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

Friday, 3rd of May 2013

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 PEPFARVoluntary 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.