UNAIDS and PEPFAR Mount Campaign for Medical Male Circumcision Scale-Up in Eastern and Southern Africa

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UNAIDS and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) launched a five-year action framework to accelerate scale up of voluntary medical male circumcision (VMMC) for HIV prevention at the 16th International Conference on AIDS and Sexually Transmitted Infections (STIs) in Africa (ICASA) Monday. The World Health Organization, UNAIDS, PEPFAR, the Bill & Melinda Gates Foundation and the World Bank, in consultation with ministries of health, developed the Joint Strategic Action Framework to Accelerate the Scale-Up of Voluntary Medical Male Circumcision for HIV Prevention in Eastern and Southern Africa. It calls for roll out and expansion of VMMC in 14 priority countries in eastern and southern Africa.

To date, scale-up of this evidence-based intervention that reduces the risk of a man contracting HIV infection during vaginal sex by more than 60 percent has been underwhelming.  An estimated 550,000 men aged 15 to 49 have been circumcised in the 14 priority countries, representing only 2.7 percent of the estimated 20 million male circumcisions needed in order to reach the desired goals.  The framework aims to circumcise at least 80 percent of the 14 to 49 year old males in the target countries, and to establish a “sustainable national program that provides medical male circumcision to all infants up to two months old and at least 80 percent of male adolescents.”

VMMC is cost-effective. Recent modeling commissioned by PEPFAR and UNAIDS found that reaching 80 percent coverage in the target countries would require performing about 20 million circumcisions at a cost of $1.5 billion, and would result in a net savings of $16.5 billion by 2025 due to averted treatment and care costs.  An estimated 3.4 million new HIV infections could be averted through 2025.

The new framework calls for strategic and coordinated action among partners at the local, national and global levels to harness resources and encourages innovation in service delivery, human resource deployment and medical devices to improve efficiency in delivering services while encouraging demand.

One thought on “UNAIDS and PEPFAR Mount Campaign for Medical Male Circumcision Scale-Up in Eastern and Southern Africa

  1. Hugh7

    Actually, it is the evidence that circumcision has any effect on HIV – let alone that it “reduces the risk… by more than 60%” – that is underwhelming.

    It might reduce transmission from women to men (one of the rarer directions) by UP TO 60% (or down to zero) IF the three trials conducted by circumcision advocates on paid volunteers for circumcision were accurate. But reviews are coming in showing how they are not accurate. The latest is published in the Australian Journal of Law and Medicine this month.

    The claim still rests on the very tiny and shaky basis of 73 circumcised men who did not get infected in less than two years, after a total of 5,400 men were circumcised in three non-double-blinded, non-placebo-controlled trials (where 64 of them did get it). 137 of the non-circumcised control group were infected, and that difference is the whole “proof”. The experimental group, but not the controls, signed a consent form in which they were told to abstain from sex for six weeks after the operation, or to use condoms if they did have sex. (They were of course never told they could stop using them.) Contacts were not traced so we don’t even know which, if any of them were infected by women or even by sex. 703 men dropped out, 327 of them circumcised, their HIV status unknown. No attempt was made to compensate for the dramatic effect the performance and results of a painful and marking operation might have on behaviour in the experimental group, but not the control group. So there are many reasons other than circumcision the infection of the 73 may have been delayed (not prevented).

    A study in Uganda (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 before it could be confirmed.

    In 10 of 18 countries for which USAID has figures (http://www.measuredhs.com/pubs/pdf/CR22/CR22.pdf ), more of the circumcised men have HIV than the non-circumcised. In Malaysia, 60% of the population is Muslim (the only circumcised people in that country) but 72% of HIV cases are Muslim. Shouldn’t that at least be explained before blundering on with mass circumcision programmes?

    The speculations about the number of cases circumcision will prevent are pure wishful thinking.

    But never mind, men will line up to be circumcised, they will get intensive counselling and be given condoms, and like the magic nail in the old story about Nail Soup, if the HIV rate does actually fall, circumcision will get all the credit, and be used as an excuse to cut baby boys until it becomes “our custom” with which no-one may argue.

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