Male Circumcision
Background
Voluntary medical male circumcision (surgical removal of the foreskin of the penis) is one of the most common surgical procedures, and is performed for a variety of reasons, including cultural, religious, social, and medical. It may be a birth ritual or, as in many parts of sub-Saharan Africa, a rite of passage performed around adolescence. In clinical settings, it is normally done as a quick outpatient procedure using local anesthesia.
Voluntary Medical Male Circumcision and HIV Prevention
In 2007–2008, the results of three randomized controlled clinical trials in sub-Saharan Africa confirmed what several ecological and observational epidemiologic studies had previously suggested: Voluntary medical male circumcision (VMMC) provided by well trained health professionals in properly equipped settings is safe and has the potential to dramatically reduce men’s risk of acquiring HIV from their female partners. The combined data of all 12,000 male participants from the three trials conducted in Kenya, South Africa, and Uganda strongly suggest a protective effect of 60 percent for the male insertive partner of heterosexual partnerships.
Research has identified plausible biological explanations for a connection between HIV infection and lack of circumcision. The tissue of the internal foreskin absorbs HIV up to nine times more efficiently than female cervical tissue, mainly because it contains Langerhans and other HIV “target cells” in much greater quantities than the cervix or other genital tissue, including other parts of the penis. In addition, the internal foreskin has a mucosal surface, as opposed to the more hardened skin-like surface of the external foreskin. This mucosal surface is particularly susceptible to tears and abrasions, and, consequently, infection by sexually transmitted diseases and HIV.
WHO/UNAIDS Recommendations and Country Ownership
In March 2007, the Joint United Nations Program on HIV/AIDS/World Health Organization (UNAIDS/WHO) issued normative guidance stating that VMMC should be recognized as an additional important intervention to reduce the risk of male heterosexually acquired HIV infection and that VMMC should always be implemented as part of a comprehensive HIV prevention package. This package includes the provision of HIV testing and counseling services; treatment for sexually transmitted infections; the promotion of safer sex practices, such as abstinence from penetrative sex, reduction in the number of sex partners, and delay in the onset of sexual relations; and the provision of male and female condoms, and promotion of their correct and consistent use. The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) looks to UNAIDS/WHO to set global norms and standards, provide policy and program guidance for the provision of safe and efficient VMMC services, and conduct high-level advocacy.
In response to the normative guidance provided by WHO, PEPFAR, under the direction of the VMMC Task Force, has become one of the major supporters of VMMC as a component of a comprehensive HIV prevention program in sub-Saharan Africa. At the invitation of host governments, the Task Force provides technical assistance to U.S. Government (USG) in-country teams and host country Ministries of Health to develop national policies and strategic plans, conduct situational assessments, and implement and evaluate VMMC service delivery programs. The Task Force is working closely with UNAIDS/WHO to define priorities, develop guidance, and refine efficiencies for male circumcision programs. It also is coordinating activities with other organizations supporting VMMC, such as the Bill & Melinda Gates Foundation, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the Clinton Foundation.
USAID’s Priorities for Providing Technical and Financial Assistance for Implementation of VMMC
This compelling evidence has led the USG, through PEPFAR, to include VMMC in its HIV/AIDS prevention strategies in Southern and Eastern Africa. VMMC provides only partial protection, so it should be only one element of a comprehensive HIV prevention package, which includes:
- The provision of HIV testing and counseling services
- Treatment for sexually transmitted infections
- The promotion of safer sex practices
- The provision of male and female condoms and promotion of their correct and consistent use
USAID, in accordance with PEPFAR, promotes safe VMMC as part of a larger prevention coordination plan.
USAID is providing a two-pronged technical and financial assistance approach for the implementation of VMMC in Southern and Eastern Africa. The first is designed to accelerate saturation coverage for adult and adolescent VMMC, and the second is a more sustainable implementation program for neonate VMMC. Specifically, USAID is providing technical leadership in the following aspects of policy development and program implementation:
- Service delivery through M-CHIP and other mechanisms
- Communication through C-CHANGE
- Data for decision making (costing and impact studies) through the Health Policy Initiative (HPI)
- Commodities and supply chain management through SCMS
- Operations Research through Project Search (R2P)
- Development of training materials and tools through M-CHIP
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