WHAT'S NEW THIS MONDAY: FOUR ON MALE CIRCUMCISION

Monday, 11th of March 2013

FOUR ON MALE CIRCUMCISION

MALE CIRCUMCISION PROGRAMS IN KENYA

Abstract below; full text is at http://www.who.int/bulletin/volumes/90/9/11-096412.pdf

Objective To provide guidance for male circumcision programmes in Kenya by estimating the population of uncircumcised men and investigating the association between circumcision and infection with the human immunodeficiency virus (HIV), with particular reference to uncircumcised, HIV-uninfected men.

Methods Data on men aged 15 to 64 years were derived from the 2007 Kenya AIDS Indicator Survey, which involved interviews and blood collection to test for HIV and herpes simplex virus 2 (HSV-2). The prevalence of HIV infection and circumcision in Kenyan provinces was calculated and the demographic characteristics and sexual behaviour of circumcised and uncircumcised, HIV-infected and HIV-uninfected men were recorded.

Findings The national prevalence of HIV infection in uncircumcised men was 13.2% (95% confidence interval, CI: 10.8–15.7) compared with 3.9% (95% CI: 3.3–4.5) among circumcised men. Nyanza province had the largest estimated number of uncircumcised, HIV-uninfected men (i.e. 601 709), followed by Rift Valley, Nairobi and Western Province, respectively, and most belonged to the Luo ethnic tribe. Of these men, 77.8% did not know their HIV status and 33.2% were HSV-2-positive. In addition, 65.3% had had unprotected sex with a partner of discordant or unknown HIV status in the past 12 months and only 14.7% consistently used condoms with their most recent partner. However, only 21.8% of the uncircumcised, HIV-uninfected men aged 15 to 19 years were sexually active.

Conclusion The Kenyan male circumcision strategy should focus on the provinces with the highest number of uncircumcised, HIV-uninfected men and target young men before or shortly after sexual debut.

MASS SAFE MALE CIRCUMCISION: EARLY LESSONS FROM A UGANDAN URBAN SITE - A CASE STUDY

Galukande M, Sekavuga DB, Duffy K, Wooding N, Rackara S, Nakaggwa F, Nagaddya T, Elobu AE, Coutinho A.

Source

International Hospital Kampala, Uganda.

Abstract below; full text is at

http://www.panafrican-med-journal.com/content/article/13/88/full/

INTRODUCTION:

It has been proven in several randomized clinical trials that HIV transmission from female to male is reduced by 60% and more among circumcised males. The national target for Uganda by 2015 is to circumcise 4.2 million adult males, an unprecedented number requiring a pragmatic approach and effective model(s) to deliver this target. The objective of the study was to describe early lessons learnt at a start up of a mass safe male circumcision (SMC) program in an urban Ugandan site, implemented through task shifting and a private public partnership approach.

METHODS:

A case study of an urban SMC site in Uganda's capital, Kampala with a catchment population of approximately 0.8 million adult males aged between 15 and 49 years. Client enrollment was voluntary; mobilization was by word of mouth and through the media. Non Physician clinicians (NPC) carried out the majority of the SMCs. The SMC and voluntary counseling and testing (VCT), adverse events (AE) management and follow up were done as per set national guidelines. The supervision was by a public and private service provider. All clients were consented.

RESULTS:

A total of 3000 males were circumcised in 27 days spread over four months. The AE rate was 2.1% all AEs were mild and reversible. No deaths occurred. The work rate was 111 SMCs per day. There was sufficient demand for SMC despite minimal mobilization effort. The bulk of the SMC work was successfully carried out by the NPCs.

CONCLUSION:

Private Public Partnership and task shifting approaches were successful at the start up phase and we anticipate will be feasible for the scale up.

CIRCUMCISIONS FOR MEDICAL REASONS IN THE BRAZILIAN PUBLIC HEALTH SYSTEM: EPIDEMIOLOGY AND TRENDS.

Einstein (Sao Paulo). 2012 Sep;10(3):342-346.

[Article in English, Portuguese]

Korkes F, Silva Ii JL, Pompeo AC.

Source

Faculdade de Medicina do ABC, Santo André, SP, Brasil.

Abstract below; full text is at http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1679-45082012000300015&lng=en&nrm=iso&tlng=en

OBJECTIVE:

To evaluate the epidemiological factors associated to medical circumcision, based on data from the Brazilian public health system.

METHODS:

Using the Unified Health System public database between 1984 and 2010, hospital admissions associated with surgical treatment of phimosis were searched. A total of 668,818 men admitted to public hospitals who underwent circumcision were identified and included in the present study.

RESULTS:

A mean±standard deviation of 47.8±13.4 circumcisions/100,000 men/year was performed through the Unified Health System for medical reasons. During the 27-year period evaluated, 1.3% of the male population required circumcision for medical reasons. Total number of circumcisions and circumcision rate increased in childhood, declined progressively after 5 years of age and rose again progressively after the sixth decade of life. In the regions of the country with better access to healthcare, 5.8% of boys aged 1 to 9 years old required circumcisions. From 1992 to 2010 there were 63 deaths associated with circumcisions (mortality rate of 0.013%).

CONCLUSION:

In conclusion, yearly circumcision rates could be estimated in Brazil, and a very low mortality rate was associated with this procedures. Circumcision is mostly performed in children in the first decade of life and a second peak of incidence of penile foreskin diseases occurs after the sixth decade of life, when circumcision is progressively performed again.

PEPFAR’S BEST PRACTICES FOR VOLUNTARY MEDICAL MALE CIRCUMCISION SITE OPERATIONS

Full text is at http://www.malecircumcision.org/resources/documents/Operational%20Guide_FinalDraft.pdf

Excerpt from Introduction

This document provides PEPFAR’s implementing partners with a comprehensive and consistent process for establishing new Voluntary Medical Male Circumcision (VMMC) services for HIV prevention. It draws upon numerous documents developed by UNAIDS/World Health Organization (WHO) and the PEPFAR Voluntary Medical Male Circumcision Technical Working Group (VMMC TWG). This guide also builds on the experiences and materials from existing VMMC programs in southern and eastern Africa. The scope of this document is limited to establishing and supporting quality VMMC services for HIV prevention at the facility or VMMC site level. The necessary steps involved in scaling up VMMC services at the national, regional, and district levels are beyond the scope of this document. For a more comprehensive view of the key steps in a national VMMC program, see GUIDANCE DOCUMENT 1, WHO’s OPERATIONAL GUIDANCE FOR SCALING UP MALE CIRCUMCISION SERVICES FOR HIV PREVENTION [1].

Background

VMMC reduces men’s risk of acquiring HIV through heterosexual intercourse by approximately 60% [2–10]. As more men become circumcised, fewer will become infected with HIV. VMMC indirectly protects men’s female sexual partners from HIV, because HIV-negative men cannot infect their female sexual partners. However, for HIV-positive men, VMMC does not reduce their risk of transmitting HIV to their sexual partners. Furthermore, if men who are already HIV-positive become circumcised, it will not reverse their HIV-positive status.

UNAIDS and PEPFAR have estimated that scaling up VMMC in men aged 15–49 years in 14 southern and eastern African countries will require 20.3 million circumcisions in five years in order to reach 80% coverage of the eligible population. Using this level of coverage over the next 15 years, mathematical modeling suggests there is the potential to avert up to 3.6 million new HIV infections and generate a potential cost savings of US $16.5 billion [11].

In addition to the reduction in risk of HIV acquisition among circumcised men, VMMC provides other health benefits to men and to women. Evidence shows that VMMC reduces some sexually transmitted infections (STIs), particularly ulcerative STIs, including chancroid, herpes, and syphilis, as well as balanitis, phimosis, and penile cancer [12, 13, 14]. One of the primary benefits of VMMC for women is its association with a reduction in penile human papillomavirus (HPV), which is associated with cervical cancer in female partners [13, 15]. As more men are circumcised, women’s likelihood of sexual exposure to HIV decreases, and their risk of HIV infection also declines. The indirect protection for women is substantial; modeling at levels of 80% circumcision coverage shows an approximately equal number of HIV infections will be averted in women as in men after 15 years [11].

Although VMMC has been shown to significantly reduce men’s risk of acquiring HIV via heterosexual intercourse, VMMC does not provide complete protection from HIV [2, 3, 4]. Because VMMC provides only partial protection from acquiring HIV [16], it is necessary for circumcised males to minimize any potential increased risky sexual behaviors following VMMC surgery (known as risk compensation) [4, 16–19]. Of note, behavioral data from two of the VMMC randomized controlled trials (RCTs) show that circumcised men were no more likely to engage in high-risk sexual practices than uncircumcised men [2,3]. In a slight contrast, the RCT study in South Africa found that men enrolled in an RCT intervention group (circumcised men) reported an average of approximately one more sexual contact in the prior eight months compared to men in the control group (uncircumcised men) who had significantly more sexual contacts [4]. In order to ensure that VMMC surgery is provided as part of a comprehensive HIV prevention package, WHO recommends that all VMMC clients receive the minimum package of services, including:

HIV testing and counseling (HTC) (offer of)

Screening and treatment for STIs

Promotion and provision of male and female condoms

Promotion of safer sex practices and risk reduction counseling

Male circumcision (surgical removal of the foreskin)

In addition to WHO’s minimum package of services, PEPFAR also recommends additional components

that ensure high-quality VMMC services including:

Identifying and implementing active linkages of HIV-positive clients to care and treatment services

Assuring voluntarism and informed consent

Rationale for Developing a Best Practices Document for VMMC Services

VMMC is a surgical procedure that must be provided safely in order to minimize risks of clinical complications. VMMC surgery can be provided safely by different cadres of health care workers (depending on individual countries’ defined regulatory scopes of work) in fixed or mobile settings that meet the quality assurance (QA) standards for infection prevention. VMMC services must be of the highest quality, and mechanisms must be in place for client follow-up and management of AEs. In some communities where VMMC is not commonly practiced, it is potentially a sensitive and controversial intervention. Given these possible sensitivities, extra care should be taken to ensure that communities are provided with complete information about, and sensitization to, VMMC.

Investing in a thorough and measured approach to establishing new VMMC services at each service delivery site will help to ensure that the clinical and the cultural considerations are addressed, minimizing potential delays that could negatively affect the program. Higher levels of local ownership and “buy-in” to providing VMMC services will also benefit the program [20]. This Best Practices document describes approaches that have been used to establish VMMC services successfully in numerous countries, while minimizing the risks and maximizing the quality and benefits of the program.

This guide is designed primarily as a reference tool for PEPFAR-funded organizations that are planning, implementing, or evaluating VMMC programs. Each specific topic is a stand-alone section that includes an overview, timeline, useful tools, references to WHO-endorsed guidance, and relevant case studies.

The guide is accompanied by a resource document that contains specific tools and resources. These tools and resources are referenced in each section and are also provided on a CD-ROM.