Dr. Emmanuel Njeuhmeli has served as the Senior Biomedical Prevention Advisor at the Office of HIV/AIDS at the U.S. Agency for International Development (USAID) for the past nine years. He has been the voluntary medical male circumcision (VMMC) technical lead for USAID, providing support to the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) programs in Eastern and Southern Africa for the introduction and acceleration of the scale-up of the VMMC program. For six years, he served as co-chair of the PEPFAR Male Circumcision Technical Working Group. Since 2011, Dr. Njeuhmeli has spearheaded the publication of three PLOS collections detailing the opportunities and challenges of successful scale-up of this massive public health intervention to further reduce HIV incidence. In this post, he reflects on how the VMMC program has evolved and shares important lessons learned along the way.

As the old adage goes, hindsight is 20/20. It is always easier to look back and re-evaluate the choices that were made in the past with the knowledge one has today. But it is an important exercise to reflect on what we have done well and what we might do differently given what we now know, so that we can build on those important lessons learned in the future. After nine years of supporting, together with many other colleagues, the scale-up of voluntary medical male circumcision (VMMC) for HIV prevention in Southern and Eastern Africa, I felt it was important to reflect and share my perspective on various decisions that were made along the way as the program evolved. What we learn from the experience of adopting a health service innovation and scaling it up not only can inform the future of VMMC programming, but will hopefully benefit other public health interventions as well.

For decades, observational data suggested a correlation between circumcision status and HIV serostatus in men. Then came the randomized control trials from 2005 through 2007 which provided the compelling evidence used by the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) to issue recommendations to implement VMMC as part of the HIV prevention portfolio in settings with high HIV prevalence and low prevalence of male circumcision in East and Southern Africa. After the trials, additional data from community impact studies conducted in South Africa’s Orange Farm township surfaced showing that the 60 percent protective effect even increased over time. This gave us a huge body of evidence that demonstrated a potentially powerful HIV prevention intervention, but all that data then had to be translated into policy and strategy, followed by implementation and scale-up.

In 2011, the first VMMC collection was published in PLOS, in conjunction with UNAIDS and PEPFAR, showing the cost, impact and challenges of accelerated scale-up of VMMC [1]. The potential cost-savings to countries due to averted care and treatment costs was evident. The data presented in that collection supported the decision for VMMC to be considered as one of three critical HIV interventions, along with treatment and prevention of mother-to-child transmission (PMTCT), to achieve an AIDS-free generation. The data also helped to provide key additional evidence that led to the launch of the WHO/UNAIDS Joint Strategic Action Framework, which set a goal to circumcise 20.3 million men by 2016 across 14 African countries. Strategically using data for advocacy allowed the program to roll out and scale up in a relatively short period of time as compared with other public health interventions. In retrospect, this was something that was done quite well. None of this would have been possible without the strong collaboration among the countries’ ministries of health, global stakeholders, USAID, the Centers for Disease Control, the U.S. Department of Defense, the U.S. Department of State’s Office of the Global AIDS Coordinator, WHO, UNAIDS, the World Bank and the Bill and Melinda Gates Foundation. The 2011 PLOS collection also focused on the many challenges the program faced, such as resource and capacity constraints, which would make it difficult for countries to reach their ambitious goals for VMMC scale-up.

Early on in designing the VMMC program, there was significant emphasis on trying to improve program efficiency and volume. In 2010, WHO outlined considerations for models to optimize the volume and efficiency (MOVE) of VMMC services. The core of what became known as the “MOVE model” included:

The efficient use of facility space through the dedication of multiple surgical beds to one surgical team

The efficient use of staff time through task shifting and task sharing, including deployment of non-physicians to complete all or specific steps in VMMC surgery

The bundling of commodities and supplies required to perform VMMC, including consumable materials and surgical instruments

By having all instruments bundled into one kit, we were able to save a significant amount of money and time. The decision was made to also pool procurement by using one central mechanism to procure commodities for several VMMC programs, which gave us a competitive advantage in the marketplace to decrease the prices of those commodities – now shown to be a wise decision.

While a lot of thinking went into improving program efficiency, our focus was primarily on the time it takes while the client is in the operating theater for the surgical procedure. We understood the critical need for client safety and the volume of people being seen needed to receive high quality care. However, translating these concepts into programmatic processes took more time than anticipated. Reaching VMMC program efficiency entails looking at the entire VMMC continuum and the client flow—from the client’s first interaction with the community mobilizer and registration at the VMMC clinic, all the way through to the client’s return to the VMMC site for his post-operative follow-up visit. Achieving that requires a careful and coordinated matching of supply with demand, which we quickly realized was a key issue to address in order to make good use of the limited resources that were successfully mobilized. As a result, improving efficiency of the demand-creation efforts, the in-service communication, counseling and quality assurance and quality improvement became our key focus.

Scaling up services while still maintaining high quality is a challenge, and from the beginning we conducted external quality assessments on a regular basis. However, it was only later that we realized how important it was to have both external and internal continuous quality assurance (QA) and quality improvement (CQI) processes in place, as they are complementary processes [2]. In retrospect, the CQI process should have been done from day one. While it is a time-consuming process, it is essential because it helps to guarantee both a culture of high-quality services and high customer satisfaction, two key indicators of any successful program. We have also learned that the process can be streamlined and made more time efficient by using new technologies, such as tablets and apps, which allow for data analysis and the generating of reports in real-time.

The quality of the in-service communication and counseling that the client receives at the VMMC site is critical to his safety, proper healing after surgery, adopting safer behaviors and remaining HIV-negative in the future. What we came to realize was the larger effect good customer service has on encouraging other men to seek this procedure, as a more positive VMMC experience leads to more satisfied clients who in turn refer their peers.

Looking back, much of our attention in the early days of the program was focused on putting in place and increasing the supply of services by expanding the number of sites and having trained staff and commodities available. There was less focus at that time on creating demand for services as we were very cautious about not going against the local culture. Rather, the program just followed the natural demand that existed and we discover the preference for being circumcised in the cooler months. In some cases, this led to low site utilization and inefficient use of resources because there was not enough demand for the service at some point. Once VMMC became more of a culturally acceptable social norm, we then had the opportunity to put more attention and resources into demand generation which then improved site utilization and efficiency. A few countries have managed to overcome the “seasonality barrier” demonstrating that it is possible to create year-round demand for services, which ultimately leads to more efficient programs [3]. In order to match supply with demand (and vice versa), it requires ongoing, effective coordination between the various partners responsible for service delivery and generating demand for services all the way down to the site-level. This has not always been easy to achieve, but we have come to realize just how critical this coordination is to increasing uptake of services and to the ultimate success of the program. A broad range of data should be collected and reported on a regular basis to better manage supply and demand.

While the initial focus of the program was on reaching men ages 15 to 49, it soon became clear that almost half of the clients coming for VMMC services were younger adolescents in the 10 to 14 year-old age group, among whom circumcision is socially and culturally more acceptable [4]. The question then was whether to turn the younger boys away or accommodate them, which meant more data was needed to understand the relative contribution of each age segment to averting future HIV infections. This led to the development of a new mathematical modeling tool (the DMPPT2) that could help countries in the planning phase to strategically prioritize sub-populations by age and geography to maximize impact, directing resources where they can generate the highest level of infections averted in the shortest period of time [5].

Finally, in the scale-up of the VMMC program, some countries have progressed faster than others, and even within countries, progress has been uneven with certain age groups and certain districts reaching saturation (i.e. 80 percent VMMC coverage) before others. These regions need to start planning for sustainability sooner than originally thought [6]. For example, the VMMC program in Tanzania has succeeded in reaching complete VMMC saturation among males ages 15 to 24 years within the planned five years in two traditionally non-circumcising regions, Iringa and Njombe, demonstrating that our goal was not just a dream, but truly attainable. These two regions of Tanzania are now piloting a sustainability approach that will help to guide other regions as they move to the transition phase. We have seen that the most successful programs have been country-owned from the outset, with sustained political support at all levels – national, regional, provincial and district.

At of the end of 2016, PEPFAR supported more than 11.7 million VMMC procedures in 14 priority countries in Eastern and Southern African. With technical and financial support that contributed to close to 12 Million out of the 14 Million VMMC done as of end of 2016, PEPFAR was a critical player in the introduction and the acceleration of the scale up of VMMC and continue to hold on this leadership. Without that support, the VMMC program would never have achieved the high level of coverage that it has in a relatively short amount of time. Assuming each country reaches the UNAIDS global 90-90-90 HIV treatment targets, modeling analysis projects that the 14 million male circumcisions conducted through December 2016 will avert more than 380,000 HIV infections by 2025. PEPFAR continues to prioritize this one-time intervention and plans to focus on saturation in priority districts by 2020.

Moving forward, one of the key challenges for the VMMC program is the most efficient use of the limited resources available. The VMMC program in the Manica and Tete provinces of Mozambique has clearly demonstrated that it is possible to bring strategic planning down to the site-level, and to succeed in improving the site utilization rate from as low as 30 percent to maintaining close to 100 percent, along with high quality services. At the same time, the Mozambique program is seeing a significant increase in uptake of services among those men most at risk of HIV, 15 to 29 year-olds, a difficult to reach age group which had eluded us until now.

As I look back, probably my greatest regret is the opportunities that have not been well explored so far, such as the potential contribution of the private sector, including private health insurance and private clinics, something we have only just begun to tap into in a few countries, but has tremendous potential. VMMC programs have increased HIV testing uptake among men who otherwise would not have accessed HIV testing services, and linked those found to be HIV-positive to care and treatment [7]. In the future, we need to focus more effort on leveraging this unique opportunity that the VMMC program presents by attracting men into the health system, in order to further link them with other HIV and health interventions.

The experience of moving a surgical intervention like VMMC from evidence to policy to implementation and scale-up provides a number of lessons, some of which could be applied to other public health interventions. We know that rolling out VMMC for HIV prevention has faced many challenges, but we also have a much better understanding today of what it takes for a country program to succeed. VMMC remains critical for epidemic control in the high-prevalence countries in East and Southern Africa. It is my hope that countries, with support from WHO, UNAIDS, PEPFAR and other donors, will succeed in implementing the new WHO and UNAIDS framework that was launched in 2017 with the goal of reaching 90 percent of adolescents and men (ages 10-29 years old) by 2021. The high male circumcision coverage we have all worked so hard to achieve, and the additional VMMCs to come, will continue to reap health benefits long into the future, and I believe the day will come when we will see new HIV infections decrease to the lowest level possible.

Hankins C, Forsythe S, Njeuhmeli E. Voluntary medical male circumcision: an introduction to the cost, impact, and challenges of accelerated scaling up. PLoS medicine. 2011 Nov 29;8(11):e1001127. Byabagambi J, Marks P, Megere H, Karamagi E, Byakika S, Opio A, Calnan J, Njeuhmeli E. Improving the quality of voluntary medical male circumcision through use of the continuous quality improvement approach: a pilot in 30 PEPFAR-supported sites in Uganda. PloS one. 2015 Jul 24;10(7):e0133369. Gold E, Mahler H, Boyee D. Overcoming seasonality in scaling up voluntary medical male circumcision. A case study from Tanzania. Njeuhmeli E, Hatzold K, Gold E, Mahler H, Kripke K, Seifert-Ahanda K, Castor D, Mavhu W, Mugurungi O, Ncube G, Koshuma S. Lessons learned from scale-up of voluntary medical male circumcision focusing on adolescents: benefits, challenges, and potential opportunities for linkages with adolescent HIV, sexual, and reproductive health services. JAIDS Journal of Acquired Immune Deficiency Syndromes. 2014 Jul 1;66:S193-9. Hankins C, Warren M, Njeuhmeli E. Voluntary medical male circumcision for HIV prevention: new mathematical models for strategic demand creation prioritizing subpopulations by age and geography. PloS one. 2016 Oct 26;11(10):e0160699. Njeuhmeli E, Gorgens M, Gold E, Sanders R, Lija J, Christensen A, Benson FN, Mziray E, Ahanda KS, Kaliel D, Sint TT. Scaling Up and Sustaining Voluntary Medical Male Circumcision: Maintaining HIV Prevention Benefits. Global Health: Science and Practice. 2016 Jul 1;4(Supplement 1):S9-17. Kikaya V, Skolnik L, García MC, Nkonyana J, Curran K, Ashengo TA. Voluntary medical male circumcision programs can address low HIV testing and counseling usage and ART enrollment among young men: lessons from Lesotho. PloS one. 2014 May 6;9(5):e83614.

Disclaimer: The content in this blog are those of the author’s and does not necessarily reflect the views of USAID, PEPFAR or the United States Government.

Dr. Emmanuel Njeuhmeli has served as the Senior Biomedical Prevention Advisor at the Office of HIV/AIDS at the U.S. Agency for International Development (USAID).