Transcript In It To Saves Lives Voluntary Male Medical Circumcision for HIV Prevention Emmanuel Njeuhmeli, MD, MPH, MBA Senior Biomedical Prevention Advisor, USAID Washington Co-Chair PEPFAR.

In It To Saves Lives
Voluntary Male Medical Circumcision
for HIV Prevention
Emmanuel Njeuhmeli, MD, MPH, MBA
Senior Biomedical Prevention Advisor, USAID Washington
Co-Chair PEPFAR Male Circumcision Technical Working group
AIDS 2012—
Turning the Tide Together
Call to Action for VMMC
• Moderated by Brenda Wilson
• Male Client Perspective
– Mr. Angelo Kaggwa
• Female Perspective
– Her Excellency Dr. Speciosa Wandira
– Ms. Hendrica Okongo
• Cultural aspects of male circumcision
– His Excellency Chief Jonathan Mumena
• Economic Aspects of VMMC
– Honorable Dr. Oburu Odinga
• Leadership in VMMC
– Honorable Pr. Christine D. J. Ondoa
– Mr. Blessing Chebundo
• Call to Action
– His Excellency Benjamin Mkapa
Champions for HIV-Free Generation
• His Excellency Benjamin Mkapa, Former
President, Tanzania
• His Excellency Kenneth Kaunda, Former
President, Zambia
• His Excellency Joaquim Chissano, Former
President, Mozambique
• Her Excellency Speciosa Wandira, Former
Vice President, Uganda
• Professor Miriam Were, Former Chairperson of
the Kenya National AIDS Council, Kenya
Scientific Evidence
• Biological plausibility:
– Inner surface of the foreskin highly vulnerable to HIV
infection
– Up to nine times more vulnerable than cervical tissue
• Over 50 ecological and observational studies: lack
of male circumcision associated with higher HIV in
men
• Three RCTs in Kenya, Uganda, and South Africa:
60% protection
• Longer-term (4–5 years) follow-up of the Kenya and
Uganda RCT participants: protective effect
sustained/increased
• Community-level impact evaluation in South Africa
(Orange Farm) demonstrated 76% incidence
reduction
WHO-UNAIDS Recommendations
Male Circumcision Priority Countries
Minimum Package of Services
• Male circumcision is always part of a package of
prevention services:
– Provider-initiated HIV counseling and testing, including
couples HTC
– Screening (and treatment) of STIs
– Age-appropriate counseling on risk reduction, including
reduced number and concurrency of sexual partners,
delaying/abstaining from sex
– Provision and promotion of correct and consistent use of
condoms (male and female)
– Active referral and linkage to HIV care/treatment/support
services, including other HIV prevention services
– Post-operative clinical care and reinforced education/
counseling
DMPPT Estimate of Number of Adult 15–49 Years
VMMC Needed per Countries to Reach 80% Coverage
5000000.0
4333134.0
4245184.0
4500000.0
4000000.0
3500000.0
3000000.0
1949292.0
2500000.0
2101566.0
1912595.0
1746052.0
2000000.0
1373271.0
1500000.0 345244.0
1059104.0
377788.0
1000000.0
376795.0
330218.0
500000.0
183450.0
40000.0
.0
13 Countries: EIMC, Adolescent
and Adult MC Required
Cumulative Number and Percentage of HIV Infections Averted
between 2011 to 2025 by Scaling Up VMMC
1,200,000
45.00%
41.693%
36.620%
35.00%
# infections averted
33.913%
800,000
28.732%
28.080%
29.925% 30.00%
28.312%
25.210%
24.515%
600,000
19.825%
400,000
15.730%
25.00%
20.00%
15.00%
12.990%
9.172%
10.00%
200,000
5.00%
-
.00%
% infections averted
1,000,000
40.00%
Challenges for Scaling Up VMMC
• Risk compensation:
– No evidence that men after circumcision adopt riskier
sexual behavior
• Skepticism of science:
– Observational studies
– RCTs
• Resumption of sex before wound healing:
– If HIV positive men are being circumcised and resume
sex without protection before the wound heals there,
is an increased risk to transmit HIV to the partner
Total – New HIV Infections Averted
HIV Infections Averted in Men and Women
Net Savings by Scaling Up VMMC
US$16.5 Billion
(2011 to 2025 in Millions US$)
6,000
5,576
5,000
4,000
2,929
3,000
1,120
2,000
548
1,000
-
1,679
316
369
6
1,443
1,085
980
70
140
295
Number of VMMCs Needed
to Prevent 1 Infection
70
59
60
50
44
40
30
26
19
20
8
10
0
8
5
13
7
10
5
5
8
4
WHO-UNAIDS Joint Strategic Framework for
Acceleration of the VMMC Scale-Up 2012–2016
More than 5 years after WHO-UNAIDS recommendations:
Neither the elegance of the science nor the strength of the effect predict the
ease of implementation.
1.
PEPFAR-UNAIDS Recent Publications in PLoS Medicine: Signpost the way
forward to accelerate the scaling-up of VMMC service delivery safely and
efficiently to reap individual- and population-level benefits
2.
PEPFAR-WHO-UNAIDS-BMGF-World Bank collaboration to launch the WHOUNAIDS Joint Strategy Action Framework for Acceleration of the Scale-Up of
VMMC
www.ploscollections.org/VMMC2011
Number of VMMCs from March 2007
to March 2012
500000.0
428852.0
450000.0
400000.0
350000.0
303534.0
204812.0
300000.0
250000.0
216112.0
174346.0
200000.0
150000.0
5012.0
869.0
100000.0 22549.0
55635.0
49793.0
38912.0
50000.0
15438.0
11644.0
8069.0
.0
Number of VMMCs Done as of March 2012
700000.0
591252.0
600000.0
500000.0
421659.0
400000.0
392627.0
300000.0
200000.0
100000.0
113919.0
16120.0
.0
2008
2009
2010
2011 (Jan- Oct2011 Oct)
March 2012
Strategy for Achieving Pace and Scale
• Political will and country ownership
• Strong leadership and coordination from MOH
• Effective demand creation strategy with strong
community-level buy-in
• Enough financial resources for service delivery,
including some level of dedication of staff time,
facility space and commodities
• Provision of excellent technical support to allow for
a good match of demand and supply and an
efficient use of the limited resources available in
order to reach the maximum number of men
possible.
High-Volume, High-Quality Service Delivery
Effective Demand
Creation
Dedicated
Commodities
Efficient VMMC Program
Dedicated Human
Resources
Dedicated Space
Thank You
Thank you!
The sponsors of this satellite would like to acknowledge that the satellite has been made possible
because of the Maternal and Child Health Integrated Program (MCHIP). MCHIP is being sponsored
by PEPFAR through USAID and managed by Jhpiego.
The information provided in this document is not official U.S. Government information and does
not necessarily represent the views or positions of USAID or PEPFAR.