIV/AIDS, Center for Global Health, CDC. Corresponding contributor: Jonathan Grund, jgrund@cdc.gov, 404-639-8978.

Editorial Note

VMMC is an effective HIV prevention intervention that can be implemented safely in countries in southern and eastern Africa. The announcement on World AIDS Day in 2011 that PEPFAR would support 4.7 million circumcisions provided an achievable goal for VMMC scale-up. In the nine CDC-supported countries, VMMC acceptance has increased nearly fourfold from 2010 to 2012.The postoperative moderate or severe AEs have remained low. Mathematical modeling suggests that reaching 80% VMMC coverage among males aged 15–49 years in the priority countries would require 20.3 million circumcisions by 2015, which would avert approximately 3.4 million HIV infections through 2025 and result in $16.5 billion in net savings from averted HIV care and treatment costs (9).

To reach 80% coverage and the World AIDS Day VMMC goals, country programs have implemented various efficiency models to expedite scale-up. Each of the nine countries included in this analysis has introduced components of WHO's model for optimizing the volume and efficiency of male circumcision services (i.e., MOVE) (10), including the use of standardized VMMC surgical techniques (nine countries), electrocautery (four countries), use of nonphysicians and lower cadres of health-care providers (nine countries). Most countries rely on nonphysicians (i.e., nurses and clinical officers) to perform VMMC surgery. VMMC country programs are also implementing standardized training programs for all cadres of VMMC providers; targeted, client-specific campaigns to increase demand for VMMC; and routine, site-level quality assurance assessments. Many countries are moving toward a mixed-service delivery model that combines fixed VMMC sites (e.g., permanent sites within existing health-care facilities, such as hospitals and health centers) with mobile and outreach sites (e.g., use of tents, prefabricated structures, and other temporary locations for VMMC service delivery). All sites offering VMMC must provide the "minimum package" of complementary services specified by WHO, including information about the risks and benefits of the procedure, HTC, screening, and treatment of sexually transmitted infections; preoperative and postoperative counseling; and promotion and provision of condoms (10).

In sub-Saharan Africa, men aged 20–39 years are at highest risk for acquiring HIV (1). Only 12.5% (33,420 of 267,158) of VMMC clients during 2010–2012 were aged ≥25 years among those countries reporting this age disaggregation (three countries in 2011 and four in 2012). VMMC programs need to identify innovative approaches to increase VMMC acceptability for men aged ≥25 years. CDC is working in Kenya, Tanzania, and South Africa to evaluate strategies to increase the proportion of older males receiving VMMC and to promote HTC among VMMC clients.

HIV prevalence among adolescents and adults aged 15–49 years of both sexes is high in the nine countries (range: 5.1%–23.0%). Because VMMC clients are all male and generally young (median age: 15–19 years), they would be expected to have a lower HIV prevalence than the general population of persons aged 15–49 years. Among the 461,323 VMMC clients included in this analysis who accepted HTC, 2.4% (10,933) tested HIV-positive (Table 2).

The findings in this report are subject to at least four limitations. First, several countries did not begin scaling up VMMC until 2010 or 2011, which is partially responsible for missing data. Second, because of differing numbers of countries included in the analyses of different variables across years, trends found might not be representative of all VMMC clients. Third, ministry of health–approved client-level data collection tools are not identical across countries, which contributed to difficulties in data aggregation across countries, including the lower age limit for VMMC clients. Finally, some national ministries of health have similar but not identical definitions for classifying type, severity, and clinical signs for VMMC AEs. Although PEPFAR guidance for AE reporting is used in all of PEPFAR's VMMC programs, discrepant diagnoses and management might result in differences in reporting.

Quality assurance processes should monitor routine reporting of additional VMMC indicators to ensure data availability and to improve data quality. CDC's external quality assurance activities provide an opportunity to work with ministry of health officials and VMMC implementers to assess and improve data collection and reporting practices. Improved data collection and reporting practices will help CDC-supported country programs meet the World AIDS Day targets for VMMC and achieve an AIDS-free generation.

Acknowledgments

Zebedee Mwandi, US Agency for International Development, Malawi. Kipruto Chesang (CDC Kenya), Donath Emusu (CDC Kenya), Evelyn Muthama (CDC Kenya), Tamsin Bowra (CDC Namibia), Sadhna Patel (CDC Namibia), Gilly Arthur (CDC Tanzania), Kathryn Rosecrans (CDC Tanzania), Rachel Weber (CDC Tanzania); Jacob Dee, Sarah Porter, Div of Global HIV/AIDS, Center for Global Health, CDC.

References

  1. Joint United Nations Programme on HIV/AIDS. Global report: UNAIDS report on the global AIDS epidemic 2013. Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS; 2013. Available at http://www.unaids.org/en/media/unaids/contentassets/documents/epidemiology/2013/gr2013/UNAIDS_Global_Report_2013_en.pdf.
  2. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trial. PLoS Med 2005; 2:e298.
  3. Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomized controlled trial. Lancet 2007;369:643–56.
  4. Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007;369:657–66.
  5. Weiss HA, Quigley MA, Hayes RJ. Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis. AIDS 2000;14:2361–70.
  6. Mehta A, Moses S, Agot K, et al. The long term efficacy of medical male circumcision against HIV acquisition. AIDS 2013 [Epub ahead of print].
  7. Gray R, Kigozi G, Kong X, et al. The effectiveness of male circumcision for HIV prevention and effects on risk behaviors in a post-trial follow up study in Rakai, Uganda. AIDS 2012;26:609–15.
  8. World Health Organization; Joint United Nations Programme on HIV/AIDS. New data on male circumcision and HIV prevention: policy and programme implications: conclusions and recommendations. Geneva, Switzerland: World Health Organization; 2007. Available at http://www.who.int/hiv/pub/malecircumcision/research_implications/en.
  9. Njeuhmeli E, Forsythe S, Reed J, et al. Voluntary medical male circumcision: modeling the impact and cost of expanding male circumcision for HIV prevention in eastern and southern Africa. PLoS Med 2011;8:e1001132.
  10. World Health Organization. Considerations for implementing models for optimizing the volume and efficiency of male circumcision services. Geneva, Switzerland: World Health Organization; 2010. Available at http://www.malecircumcision.org/programs/documents/mc_MOVE_2010_web.pdf.

* The 14 countries with 2013 HIV prevalence reported include Botswana (23.0%), Ethiopia (1.3%), Kenya (6.1%), Lesotho (23.1%), Malawi (10.8%), Mozambique (11.1%), Namibia (13.3%), Rwanda (2.9%), South Africa (17.9%), Swaziland (26.5%), Tanzania (5.1%), Uganda (7.2%), Zambia (12.7%), and Zimbabwe (14.7%).

Additional information available at http://www.whitehouse.gov/the-press-office/2011/12/01/fact-sheet-beginning-end-aids.

§ Data are reported by fiscal year in this report, unless noted otherwise. U.S. government fiscal year is October 1–September 30.

Summary results from PEPFAR's 2012 annual progress report are available at http://www.pepfar.gov/documents/organization/201387.pdf.

** CDC support includes hiring of clinical staff to provide VMMCs, conducting trainings and quality assurance assessments, providing technical assistance, and procurement of VMMC supplies, medications, and instruments.

†† PEPFAR's indicator reference sheet for VMMC is available at http://www.malecircumcision.org/resources/documents/PEPFAR_Guide_Monitoring_Reporting_VMMC_Indicators_Appendices.pdf.


What is already known on this topic?

Voluntary medical male circumcision (VMMC) has been recognized by the World Health Organization and Joint United Nations Programme on HIV/AIDS as an effective human immunodeficiency virus (HIV) prevention intervention in settings with a generalized HIV epidemic and low male circumcision prevalence.

What is added by this report?

This report summarizes progress toward the 2011 World AIDS Day VMMC target of 4.7 million circumcisions by 2013. During 2010–2012, VMMC progress has been increasing in nine countries where CDC supports VMMC service delivery, with 137,096 VMMCs in 2010, 347,724 in 2011, and 535,604 in 2012.

What are the implications for public health practice?

Accelerated VMMC scale-up can be achieved in southern and eastern Africa while maintaining high acceptance of HIV testing and counseling and low rates of adverse events.


TABLE 1. Voluntary medical male circumcisions (VMMCs) performed by CDC-supported programs, by country and fiscal year, 2010–2013

Country

No. of VMMCs

2010

2011

2012

Total

Botswana

8,590

8,590

Kenya*

104,131

166,310

116,311

386,752

Malawi

778

7,420

8,198

Mozambique

4,009

18,472

68,924

91,405

Namibia

1,197

5,292

5,965

12,454

South Africa§

3,820

15,574

80,701

100,095

Tanzania

1,519

50,325

49,756

101,600

Uganda

9,052

57,132

139,628

205,812

Zambia

13,368

33,841

58,309

105,518

Total

137,096

347,724

535,604

1,020,424

Source: President's Emergency Plan for AIDS Relief (PEPFAR) annual progress report (APR) submissions for CDC-supported partners, for fiscal years October 1–September 30, except where noted.

* Kenya's data for 2010 and 2011 are reported from January–December, but data from 2012 are from October–September.

Malawi's data are from APR results and CDC Malawi's partner reports for 2012.

§ South Africa's data are reported from January–December for 2010–2012.

Tanzania's data for 2010–2012 are from APR reports and Tanzania's national database.


TABLE 2. Voluntary medical male circumcision (VMMC) progress, HIV testing and counseling (HTC) acceptance, human immunodeficiency virus (HIV) prevalence among VMMC clients, postoperative follow-up reviews among VMMC clients, and postoperative moderate or severe VMMC adverse event (AE) rates, by country and year, 2010–2012

Country

Total VMMCs performed

HTC uptake among VMMC clients

HIV prevalence among VMMC clients

Postoperative follow-up within 14 days of VMMC

Postoperative moderate or severe AEs

No.

No.

(%)

No.

(%)

No.

(%)

No.

(%)

2012

Botswana

8,590

7,702

(89.7)

234

(3.0)

6,571

(76.5)

136

(2.1)

Kenya

116,311

97,647

(84.0)

3,386

(3.5)

40,084

(34.5)

506*

(1.3)

Malawi

7,420

526

(53.1)

38

(7.2)

398

(40.2)

Mozambique

68,924

68,924

(100.0)

1,915

(1.3)

Namibia

5,965

5,259

(88.2)

69

(1.3)

5,777

(96.8)

62

(1.1)

South Africa

80,701

79,087

(98.0)

1,788

(2.3)

72,631

(90.0)

290

(0.4)

Tanzania

49,756

43,637

(87.7)

590

(1.4)

41,561

(83.5)

272*

(0.7)

Uganda

139,628

Zambia

58,309

23,802

(40.8)

165

(0.7)

45,026

(77.2)

351*

(0.8)

Total

535,604

326,584

(83.8)

8,185

(2.5)

212,048

(64.8)

1,617

(0.8)

2011

Botswana

Kenya

166,310

42,937

(25.8)

284*

(0.7)

Malawi

778

Mozambique

18,472

18,472

(100.0)

753

(4.1)

Namibia

5,292

4,770

(90.1)

71

(1.5)

5,084

(96.1)

92

(1.8)

South Africa

15,574

13,091

(84.1)

526

(4.0)

12,023

(77.2)

87

(0.7)

Tanzania

50,325

47,658

(94.8)

636

(1.3)

48,078

(95.5)

421*

(0.9)

Uganda

57,132

Zambia

33,841

33,841

(100.0)

339

(1.0)

27,530

(81.4)

252

(0.9)

Total

347,724

117,832

(95.4)

2,325

(2.0)

135,652

(50.0)

1,196

(0.9)

2010

Botswana

Kenya

104,131

Malawi

Mozambique

4,009

3,701

(92.3)

154

(4.2)

Namibia

1,197

996

(83.2)

26

(2.6)

891

(74.4)

20

(2.2)

South Africa

3,820

Tanzania

1,519

1,346

(88.6)

16

(1.2)

1,267

(83.4)

53*

(4.2)

Uganda

9,052

Zambia

13,368

10,864

(81.3)

227

(2.1)

10,023

(75.0)

130

(1.3)

Total

137,096

16,907

(84.1)

423

(2.5)

12,181

(75.7)

203

(1.7)

Summary 2010–2012

Botswana

8,590

7,702

(89.7)

234

(3.0)

6,571

(76.5)

136

(2.1)

Kenya

386,752

97,647

(84.0)

3,386

(3.5)

790

(—)

Malawi

8,198

526

(53.1)

38

(7.2)

398

(5.4)

(—)

Mozambique

91,405

91,097

(99.7)

2,822

(3.1)

446

(—)

Namibia

12,454

11,025

(88.5)

166

(1.5)

11,752

(94.4)

174

(1.5)

South Africa

100,095

92,178

(95.7)

2,314

(2.5)

84,654

(87.9)

377

(0.4)

Tanzania

101,600

92,641

(91.2)

1,242

(1.3)

90,906

(89.5)

746

(0.8)

Uganda

205,812

470

(—)

Zambia

105,518

68,507

(64.9)

731

(1.1)

82,579

(78.3)

733

(0.9)

Total

1,020,424

461,323

(86.5)

10,933

(2.4)

359,881

(58.6)

3,016

(0.8)

* Contains both intraoperative and moderate or severe postoperative AEs.

Tanzania's data for postoperative follow-up visits are within 48 hours of surgery, not 14 days. Tanzania's national database collects HTC data on all patients regardless of whether they received VMMC. HTC acceptance among VMMC clients in this table has been imputed by using HTC data from all clients testing at the VMMC site.


TABLE 3. Voluntary medical male circumcisions, by age group, country, and year, 2010–2012

Country

2012

Age group (yrs)

<15

≥15

15–19

20–24

≥25

Total

Botswana

865

7,725

2,385

2,267

3,073

8,590

Kenya*

16,725

99,586

99,586

116,311

Malawi

Mozambique*

36,504

32,420

20,388

6,988

5,044

68,924

Namibia

1,183

4,782

4,782

5,965

South Africa

11,825

68,876

37,069

16,738

15,069

80,701

Tanzania

24,209

25,547

22,139

3,408

49,756

Uganda*

43,540

90,549

90,549

134,089

Zambia

13,121

30,150

23,518

2,673

3,959

43,271

Total

147,972

400,560

300,416

28,666

30,553

507,607

Percentage

29.2%

79.4%

59.2%

5.6%

6.0%

100.0%

Country

2011

Age group (yrs)

<15

≥15

15–19

20–24

≥25

Total

Botswana

Kenya*

20,129

146,181

146,181

166,310

Malawi*

180

598

598

778

Mozambique*

7,181

11,291

5,958

3,185

2,148

18,472

Namibia*

976

4,316

4,316

5,292

South Africa§

295

13,064

6,467

3,651

2,946

13,359

Tanzania

19,432

30,893

26,919

3,974

50,325

Uganda*

16,406

40,726

40,726

57,132

Zambia

8,872

24,969

20,139

3,649

1,181

33,841

Total

73,471

272,038

251,304

10,485

10,249

345,509

Percentage

21.3%

78.7%

72.7%

3.0%

3.0%

100.0%

Country

2010

Age group (yrs)

<15

≥15

15–19

20–24

≥25

Total

Botswana

Kenya*

36,565

67,566

67,566

104,131

Malawi

Mozambique*

492

3,517

3,517

4,009

Namibia*

28

1,169

1,169

1,197

South Africa

Tanzania

417

1,102

1,032

70

1,519

Uganda*

2,561

6,491

6,491

9,052

Zambia

3,933

9,435

9,435

13,368

Total

43,969

89,280

89,210

70

133,276

Percentage

33.0%

67.0%

66.9%

0.0%

0.1%

100.0%

Country

Summary 2010–2012

Age group (yrs)

<15

≥15

15–19

20–24

≥25

Total

Botswana

865

7,725

2,385

2,267

3,073

8,590

Kenya*

73,419

313,333

313,333

0

0

386,752

Malawi

180

598

598

0

0

778

Mozambique*

44,177

47,228

29,863

10,173

7,192

91,405

Namibia*

2,187

10,267

10,267

0

0

12,454

South Africa

12,120

81,940

43,536

20,389

18,015

94,060

Tanzania

44,058

57,542

50,090

0

7,452

101,600

Uganda*

62,507

137,766

137,766

0

0

200,273

Zambia

25,926

64,554

53,092

6,322

5,140

90,480

Total

265,439

761,878

640,930

39,151

40,872

986,392

Percentage

26.9%

77.2%

65.0%

4.0%

4.1%

100.0%

* These countries only reported age groups as 1–14 years and ≥15 years.

Tanzania's age groups reported as <15, 15–25, and ≥26 years.

§ Age missing for some VMMC clients.


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