Voluntary Medical Male Circumcision for HIV Prevention – An Interview With Emmanuel Njeuhmeli
Today PLOS officially launches a new collection, Voluntary Medical Male Circumcision for HIV Prevention: New Mathematical Models for Prioritizing Sub-Populations by Age & Geography, featuring new modeling research that aims to help country decision-makers examine the potential effects of targeting sub-populations for voluntary medical male circumcision (VMMC) services. Dr. Emmanuel Njeuhmeli, Senior Biomedical Prevention Advisor in the USAID Office of HIV/AIDS, recently sat down with PLOS Collections to discuss the importance of VMMC and this collection.
Why is VMMC and the continued examination of VMMC programs of such importance?
Evidence of the effectiveness of voluntary medical male circumcision in decreasing the risk of HIV infection for men in southern and eastern Africa by 60%  was so compelling that three randomized clinical trials were halted prematurely between 2005 and 2007. Since then, the evidence has continued to mount. Follow-up studies in South Africa, Kenya , and Uganda  showed male circumcision’s sustained protective effect against HIV. This protective effect may even become stronger over time, with studies in Uganda showing a decrease in the risk of HIV infection by as much as 73%.
Today, VMMC remains critical for HIV epidemic control, part of the UNAIDS fast track strategy that includes, among other interventions, rapid scale up of treatment for prevention.
While historically VMMC programs have been well-funded by the President’s Emergency Plan for AIDS Relief (PEPFAR), the World Bank, the Bill and Melinda Gates Foundation, and the governments of countries in southern and eastern Africa, funding for VMMC programs (as it has for much of all other HIV Prevention, Care and Treatment interventions) has plateaued, leading to calls for a greater emphasis on efficiency and effective use of limited resources. If countries focus now on prioritizing certain age groups, risk groups, and geographic areas, they will minimize new HIV infections more efficiently and save future HIV treatment dollars.
What progress has been made since the last collection in 2014?
Over 11.7 million VMMCs were performed by the end of 2015: 54% of the estimated 20.3 million VMMCs that were required to reach 80% male circumcision coverage in the 14 priority countries by end 2015. Assuming each country reaches their 90-90-90 HIV treatment targets by 2020, the new modeling analysis projects that the VMMCs that have been conducted through December 2015 will avert a total of 452,000 infections by 2030. Across all countries modeled, 50% of the projected HIV infections averted were attributable to circumcising 10–19 year-old males. If male circumcision is scaled up to 80% coverage among 10 to 29 year-olds by 2020 and maintained at that level of coverage, an additional 470,000 HIV infections will be averted by 2030.
But progress has been uneven. A few countries such as Tanzania, Kenya, and Mozambique have made great progress in meeting their initial male circumcision targets in a relatively short time period. Two traditionally non-circumcising regions of Tanzania, Iringa and Njombe, have made significant progress toward their regional targets and have reached complete saturation among adolescents and men ages 10-29. In Mozambique and Kenya, several districts have also reached saturation.
We’ve also made great progress in getting more men to learn their HIV status and linking them to care and treatment with VMMC programs serving as a unique entry point for men into health services. Some of the findings from the 2014 PLOS collection on VMMC revealed that as we were increasing the volume of services, sometimes quality would suffer. Since then we have strengthened our strategies for quality assurance/quality improvement which are making remarkable differences in the quality of VMMC services.
How will these new mathematical models help decision makers?
These models have influenced various global stakeholders in a number of ways. For Ministries of Health in priority countries, the modelling has informed strategic changes in program planning to focus on reaching specific age groups in order to maximize impact given available resources. For the PEPFAR program in the field, the modelling tools have informed estimates of male circumcision coverage, the setting of new targets, and decisions on how to best allocate resources to achieve those targets. In particular, the modelling has helped PEPFAR decide which geographical and age prioritizations will maximize impact and foster efficient use of resources. In addition, WHO and UNAIDS have used the modelling results to inform the targets and impact estimates that appear in their 2021 VMMC strategy document.
Now, assisted by the new DMPPT 2 online modelling tool, program planners can tailor demand creation to increase uptake of VMMC services among specific age groups in specific districts, based on needs and program objectives. The models are also helping countries to begin to plan for sustainability once a particular district or province approaches high coverage among priority age groups.
What is the ‘take-home message’ of this new collection?
There are several take home messages here. First, the articles in this collection confirm our 2008 prediction that VMMC is an excellent investment for the global community and countries in eastern and southern Africa.
Second, the articles provide a good understanding of the age groups that we need to focus on for cost effectiveness, immediacy of impact, and magnitude of impact. They enable program planners to create scale-up targets that are both realistic and cost-effective.
Finally, we have realized that progress is uneven both by age group and geographically. Several districts in a few countries have already achieved high coverage rates of VMMC among priority age groups, indicating that they need to plan now for sustainability of VMMC coverage to prevent losing the significant HIV prevention gains that have been made.
VMMC: New Mathematical Models for Strategic Planning
Please join us on 27 October 2016 for a webinar to officially launch the newly released PLOS ONE Collection, “Voluntary Medical Male Circumcision (VMMC) for HIV Prevention: New Mathematical Models for Prioritizing Sub-Populations by Age & Geography.”
In the first half of the webinar, presenters will discuss new findings from mathematical models featured in the collection that relate to the potential effects of targeting sub-populations for voluntary medical male circumcision services. The second half of the webinar will feature panelists who will discuss how the models have been used to inform their choices about where best to invest their resources to prevent HIV.
The collection was produced in collaboration with USAID, PEPFAR, the World Bank, and the Bill & Melinda Gates Foundation.
Date: Thursday, 27 October 2016
Time: 8.00 AM to 10.00 AM (EST)
Where: WebEx (Web Platform)
Dr. Emmanuel Njeuhmeli is the Senior Biomedical Prevention Advisor with USAID.
 1. 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 Medicine. 2005;2(11):e298 doi: 10.1371/journal.pmed.0020298
 2. Bailey RC, Moses S, Parker CB, Agot K, Maclean I, Krieger JN, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet. 2007;369(9562):643–56. Epub 2007/02/27. doi: 10.1016/s0140-6736(07)60312-2
 3. Gray RH, Kigozi G, Serwadda D, Makumbi F, Watya S, Nalugoda F, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet. 2007;369(9562):657–66. Epub 2007/02/27. doi: 10.1016/s0140-6736(07)60313-4
Claiming that circumcision prevents a health problem is a compulsion of circumcised men to have done to others what was done to them. Historically, this compulsion has led to over 200 potential health claims for circumcision. All have been refuted. Thirteen national and international organizations recommend against circumcision.
Many professionals have criticized the studies claiming that circumcision reduces HIV transmission. The investigators did not seek to determine the source of the HIV infections during their studies. They assumed all infections were heterosexually transmitted.
Many HIV infections in Africa are transmitted by contaminated injections and surgical procedures. The absolute rate of HIV transmission reduction is only 1.3%, not the claimed 60%. Even if the claim were true, based on the studies, about 60 men had to be circumcised to prevent one HIV infection.
Authorities that cite the studies have other agendas including political and financial. All other national and international organizations that have positions on circumcision oppose it. Research shows that circumcision causes physical, sexual, and psychological harm, reducing the sexual pleasure of both partners. 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. Even HIV/circumcision studies advise using condoms. With condoms circumcision adds no benefit to HIV prevention.
Circumcision will not be “voluntary” when it is forced on children.