Male Circumcision: Progress and Problems with Implementing this Prevention Tool

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This post is by Global Center Director Christine Lubinski, reporting this week from CROI in San Francisco.

It’s been almost 3 years since the World Health Organization developed its recommendations and goals for male circumcision. As Kim Dickson, MD, an AIDS expert with the WHO, outlined in a presentation at CROI today, scale-up has not been speedy or simple.

In her talk, Dickson noted that the WHO identified 13 priority countries for scale up, especially those with high prevalence, generalized heterosexual epidemics, and low levels of circumcision.  All of the countries are in eastern and southern Africa. The goal: reach 80 percent of adult males and newborns by 2015 in the target countries. 

This intervention could prevent more than 4 million adult HIV infections over 15 years, but millions of circumcisions would have to be performed during this time period. The approximate cost of the procedure in these settings is $50. 

 Advocacy has been vibrant at all levels, and there have been multi-stakeholder consultations in all countries including various groups. A number of funding agencies have made money available for male circumcision-related activities, including PEPFAR, the Global Fund, and the Bill & Melinda Gates Foundation.  Male circumcision policies have been developed in Lesotho, Namibia, South Africa, Swaziland, Uganda and Zimbabwe. Kenya has developed actual guidelines.  Most countries are focused on so-called “catch-up” strategies to reach adult men, but longer term neonatal strategies are under consideration in Botswana, Swaziland and Zambia.  Provider training programs have been implemented in almost all 13 countries.

The bottom line question, however, is how many circumcisions have been done? 

Only Kenya has scaled up male circumcision in any significant way.  Using teams of providers, Kenya did 36,000 circumcisions in 30 days in 11 districts at an approximate cost of $30 per procedure.  Almost 100,000 procedures have been performed to date.  Kenya’s success is in part related to a successful partnership between government and NGOs.

There are many challenges and constraints.  Human resource issues loom large, not only to do the procedure but even to identify dedicated staff to focus on developing and launching this intervention in resource-poor settings.  Task shifting is not permitted in some countries, and the number of available doctors and nurses are simply inadequate. It is difficult in some cases to get the necessary political support.  In addition, it appears that country health leaders are not always aware that specific funding for MC is available or don’t know how to access it.

Most of these countries have traditional providers of male circumcision, and there is no clear guidance on how to involve them.  Service delivery sites also need guidance on how to deal with HIV-positive men who may present. While circumcision is not generally recommended for this group in this context, it is important that they be dealt with in an appropriate and non-discriminatory way.

We need strategies for demand creation.  We also need effective communication strategies to convey messages about the partial protection provided by MC and messages to reduce risk compensation.  We already know that political commitment accelerates programs and that early engagement and consultations with stakeholders prevent setbacks. We need innovation to scale up service delivery and new devices to accelerate delivery and reduce adverse events.

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