AIDS 2012—Turning the Tide

Together

Emmanuel Njeuhmeli, MD, MPH, MBA

Senior Biomedical Prevention Advisor, USAID Washington

Co-Chair PEPFAR Male Circumcision Technical Working group

In It To Saves Lives Voluntary Male Medical Circumcision

for HIV Prevention

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 RecommendationsMale Circumcision Priority Countries

• 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

Minimum Package of Services

DMPPT Estimate of Number of Adult 15–49 Years VMMC Needed per Countries to Reach 80% Coverage

.000500000.000

1000000.0001500000.0002000000.0002500000.0003000000.0003500000.0004000000.0004500000.0005000000.000

345244.000

40000.000

377788.000376795.000

2101566.000

1059104.000

330218.000

1746052.000

4333134.000

183450.000

1373271.000

4245184.000

1949292.000

1912595.000

13 Countries: EIMC, Adolescent and Adult MC Required

Botswana

Lesoth

o

Mala

wi

Moza

mb...

Namib

ia

Nyanza

, K...

Rwanda

South A

frica

Swaziland

Tanzania

Uganda

Zambia

Zimbabwe

-

200,000

400,000

600,000

800,000

1,000,000

1,200,000

.000%

5.000%

10.000%

15.000%

20.000%

25.000%

30.000%

35.000%

40.000%

45.000%

28.080%

36.620%

28.312%

12.990%

25.210%

15.730%

28.732%

19.825%

33.913%

9.172%

24.515%

29.925%

41.693%

# in

fect

ion

s a

vert

ed

% in

fect

ion

s a

vert

ed

Cumulative Number and Percentage of HIV Infections Averted between 2011 to 2025 by Scaling Up VMMC

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$)

Botsw

ana

Ethiop

ia

Kenya

Leso

tho

Mala

wi

Moz

amb.

..

Namibi

a

Rwanda

South

Af..

.

Swazila

nd

Tanza

nia

Ugand

a

Zambia

Zimba

bwe

-

1,000

2,000

3,000

4,000

5,000

6,000

316 6

369 548

1,120 1,085

70 140

5,576

295

980 1,443

1,679

2,929

Number of VMMCs Needed to Prevent 1 Infection

Botsw

ana

Ethiop

ia

Kenya

Leso

tho

Mala

wi

Moz

amb.

..

Namibi

a

Rwanda

South

Afri

ca

Swazila

nd

Tanza

nia

Ugand

a

Zambia

Zimba

bwe

0

10

20

30

40

50

60

70

8

59

8 5 137

26

44

5 510

198

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 WHO-UNAIDS 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

.00050000.000

100000.000150000.000200000.000250000.000300000.000350000.000400000.000450000.000500000.000

22549.000

15438.000

428852.000

869.000

8069.00049793.000

5012.000

11644.000

303534.000

38912.000

174346.000

204812.000

216112.000

55635.000

Number of VMMCs Done as of March 2012

20082009

2010

2011 (Jan-O

ct)

Oct2011 -M

arch 2012

.000100000.000200000.000300000.000400000.000500000.000600000.000700000.000

16120.000113919.000

421659.000

591252.000

392627.000

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

Dedicated Human Resources

Dedicated Space

Efficient VMMC Program

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.