Emmanuel Njeuhmeli

Voluntary medical male circumcision: modeling the impact and cost of expanding male circumcision for HIV prevention in eastern and southern Africa.

Emmanuel Njeuhmeli and colleagues estimate the impact and cost of scaling up adult medical male circumcision in 13 priority countries in eastern and southern Africa, finding that reaching 80% coverage and maintaining it until 2025 would avert 3.36 million new HIV infections.

Voluntary Medical Male Circumcision: An Introduction to the Cost, Impact, and Challenges of Accelerated Scaling Up

Catherine Hankins, Steven Forsythe, and Emmanuel Njeuhmeli provide an overview of the “Voluntary Medical Male Circumcision for HIV Prevention: The Cost, Impact, and Challenges of Accelerated Scale-Up in Southern and Eastern Africa” Collection, calling for leadership and vision to help halt the HIV epidemic.

Barriers and Motivators to Voluntary Medical Male Circumcision Uptake among Different Age Groups of Men in Zimbabwe: Results from a Mixed Methods Study

Background We conducted quantitative and qualitative studies to explore barriers and motivating factors to VMMC for HIV prevention, and to assess utilization of existing VMMC communication channels. Methods and Findings A population-based survey was conducted with 2350 respondents aged 15–49. Analysis consisted of descriptive statistics and bivariate analysis between circumcision and selected demographics. Logistic regression was used to determine predictors of male circumcision uptake compared to intention to circumcise. Focus group discussions (FGDs) were held with men purposively selected to represent a range of ethnicities. 68% and 53% of female/male respondents, respectively, had heard about VMMC for HIV prevention, mostly through the radio (71%). Among male respondents, 11.3% reported being circumcised and 49% reported willingness to undergo VMMC. Factors which men reported motivated them to undergo VMMC included HIV/STI prevention (44%), improved hygiene (26%), enhanced sexual performance (6%) and cervical cancer prevention for partner (6%). Factors that deterred men from undergoing VMMC included fear of pain (40%), not believing that they were at risk of HIV (18%), lack of partner support (6%). Additionally, there were differences in motivators and barriers by age. FGDs suggested additional barriers including fear of HIV testing, partner refusal, reluctance to abstain from sex and myths and misconceptions. Conclusions VMMC demand-creation messages need to be specifically tailored for different ages and should emphasize non-HIV prevention benefits, such as improved hygiene and sexual appeal, and need to address mens fear of pain. Promoting VMMC among women is crucial as they appear to have considerable influence over mens decision to get circumcised.

Voluntary Medical Male Circumcision: Translating Research into the Rapid Expansion of Services in Kenya, 2008–2011

Zebedee Mwandi and colleagues discuss Kenyas scale-up of voluntary medical male circumcision services, highlighting government leadership, a clear implementation strategy, and program flexibility and innovation as keys to Kenyas success.

Voluntary Medical Male Circumcision: Strategies for Meeting the Human Resource Needs of Scale-Up in Southern and Eastern Africa

Kelly Curran and colleagues conducted a program review to identify human resource approaches that are being used to improve voluntary medical male circumcision volume and efficiency, identifying several innovative responses to human resource challenges.

Voluntary Medical Male Circumcision: Matching Demand and Supply with Quality and Efficiency in a High-Volume Campaign in Iringa Region, Tanzania

Hally Mahler and colleagues evaluate a six-week voluntary medical male circumcision campaign in Iringa province of Tanzania, providing a model for matching supply with demand for services and showing that high-volume circumcisions can be performed without compromising client safety.

Voluntary Medical Male Circumcision: A Framework Analysis of Policy and Program Implementation in Eastern and Southern Africa

Kim Dickson and colleagues analyze the progress made by 13 priority countries toward scale-up of medical male circumcision programs, finding that the most successful programs involve country ownership of the program and have sustained leadership at all levels.

Voluntary medical male circumcision: an HIV prevention priority for PEPFAR.

Abstract: As the science demonstrating strong evidence for voluntary medical male circumcision (VMMC) for HIV prevention has evolved, the Presidents Emergency Plan for AIDS Relief (PEPFAR) has collaborated with international agencies, donors, and partner country governments supporting VMMC programming. Mathematical models forecast that quickly reaching a large number of uncircumcised men with VMMC in strategically chosen populations may dramatically reduce community-level HIV incidence and save billions of dollars in HIV care and treatment costs. Because VMMC is a 1-time procedure that confers life-long partial protection against HIV, programs for adult men are vital short-term investments with long-term benefits. VMMC also provides a unique opportunity to reach boys and men with HIV testing and counseling services and referrals for other HIV services, including treatment. After formal recommendations by WHO in 2007, priority countries have pursued expansion of VMMC. More than 1 million males have received VMMC thus far, with the most notable successes coming from Kenyas Nyanza Province. However, a myriad of necessary cultural, political, and ethical considerations have moderated the pace of overall success. Because many millions more uncircumcised men would benefit from VMMC services now, US President Barack Obama committed PEPFAR to provide 4.7 million males with VMMC by 2014. Innovative circumcision methods—such as medical devices that remove the foreskin without injected anesthesia and/or sutures—are being rigorously evaluated. Incorporation of safe innovations into surgical VMMC programs may provide the opportunity to reach more men more quickly with services and dramatically reduce HIV incidence for all.

Lessons learned from scale-up of voluntary medical male circumcision focusing on adolescents: benefits, challenges, and potential opportunities for linkages with adolescent HIV, sexual, and reproductive health services.

Background and Methods:By December 2013, it was estimated that close to 6 million men had been circumcised in the 14 priority countries for scaling up voluntary medical male circumcision (VMMC), the majority being adolescents (10–19 years). This article discusses why efforts to scale up VMMC should prioritize adolescent men, drawing from new evidence and experiences at the international, country, and service delivery levels. Furthermore, we review the extent to which VMMC programs have reached adolescents, addressed their specific needs, and can be linked to their sexual and reproductive health and other key services. Results and Discussion:In priority countries, adolescents represent 34%–55% of the target population to be circumcised, whereas program data from these countries show that adolescents represent between 35% and 74% of the circumcised men. VMMC for adolescents has several advantages: uptake of services among adolescents is culturally and socially more acceptable than for adults; there are fewer barriers regarding sexual abstinence during healing or female partner pressures; VMMC performed before the age of sexual debut has maximum long-term impact on reducing HIV risk at the individual level and consequently reduces the risk of transmission in the population. Offered as a comprehensive package, adolescent VMMC can potentially increase public health benefits and offers opportunities for addressing gender norms. Additional research is needed to assess whether current VMMC services address the specific needs of adolescent clients, to test adapted tools, and to assess linkages between VMMC and other adolescent-focused HIV, health, and social services.

Voluntary Medical Male Circumcision: Logistics, Commodities, and Waste Management Requirements for Scale-Up of Services

Dianna Edgil and colleagues evaluate the supply chain and waste management costs needed to deliver mobile medical male circumcision services to 152,000 men in Swaziland, finding that per-procedure costs almost double when these factors are taken into account.