emmanuel njeuhmeli, md, mph, mba senior biomedical prevention advisor, usaid washington
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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. Call to Action for VMMC. Moderated by Brenda Wilson - PowerPoint PPT PresentationTRANSCRIPT
AIDS 2012—Turning the Tide
Together
Emmanuel Njeuhmeli, MD, MPH, MBASenior Biomedical Prevention Advisor, USAID WashingtonCo-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
Leso
tho
Malawi
Mozamb...
Namibia
Nyanza
, K...
Rwanda
South A
frica
Swazila
nd
Tanza
nia
Uganda
Zambia
Zimba
bwe -
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
ions
ave
rted
% in
fect
ions
ave
rted
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$16.5 Billion
(2011 to 2025 in Millions US$)
Botswan
a
Ethiop
iaKen
ya
Leso
tho
Malawi
Mozam
b...
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
Botswan
a
Ethiop
iaKen
ya
Leso
tho
Malawi
Mozam
b...
Namibi
a
Rwanda
South
Africa
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
204812.000216112.000
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.