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

Countries in Southern and Eastern Africa have the highest prevalence of human immunodeficiency virus (HIV) infection in the world; in 2015, 52% (approximately 19 million) of all persons living with HIV infection resided in these two regions.* Voluntary medical male circumcision (VMMC) reduces the risk for heterosexually acquired HIV infection among males by approximately 60% (1). As such, it is an essential component of the Joint United Nations Programme on HIV/AIDS (UNAIDS) strategy for ending acquired immunodeficiency syndrome (AIDS) by 2030 (2). Substantial progress toward achieving VMMC targets has been made in the 10 years since the World Health Organization (WHO) and UNAIDS recommended scale-up of VMMC for HIV prevention in 14 Southern and Eastern African countries with generalized HIV epidemics and low male circumcision prevalence (3).† This has been enabled in part by nearly $2 billion in cumulative funding through the President's Emergency Plan for AIDS Relief (PEPFAR), administered through multiple U.S. governmental agencies, including CDC, which has supported nearly half of all PEPFAR-supported VMMCs to date. Approximately 14.5 million VMMCs were performed globally during 2008-2016, which represented 70% of the original target of 20.8 million VMMCs in males aged 15-49 years through 2016 (4). Despite falling short of the target, these VMMCs are projected to avert 500,000 HIV infections by the end of 2030 (4). However, UNAIDS has estimated an additional 27 million VMMCs need to be performed by 2021 to meet the Fast Track targets (2). This report updates a previous report covering the period 2010-2012, when VMMC implementing partners supported by CDC performed approximately 1 million VMMCs in nine countries (5). During 2013-2016, these implementing partners performed nearly 5 million VMMCs in 12 countries. Meeting the global target will require redoubling current efforts and introducing novel strategies that increase demand among subgroups of males who have historically been reluctant to undergo VMMC.

persons living with HIV infection resided in these two regions.* Voluntary medical male circumcision (VMMC) reduces the risk for heterosexually acquired HIV infection among males by approximately 60% (1). As such, it is an essential component of the Joint United Nations Programme on HIV/AIDS (UNAIDS) strategy for ending acquired immunodeficiency syndrome (AIDS) by 2030 (2). Substantial progress toward achieving VMMC targets has been made in the 10 years since the World Health Organization (WHO) and UNAIDS recommended scale-up of VMMC for HIV prevention in 14 Southern and Eastern African countries with generalized HIV epidemics and low male circumcision prevalence (3). † This has been enabled in part by nearly $2 billion in cumulative funding through the President's Emergency Plan for AIDS Relief (PEPFAR), administered through multiple U.S. governmental agencies, including CDC, which has supported nearly half of all PEPFAR-supported VMMCs to date. Approximately 14.5 million VMMCs were performed globally during 2008-2016, which represented 70% of the original target of 20.8 million VMMCs in males aged 15-49 years through 2016 (4). Despite falling short of the target, these VMMCs are projected to avert 500,000 HIV infections by the end of 2030 (4). However, § CDC support includes hiring of clinical staff members to provide VMMCs, conducting training and quality assurance assessments, providing technical assistance, and procurement of VMMC supplies, medications, and instruments.
UNAIDS has estimated an additional 27 million VMMCs need to be performed by 2021 to meet the Fast Track targets (2). This report updates a previous report covering the period 2010-2012, when VMMC implementing partners supported by CDC performed approximately 1 million VMMCs in nine countries (5 Data from multi-country analyses indicated that, during 2013-2016, 89.3% of VMMC clients participated in HIV testing services, and among those tested, the percentage of clients who tested positive ranged from 0.8% to 1.3% (at the country level, the percentage testing positive ranged from <0.1% to 4.4%) ( Table 2). All VMMC clients were advised to return for a postoperative assessment; overall, 71.9% returned to the circumcising site within 14 days of surgery.

Discussion
During 2013-2016, nearly 5 million adolescent and adult males were medically circumcised by CDC-supported VMMC programs in 12 countries in Southern and Eastern Africa. Considering that a decade ago, male circumcision was not a social norm in many of these countries, and the human and structural resources for this surgical intervention were minimal before scale-up, this represents a substantial accomplishment.
In addition, many of the men who sought VMMC would not have otherwise had contact with the medical system in the absence of significant injury or illness.
However, the number of VMMCs declined in 2016, and several large-volume programs also performed fewer VMMCs in 2015. Multiple factors likely contributed to this decline, including 1) slowing of service delivery in several countries following recognition of tetanus as a rare but severe complication of VMMC, because many males in Southern and Eastern Africa were never fully immunized (6) ¶ ; 2) retraining providers in dorsal slit circumcision technique in some countries upon identification that the forceps-guided technique posed elevated risk for injury to the immature penis (7); 3) prioritization of VMMC service delivery to geographic regions with the highest HIV prevalence for greater impact; and 4) possibly declining demand because many early adopters had already been circumcised.
Multiple countries increased the proportion of males aged 15-29 years who were provided VMMC in 2016, when PEPFAR began emphasizing prioritizing VMMC in this age group to most immediately achieve the HIV preventive benefit of VMMC (8); however, the overall percentage of males aged 15-29 years who were circumcised declined in 2016. CDC continues to work with partners to identify and implement innovative approaches to increase VMMC demand among these men (9). The large proportion of VMMC clients aged <15 years also likely accounts for the lower HIV prevalence observed among VMMC clients compared with national estimates,** because many of those aged <15 years likely had not yet had sexual intercourse, the primary mode of HIV transmission in this setting. The findings in this report are subject to at least four limitations. First, the findings reflect results from CDCsupported VMMC programs rather than national, PEPFAR, or global totals. Data entry errors and reporting variations are possible, and data were incomplete for some countries in some years. Second, during 2013-2014, the disaggregated age group indicator definition prevented reporting on males aged 15-29 years. Third, use of HIV testing services did not include clients with indeterminate results or those who might have been tested elsewhere recently, possibly affecting the HIV prevalence estimate among VMMC clients. Finally, follow-up within 14 days was likely underestimated because reported data might not include males who sought care at another health care site different from the one where they underwent circumcision.
VMMC is an evidence-based, one-time intervention that confers lifelong partial protection against HIV infection for males. In addition, its benefits carry over to females by lowering the prevalence of HIV (and several other sexually transmitted infections) among potential sex partners (10). To date, significant progress has been made by countries with VMMC programs. However, many more VMMCs need to be performed to reach the ambitious UNAIDS target by 2021. Enhancing VMMC service delivery will involve simultaneous focusing on supply-side and demand-side factors. On the supply side, VMMC programs are 1) offering service delivery on days and

TABLE 2. (Continued) Disaggregated indicators for CDC-supported VMMC programs -12 Southern and Eastern African countries, 2013-2016
times that best match clients' needs, including evening and weekend hours; 2) using mobile outreach service delivery to overcome geographic barriers; 3) ensuring safe service delivery through quality improvement and assurance activities and rigorous adverse event monitoring (6); 4) where possible, layering VMMC service delivery with other health care services such as preexposure prophylaxis, HIV care and treatment, and general medical care; and 5) incorporating medical innovations (e.g., new circumcision devices) that might enhance acceptability of VMMC for some males.
To increase demand for VMMC, programs are 1) evolving messaging from generating general awareness to addressing specific concerns of persons who have been hesitant to undergo VMMC; 2) linking VMMC with prevention activities for women (e.g., perinatal HIV testing services and HIV prevention programs that target adolescent girls and young women [i.e., the DREAMS program † † ]); 3) engaging community stakeholders, such as traditional and religious leaders, celebrities, and satisfied VMMC clients, to become VMMC champions; 4) compensating clients for the opportunity cost of undergoing VMMC; and 5) ensuring VMMC services are available to men regardless of HIV status, through voluntarism of HIV testing services. Going forward, country programs at or nearing targets should begin planning for VMMC program sustainability, including VMMC training and program staffing operated by ministries of health, regional or national government contributions to VMMC financing, and establishing a framework to maintain high male circumcision coverage by continuing a VMMC program for adolescents males aged 10-14 years and/or introducing routine early infant male circumcision. Reaching and maintaining high male circumcision coverage in countries with high prevalence of HIV infection remains a critical component of achieving an AIDS-free generation.