A collection of articles on voluntary medical male circumcision published in the PLOS One online journal
Policymakers and programme planners who are involved in accelerating scale-up of voluntary medical male circumcision (VMMC) are seeking to improve efficiency of services, maintain or improve quality of services, achieve the maximum impact at the lowest cost, and create demand for services while providing timely level of supply to match existing demand. They will find valuable information in this collection to support all of these efforts.
These articles highlight key findings from several countries that have moved to high-volume VMMC services, explore current challenges, and offer recommendations for programmes as they accelerate scale-up of VMMC services in their countries. Each article in the collection is linked below.
To view the entire collection, click here.
To read media coverage of the collection, click here (2014, PDF, 409 KB).
Introduction
While programmes under the WHO/UNAIDS Joint Strategic Action Framework for Accelerating the Scale-up of VMMC for HIV prevention in Eastern and Southern Africa (2011, PDF, 257 KB) have grown dramatically since inception, challenges remain to reach 80% coverage of adult male circumcision in the priority countries by 2016. The editorial provides an overview of the articles in this collection and emphasizes management solutions to help VMMC programmes avert the greatest possible number of HIV infections. Recommendations include advocating for prioritisation and funding of VMMC, increasing strategic targeting to achieve the goal of reducing HIV incidence, focusing on programmatic efficiency, exploring the role of new technologies, rethinking demand creation, strengthening data use for decision-making, improving governments’ programme management capacity, strategising for sustainability, and maintaining a flexible scale-up strategy informed by a strong monitoring, learning, and evaluation platform.
PMEDICINE-D-14-00280: Achieving the HIV Prevention Impact of Voluntary Medical Male Circumcision: Lessons and Challenges for Managing Program
Quality of Services
The rapid expansion of VMMC services in priority countries in eastern and southern Africa has raised some skepticism and concerns about whether health systems can deliver high volume of services and still keep the quality of services high. The Systematic Monitoring of the Voluntary Medical Male Circumcision Scale up (SYMMACS) was a facility-based survey conducted in Kenya, South Africa, Tanzania, and Zimbabwe with two rounds of data (2011 and 2012). Results showed that, for the most part, safe, high quality VMMC can be implemented and sustained at scale, although expansion of services caused a decrease in quality where the number of new sites increased most rapidly. All four countries received the highest scores on quality of surgical procedure techniques. Areas for improvement included infection control, pre-operative examinations, and post-operative patient monitoring and counseling, depending on country.
VMMC also represents a unique opportunity to reach men with other HIV services including HIV testing, counseling, and linkages to care and treatment. Linking HIV-infected men who are diagnosed in VMMC clinic to HIV care and treatment will improve survival and lower viral load, potentially decreasing onward transmission. A programmematic experience in Lesotho demonstrates that the introduction of VMMC can dramatically increase uptake of HIV testing, counseling and ART among men if referrals are well coordinated.
- PONE-D-13-32628: Systematic Monitoring of Voluntary Medical Male Circumcision Scale-up: Adoption of Efficiency Elements in Kenya, South Africa, Tanzania, and Zimbabwe
- PONE-D-13-36124: Implications of the fast-evolving scale-up of adult Voluntary Medical Male Circumcision for quality of services in South Africa
- PONE-D-13-31472: Quality of Voluntary Medical Male Circumcision Services during Scale-Up: A Comparative Process Evaluation in Kenya, South Africa, Tanzania and Zimbabwe
- PONE-D-13-33438: Voluntary medical male circumcision programmes can address low HIV testing and counseling usage and ART enrollment among young men: lessons from Lesotho
- VMMC Quality of Services Fact Sheet (2014, PDF, 171 KB). Rapid expansion of VMMC services in priority countries in eastern and southern Africa raises the question of whether health systems can absorb a high volume of new services while maintaining quality. Do at-scale VMMC programmes provide adequate linkages to HIV testing and quality care and treatment services for HIV-positive clients? Four studies examined how quality services and linkages are achieved during scale-up.
Efficiencies
The adoption of practices designed to improve surgical efficiency in the operating room varied by country, reflecting national policy and regulations. Kenya and Tanzania effectively employed task shifting. South Africa and Zimbabwe demonstrated efficiencies related to use of electrocautery and task sharing on suturing and disposable kits. All countries have adopted forceps guided as the surgical method of choice. SYMMACS focused greater attention on the quality of services in all countries, and it contributed to a favourable reversal of policy that previously disallowed task shifting in Zimbabwe.
- PONE-D-13-31478: Surgical efficiencies and quality in the performance of voluntary medical male circumcision procedures in Kenya, South Africa, Tanzania, and Zimbabwe
- PONE-D-13-31469: Work experience, job-fulfillment and burnout among VMMC providers in Kenya, South Africa, Tanzania and Zimbabwe
- PONE-D-13-31479: Provider attitudes toward the voluntary medical male circumcision scale-up in Kenya, South Africa, Tanzania and Zimbabwe
- VMMC Efficiencies Fact Sheet (2014, PDF, 109 KB). Adoption of practices designed to improve VMMC surgical efficiency in the operating room is a key element of achieving performance targets. However, it is important to document whether these efficiencies compromise quality when programmes expand quickly during scale-up. Three studies examined efficiencies in relation to primary providers’ time spent with clients and total elapsed operating times. In addition, the studies explored provider perceptions of efficiencies and VMMC scale-up, with relation to burnout and job fulfillment.
Costing and Impact
Findings from three new studies by PEPFAR through the USAID-funded Health Policy Project will be of interest to decision-makers determining the allocation of HIV prevention resources. An analysis by Bollinger, et al showed that there is significant room for exploiting economies of scale in the delivery of VMMC as the volume of circumcisions expand. VMMC remains in the scale-up phase, with personnel and consumables the most significant factors affecting the cost of VMMC. In addition to benefitting from economies of scale as service delivery scales-up, there are other key opportunities to increase efficiency through task shifting/sharing. In another study in Zimbabwe, Njeuhmeli et al found that integrating device-based circumcisions into existing VMMC programmes did not result in substantial cost savings. Menon, et al found that in Tanzania, scaling up VMMC to reach target levels over a five-year period and then maintaining coverage through 2025 could prevent 190,500 HIV infections and result in savings of over US $800 million.
PONE-D-13-34035: Cost Drivers for Voluntary Medical Male Circumcision Using Primary Source Data from sub-Saharan Africa
PONE-D-13-32633: Costs and Impacts of Scaling up Voluntary Medical Male Circumcision in Tanzania
PONE-D-13-31476: Cost Analysis of Integrating The PrePexTM Medical Device Into a Voluntary Medical Male Circumcision Program in Zimbabwe
VMMC Costing Fact Sheet (2014, PDF, 100 KB). Estimating the costs and benefits of VMMC services is crucial to the success of scale-up. Findings from three new studies by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the USAID-funded Health Policy Project, which examines issues related to costing VMMC programmes, may aid decision makers in future allocation of HIV prevention resources.
Demand Creation
Creating sustained demand for VMMC is essential to the success of scale-up. Formative research should be an integral part of VMMC programmeming to guide the design of service delivery modalities that meet specific needs and desires of communities and specific age groups of men to take up VMMC. Demand creation messages and approaches need to be specifically tailored for different ages as there are important disparities in motivators and barriers to VMMC uptake by age groups. Positioning VMMC as a lifestyle choice with other health benefits rather than an HIV prevention method might increase acceptance of the service by both older men (over 25 years of age) and women, as demonstrated in the case of Zimbabwe. Service delivery modality and intensity through campaigns also is important to generate demand, influencing uptake of services especially by younger age groups such as adolescents. In both Zimbabwe and Tanzania, high numbers of adolescents (10-19 years) are accessing services during school holiday campaigns, which is not the case for older men who have proven to be more challenging to reach. VMMC programmes need to explore underlying cultural preferences and barriers to effectively target older clients. The barriers to VMMC demand in Kenya for older men included stigma associated with VMMC, and the perception of low risk for HIV for older men. Clearly, as programmes scale up, it is essential to understand and tailor both demand creation interventions and service delivery models to the specific age groups of clients.
- PONE-D-13-35744: Barriers and Motivators to Voluntary Medical Male Circumcision Uptake among Different Age Groups of Men in Zimbabwe: Results from a Mixed Methods Study
- PONE-D-13-40327: Attitudes, Perceptions, and Potential Uptake of Male Circumcision among Older Men in Turkana County, Kenya Using Qualitative Methods
- PONE-D-13-32867: Voluntary Medical Male Circumcision (VMMC) in Tanzania and Zimbabwe: Service Delivery Intensity and Modality and Their Influence on the Age of Clients
- VMMC Demand Creation Fact Sheet (2014, PDF, 56 KB). Creating sustained demand for VMMC is essential to the success of scale-up. Studies from Zimbabwe, by Population Services International (PSI) Zimbabwe; Kenya, by the President’s Emergency Plan for AIDS Relief (PEPFAR) through USAID’s Research to Prevention project; and Tanzania, by PEPFAR through USAID’s Maternal and Child Health Integrated Program (MCHIP), examined what is influencing uptake of VMMC services in each respective country.