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Voluntary Medical Male Circumcision (VMMC) – a cost-effective HIV prevention measure in eastern and southern Africa: a UNAIDS and PEPFAR collection

This post has also appeared on PLoS Medicine’s blog Speaking of Medicine.

Today PLoS Medicine is delighted to announce the publication of a sponsored Collection, in conjunction with the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the United States President’s Emergency Plan for AIDS Relief (PEPFAR) –  Voluntary Medical Male Circumcision for HIV Prevention: The Cost, Impact, and Challenges of Accelerated Scale-Up in Southern and Eastern Africa.

The Collection comprises four reviews and five research articles, and highlights how scaling up voluntary medical male circumcision (VMMC) for HIV prevention in eastern and southern Africa can help prevent HIV, not only at the individual level but also at the community and population level, as well as leading to substantial cost savings for countries due to averted treatment and care costs. Two of the research articles are published in PLoS ONE; the remaining seven articles are published in PLoS Medicine on 29th November 2011. They can be accessed from the PLoS Medicine VMMC Collection page; the table of contents is also included below.

The first article by Catherine Hankins of UNAIDS, Steven Forsythe of The Futures Institute, and Emmanuel Njeuhmeli of PEPFAR/USAID, offers an introduction to the cost, impact and challenges of accelerated scaling up and lays out the rationale for the Collection. The remaining eight papers focus on the various factors that have important roles in effective program expansion of VMMC, including data for decision making, policy and programmatic frameworks, logistics, demand creation, human resources, and translating research into services.

The potential cost savings of scale-up are clear. An initial investment of US$1.5 billion between 2011 and 2015 to achieve 80% coverage of VMMC services in 14 priority countries in southern and eastern Africa, and thereafter US$0.5 billion between 2016 and 2025 to maintain coverage of 80%, could result in net savings of US$16.5 billion between 2011 and 2025. However, as the articles in the Collection show, strong political leadership, country ownership, and stakeholder engagement, along with effective demand creation, community mobilization and human resource deployment, are essential for effectively expanding and maintaining VMMC programs.

All 9 articles were peer-reviewed, revised and considered in depth by the editorial team, and subjected to all the usual PLoS Medicine or PLoS ONE editorial processes. We would like to thank the numerous peer reviewers for their detailed critiques, which helped to shape the articles, and we would also like to thank the authors for their patience in making appropriate revisions to these reviews. In particular we would like to Stephanie Sansom, guest academic editor, who read all the articles and provided critical feedback and reviewer advice to the editorial team. A special thank you goes to Emmanuel Njeuhmeli of PEPFAR/USAID who served as the main editorial contact for the articles in this Collection.

A question-and-answer Twitter expert session [#VMMC@USAIDGH] will be held on December 19 2011, from 1pm-2pm EST, with Emmanuel Njeuhmeli, Senior Biomedical Prevention Advisor of the Office of HIV/AIDS/USAID Washington, Co-Chair PEPFAR, Male Circumcision Technical Working Group, and an author on several of the articles in the Collection. In regard to this Collection Dr. Njeuhmeli comments:

“The collaboration that led to the findings in the PLoS Collection is a true testament to what international partners can accomplish when they work together and do so effectively to support country strategy for HIV Prevention. I can say with confidence this collaboration has played a major role in moving the needle on VMMC and HIV prevention. This Collection represents extensive collaboration between Ministries of Health, WHO, UNAIDS, PEPFAR and implementing partners to document and share with policy makers and program implementers the estimated cost and potential impact of scaling up voluntary medical male circumcision (VMMC) services in southern and eastern Africa. The papers included in this Collection document the enormous potential of VMMC to alter the course of the epidemic. They also describe the way that country programs have successfully navigated human resource, demand generation and other challenges in an effort to rapidly scale up comprehensive VMMC services.”

Collection Table of Contents :

1)       Voluntary Medical Male Circumcision: An Introduction to the Cost, Impact, and Challenges of Accelerated Scaling Up

2)       Voluntary Medical Male Circumcision: Modeling the Impact and Cost of Expanding Male Circumcision for HIV Prevention in Eastern and Southern Africa

3)       Voluntary Medical Male Circumcision: A Framework Analysis of Policy and Program Implementation in Eastern and Southern Africa

4)       Voluntary Medical Male Circumcision: A Cross-Sectional Study Comparing Circumcision Self-Report and Physical Examination Findings in Lesotho

5)       Voluntary Medical Male Circumcision: Logistics, Commodities, and Waste Management Requirements for Scale-Up of Services

6)       Voluntary Medical Male Circumcision: A Qualitative Study Exploring the Challenges of Costing Demand Creation in Eastern and Southern Africa

7)       Voluntary Medical Male Circumcision: Strategies for Meeting the Human Resource Needs of Scale-Up in Southern and Eastern Africa

8)       Voluntary Medical Male Circumcision: Translating Research into the Rapid Expansion of Services in Kenya, 2008–2011

9)      Voluntary Medical Male Circumcision: Matching Demand and Supply with Quality and Efficiency in a High-Volume Campaign in Iringa Region, Tanzania

Disclaimer: The views expressed in the VMMC collection are those of the authors and do not necessarily reflect the official policy or position of the U.S. Government and UNAIDS. The collection was produced with support from the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the United States President’s Emergency Plan for AIDS Relief (PEPFAR). The PLoS Medicine editors have sole editorial responsibility for the content of this collection.

Image Credit: PEPFAR Male Circumcision Technical Working Group

Permission to use the CCAL license granted by the PEPFAR Male Circumcision Technical Working Group.

  1. Just a bit of clarification.
    “The Collection comprises four reviews and five research articles, and highlights how scaling up voluntary medical male circumcision (VMMC) for HIV prevention in eastern and southern Africa can help prevent HIV, not only at the individual level but also at the community and population level, as well as leading to substantial cost savings for countries due to averted treatment and care costs. ”

    Does this mean can help, as in sugar cereals can be part of a nutritious breakfast?
    Or does it mean that the men were circumcised, studied continuously against a control group, and circumcision actually lowered the HIV infection rate over a number of years?
    In other words, has there been any followup to the less-than-scientifically-ideal studies of Auvert, Bailey, Gray, etc? Have we learned anything new?
    Or are we simply supposed to swallow the old stuff, and ‘believe’ that circumcision made a difference in infection rates?
    Specifically, I am wondering if the miraculous 60% figure holds up to scrutiny over time, and totally contradicts what we have seen in the US…namely the deaths of nearly a million mostly circumcised men from AIDS?

  2. Many professionals have criticized the studies claiming that circumcision reduces HIV transmission. They have various flaws. Authorities that cite the studies have other agendas, including political and financial. Circumcision causes physical, sexual, and psychological harm. This harm is ignored by circumcision advocates. Other methods to prevent HIV transmission (e.g., condoms and sterilizing medical instruments) are much more effective, much cheaper, and much less invasive. Please see for links to literature and more information.

    “There appears no clear pattern of association between male circumcision and HIV prevalence—in 8 of 18 countries with data, HIV prevalence is lower among circumcised men, while in the remaining 10 countries it is higher.”

    If male circumcision worked against HIV in the real world, this simply would not happen.

    The South African National Communication Survey on HIV/AIDS, 2009 found that 15% of adults across age groups “believe that circumcised men do not need to use condoms”.

    From the committee of the South African Medical Association Human Rights, Law & Ethics Committee :
    “the Committee expressed serious concern that not enough scientifically-based evidence was available to confirm that circumcisions prevented HIV contraction and that the public at large was influenced by incorrect and misrepresented information. The Committee reiterated its view that it did not support circumcision to prevent HIV transmission.”

    The one randomized controlled trial into male-to-female transmission showed a 54% higher rate in the group where the men had been circumcised btw:
    The figures were too small to show statistical significance, but there will be no larger scale study to find out if circumcising men increases the risk to women. Somehow that’s considered unethical, yet it’s considered ethical to promote male circumcision whilst not knowing if the risk to women is increased (by 54%?, 25%?, 80%? – who knows?)

    ABC (Abstinence, Being faithful, and especially Condoms) is the way forward. Any diversion of funds or focus from that seems likely to cost African lives, not save them.

  4. This is really a fantastic collection of seminal research and provides a great background on what we all need to know about VMMC in order to move forward. AIDSTAR-One, led by Emmanuel Njeuhmeli and the PEPFAR Technical Working Groups, produced a special collection of best practices and tools for putting the impressive research from this collection into practice. Included in this collection are all of the articles from the PloS collection.

    Access the collection online:

  5. The three RCTs that purport to show that circumcision reduces transmission of HIV were all terminated early. Early termination of studies has been proven over and over again to exaggerate the effect of the intervention. These three RCTs are irremediable flawed, so they should not be used to guide public health policy.

  6. This campaign, and any study involving circumcision, should not get past any ethics committees, if those committees are actually enforcing medical ethics.

    It is completely unethical in medicine or public health to base any investigation on the premise of mutilation. Whatever the alleged benefits, they cannot outweigh the fact that circumcision is a harmful procedure.

    “First, do no harm.”

  7. The Journal of Law and Medicine has published a new critique of those three randomized clinical trials from Africa that have purported to find that male circumcision reduces female-to-male sexual transmission of HIV by 60 percent. This critique finds numerous flaws in the execution of these studies and finds that the actual reduction in HIV transmission is about 1.3 percent, not the claimed 60 percent. The 1.3 percent is not considered to be clinically significant. This is balanced by a 61 percent relative increase in male to female HIV transmission when the male partner is circumcised. Given this, the three RCTs should not be used in the formulation of public health policy. See:

    Boyle GJ, Hill G. Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns. J Law Med 2011;19:316-34.

  8. The use of male circumcision to prevent HIV infection is based on three discredited randomised clinical trials. The trials purported to show a 60 percent reduction in female-to-male HIV transmission if the male was circumcised, however the percentage was incorrectly calculated. The correct percentage is 1.3 percent, which falls below statistical significance.

    This tiny reduction is completely overbalanced by a 61 percent INCREASE in male-to-female HIV transmission if the male partner is circumcised.

    The premise on which these papers are based – that male circumcision reduces HIV infection – is false and the papers draw false conclusions.

  9. This pile of material reminds me of the TranAmerica building standing upside down. It all rests on the tiny point of 73 out of 5,400 circumcised men who didn’t get HIV in less than two years, who MIGHT have if they hadn’t been circumcised, while 64 circumcised men DID get it.

    A new review in the Australian Journal of Law and Medicine unravels some of the many reasons that may not be cause and effect:
    researcher expectation bias;
    participant expectation bias;
    inadequate double blinding;
    lead-time bias;
    selection and sampling bias;
    attrition bias; and
    early termination.
    Contacts were not traced so we don’t even know which if any of the men got HIV from women or even by sex

    Wawer et al. (Lancet 374:9685, 229-37) started to find that circumcising men INcreases the risk to women (who are already at greater risk), but they cut that one short for no good reason (nothing they could then do or not do would prevent any new infections) before it could be confirmed.

  10. Even if one were to accept the conclusions of the African RCT’s, (and the statistical sleights-of-hand suggest wariness), that does not necessarily make VMMC good epidemiology. There is a melancholy list of contraindications which transcend computer modeling:

    • Risk avoidance by circumcised men who will now feel ‘invulnerable’ and will avoid condoms. This is especially true where the men feel a western ‘surgery’ confers extra immunity over tribal rituals.

    • That trend, already identified, endangers millions of women and may even worsen the epidemic.

    • VMMC will inevitably ensnare minors. In no world culture is MC entirely voluntary, that is, for consenting adults only. VMMC has always been a stalking horse for unconsented infant circumcision.

    • In cultures which value displays of masculine bravery, MC will veer toward the gruesome rather than stay within clinical standards. South Korea is an example of this phenomenon.

    • The initial clinical standards will soon decline in village settings where even clean water is a luxury. Indeed one of the unaccounted for factors in the RCT’s is the vector of iatogenic transmission via contaminated medical equipment.

    • Once introduced, MC will prove difficult to eradicate when an HIV immunization is eventually found, as genital mutilations are self-replicating and self-sustaining. They need no reason other than, “They did it to me.” The Cut always become Cutters.

    • An AIDS vaccine has already been found -in HAART- which reduces infection rates to near zero between discordant partners. HAART will surely prove less expensive than huge VMMC campaigns in the long run.

    • VMMC will firmly plant the notion that amputations are the preferred solution to disease processes, a giant step backwards in both human rights and medical science.

    • VMMC will slow attempts to control FGC, female genital cutting, and may introduce FGC, unbidden, where it is now unknown. Blaming female mucosal tissue is a small additional step after VMMC.

    • VMMC may pit tribe against tribe. In Kenya, the Luo (the tribe of Barack Obama’s father), do not engage in MC. But the Kikuyu, who blame the Luo for HIV /AIDS at the urging of researchers, do so. This has led to kidnapping and forced MC of the Luo. This will surely escalate in multiple cultures across Africa, creating a fertile ground for regional conflicts.

    John V. Geisheker, J.D., LL.M.
    Executive Director,
    General Counsel,
    Seattle, Washington, USA

  11. The hypothesis that VMMC is actually effective in preventing HIV is based on several studies with very questionable results. This hardly seems a prudent way to determine a major health policy. Nonetheless, even if VMMC had an effect in reducing HIV, is it worth the human and monitary cost?

    The article on the Kenyan study cites a 1% complication rate. Could it be said that the approximately 100 men with reported complications out of the approximately 10,000 men in the study would otherwise have contracted HIV?

    MC is the only routine surgical procedure which is done for prophylactic reasons and not to treat pathology. The logistics of mounting a massive VMMC campaign in Africa are daunting. This is not to mention the prospect of the cited “assembly lines” and the empowerment of paraprofessionals to do surgery which would simply invite complications and provide incentive for unscrupulous individuals to victimize the male population for financial gain.

    It seems imprudent to spend billions of public health dollars on an intervention involving a harmful surgical procedure with a significant complication rate, with questionable effectiveness. It seems even more imprudent to divert scarce resources from other interventions including hygiene, condoms, education, and an HIV vaccine.


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