Preventing HIV in high HIV burden settings through voluntary medical male circumcision
Preventing heterosexually acquired HIV and achieving global HIV incidence goals require a combination of interventions. Voluntary medical male circumcision (VMMC) is one of these interventions in settings with a high burden of HIV. New guidelines from the World Health Organization (WHO) updates earlier recommendations on VMMC for HIV prevention.
These new guidelines present additional evidence in support of continuing VMMC services as part of combination prevention for adult men and adolescent boys ages 15 years and older, on the safety of prequalified device-based male circumcision methods and on interventions to enhance service uptake among men. The guidelines also outline a health systems framework to guide transitioning to adolescent-focused sustainable services and maintaining high VMMC coverage.
“In 2007 three 'gold standard’ randomized controlled trials showed that VMMC reduced men’s risk of heterosexually acquired HIV by 59%. Now, more than 10 years of further evidence shows that VMMC is having a substantial effect in real-world settings as well. This includes an independent prevention effect in settings where other HIV prevention interventions, such as Pre-exposure prophylaxis (PrEP) and anti-retroviral therapy have been taken to scale. VMMC is a cost-saving intervention -- eliminating the costs of lifelong HIV treatment among those protected from infection. We must do all that we can to advocate for greater political support and funding to increase and maintain VMMC service coverage in East and Southern Africa, where the HIV burden and potential impact is greatest.” said Meg Doherty, Director, Global HIV, Hepatitis and STIs Programmes, WHO.
“Similar to preventing COVID by using several interventions, VMMC is an essential option in the toolkit of effective HIV prevention interventions in East and Southern Africa. The new guidelines recommend VMMC services for adolescents age 15 years and older and for men, particularly those at higher risk of HIV infection. Considerations are also presented on whether to offer VMMC to younger adolescent boys (ages 10-14 years), taking into account their diversity in physical and cognitive development, including their capacity to consent. When communities, parents and partners are engaged, they can support decisions about this prevention option.” said Frank Lule, Medical Officer, WHO African Regional Office.
“VMMC has reached over 25 million men in East and Southern Africa through 2019, averting an estimated 650 000 to 1.5 million HIV infections by 2030 depending on the scale up of other prevention interventions. As countries achieve higher VMMC coverage levels, services will transition to sustainable approaches focused on each new generation of adolescents. Embedding service delivery within established health systems aligns with global efforts to strengthen health systems. These new guidelines offer considerations to sustain VMMC services by using the WHO health systems ‘building blocks’.” said Lycias Zembe, Technical Officer, Prevention, United Nations Joint Programme on HIV/AIDS, Switzerland.
In the guidelines, WHO emphasizes the importance of providing safe and effective VMMC services. Patient safety measures and monitoring for adverse events is critical for all VMMC programmes.
“Patient safety is a top priority for VMMC programmes in Zambia. The country’s National Surgical, Obstetric, and Anaesthesia Strategic Plan (NSOASP), 2017−2021 provides a broad framework for the planning, delivery and management of quality surgical (including VMMC), obstetric and anaesthesia services at all levels of health delivery systems. One of the objectives of this strategy is to build safe and high-quality surgical systems. For the VMMC intervention, keys to this success are effective and timely monitoring of adverse events and enhancing a culture of learning through strengthened health management information systems and research capabilities.” explained Albert Kaonga, HIV Prevention Program Manager, Ministry of Health, Zambia.
The WHO guidelines update recommendations on the use and safety of WHO-prequalified device-based male circumcision methods, including new techniques and devices. Such innovative surgical methods may further improve safety, simplify the procedure and possibly increase acceptability and access. These additional methods may have advantages over conventional surgery, but their use has been limited and needs to be further expanded and safety measured in real-world settings.
“VMMC services are reaching men and adolescent boys, who often do not seek out health care. Services include a package with safer sex education, condom promotion and the identification and treatment of sexually transmitted infections. VMMC contributes to reducing the risk of other STIs such as human papillomavirus, which causes cervical cancer. HIV, STI and sexual and reproductive health programmes and services need to work more closely together to deliver multiple health services needed by adolescent boys and men. Service delivery must be enhanced and reoriented to be more male-friendly, including for adolescents.” said Sinokuthemba Xaba, National VMMC Program Coordinator, Ministry of Health and Child Care, Zimbabwe.