Scaling-up voluntary medical male circumcision – what have we learned?

Abstract

In 2007, the World Health Organization (WHO) and the joint United Nations agency program on HIV/AIDS (UNAIDS) recommended voluntary medical male circumcision (VMMC) as an add-on strategy for HIV prevention. Fourteen priority countries were tasked with scaling-up VMMC services to 80% of HIV-negative men aged 15–49 years by 2016, representing a combined target of 20 million circumcisions. By December 2012, approximately 3 million procedures had been conducted. Within the following year, there was marked improvement in the pace of the scale-up. During 2013, the total number of circumcisions performed nearly doubled, with approximately 6 million total circumcisions conducted by the end of the year, reaching 30% of the initial target. The purpose of this review article was to apply a systems thinking approach, using the WHO health systems building blocks as a framework to examine the factors influencing the scale-up of the VMMC programs from 2008–2013. Facilitators that accelerated the VMMC program scale-up included: country ownership; sustained political will; service delivery efficiencies, such as task shifting and task sharing; use of outreach and mobile services; disposable, prepackaged VMMC kits; external funding; and a standardized set of indicators for VMMC. A low demand for the procedure has been a major barrier to achieving circumcision targets, while weak supply chain management systems and the lack of adequate financial resources with a heavy reliance on donor support have also adversely affected scale-up. Health systems strengthening initiatives and innovations have progressively improved VMMC service delivery, but an understanding of the contextual barriers and the facilitators of demand for the procedure is critical in reaching targets. There is a need for countries implementing VMMC programs to share their experiences more frequently to identify and to enhance best practices by other programs.

Early resumption of sexual activity following voluntary medical male circumcision in Botswana: A qualitative study

“…This recommendation was prompted by evidence from three randomized clinical trials demonstrating that VMMC reduces the risk of acquiring HIV infection by 51% to 60% among heterosexual men [ 2 – 4 ]. Since 2007, there have been substantive efforts to expand VMMC interventions in countries with high HIV prevalence and low rates of male circumcision [ 5 , 6 ]. Mathematical modeling suggests that rapid scale-up of VMMC in high HIV prevalence settings is a cost-effective intervention to reduce population-level HIV transmission [ 7 – 10 ].…”

Quality of service and continuous quality improvement in voluntary medical male circumcision programme across four provinces in South Africa: Longitudinal and cross-sectional programme data

“…However, 86% of the WHO VMMC priority countries were operating with inadequate supplies and equipment [ 26 ]. In South Africa, a significant proportion of sites were operating with inadequate VMMC supplies and equipment, and also without guideline documents [ 11 ].…”

Identification of gaps for implementation science in the HIV prevention, care and treatment cascade; a qualitative study in 19 districts in Uganda

“…The last two decades have seen significant progress in the implementation of programs for HIV prevention, care and treatment in several countries in sub-Saharan Africa. In the area of prevention, there are examples of progress that has been made in expanding programs for voluntary counseling and testing [ 1 , 2 ], Mother-to-child HIV transmission (PMTCT) [ 3 – 5 ] and scaling up programs for safe male circumcision [ 6 – 8 ]. In the area of treatment, antiretroviral therapy is now widely available and has been associated with significant reductions in morbidity and mortality [ 9 , 10 ].…”