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Achieving the HIV Prevention Impact of Voluntary Medical Male Circumcision: Lessons and Challenges for Managing Programs

Achieving the HIV Prevention Impact of Voluntary Medical Male Circumcision: Lessons and... Collection Review Achieving the HIV Prevention Impact of Voluntary Medical Male Circumcision: Lessons and Challenges for Managing Programs 1,2 3 4 5 Sema K. Sgaier *, Jason B. Reed , Anne Thomas , Emmanuel Njeuhmeli 1 Integrated Delivery, Global Development Program, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America, 2 Department of Global Health, University of Washington, Seattle, United States of America, 3 Office of the U.S. Global AIDS Coordinator, Washington (DC), United States of America, 4 Naval Health Research Center, US Department of Defense, San Diego, California, United States of America, 5 United States Agency for International Development, Washington (DC), United States of America women to men (Figure 1) [1–4]. Fourteen countries in Eastern and Abstract: Voluntary medical male circumcision (VMMC) is Southern Africa with high HIV prevalence and low levels of male capable of reducing the risk of sexual transmission of HIV circumcision (MC) are following the recommendations of the from females to males by approximately 60%. In 2007, the World Health Organization (WHO) and the Joint United Nations WHO and the Joint United Nations Programme on HIV/ Programme on HIV/AIDS (UNAIDS) to expand VMMC services AIDS (UNAIDS) recommended making VMMC part of a as an HIV prevention strategy [5,6]. These countries are comprehensive HIV prevention package in countries with Botswana, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, a generalized HIV epidemic and low rates of male Namibia, Rwanda, South Africa, Swaziland, Uganda, the United circumcision. Modeling studies undertaken in 2009–2011 Republic of Tanzania, Zambia, and Zimbabwe. Modeling studies estimated that circumcising 80% of adult males in 14 done in 2009–2011 showed that in these 14 priority countries, priority countries in Eastern and Southern Africa within achieving 80% circumcision prevalence among males aged 15–49 five years, and sustaining coverage levels thereafter, could within five years (‘‘catch-up’’), and maintaining this coverage rate avert 3.4 million HIV infections within 15 years and save in subsequent years (‘‘sustainability’’), could avert 3.4 million new US$16.5 billion in treatment costs. In response, WHO/ UNAIDS launched the Joint Strategic Action Framework HIV infections within 15 years and generate treatment and care for accelerating the scale-up of VMMC for HIV prevention savings of US$16.5 billion [7,8]. VMMC is a highly cost-effective in Southern and Eastern Africa, calling for 80% coverage HIV prevention strategy for both generalized and high-prevalence of adult male circumcision by 2016. While VMMC HIV epidemics [7]. It differs from most other prevention methods programs have grown dramatically since inception, they (e.g., pre-exposure prophylaxis, sexual behavior change, or appear unlikely to reach this goal. This review provides an condom use) in that it only requires a one-time action in order overview of findings from the PLOS Collection ‘‘Voluntary Medical Male Circumcision for HIV Prevention: Improving Quality, Efficiency, Cost Effectiveness, and Demand for Citation: Sgaier SK, Reed JB, Thomas A, Njeuhmeli E (2014) Achieving the HIV Prevention Impact of Voluntary Medical Male Circumcision: Lessons and Services during an Accelerated Scale-up.’’ The use of Challenges for Managing Programs. PLoS Med 11(5): e1001641. doi:10.1371/ devices for VMMC is also explored. We propose empha- journal.pmed.1001641 sizing management solutions to help VMMC programs in Published May 6, 2014 the priority countries achieve the desired impact of averting the greatest possible number of HIV infections. This is an open-access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for Our recommendations include advocating for prioritiza- any lawful purpose. The work is made available under the Creative Commons CC0 tion and funding of VMMC, increasing strategic targeting public domain dedication. to achieve the goal of reducing HIV incidence, focusing on Funding: The United States President’s Emergency Plan for AIDS Relief (PEPFAR) programmatic efficiency, exploring the role of new supported the manuscripts included in this collection through the US Agency for technologies, rethinking demand creation, strengthening International Development (USAID). This collection was funded by PEPFAR data use for decision-making, improving governments’ through USAID’s Maternal and Child Health Integrated Program (MCHIP), under Cooperative Agreement #GHS-A-00-08-00002-000 and AIDS Support and program management capacity, strategizing for sustain- Technical Assistance Resources (AIDSTAR-One) Project, Sector I, Task Order 1 ability, and maintaining a flexible scale-up strategy under contract number GHH-I-00-07-00059-00. Staff from the funding bodies informed by a strong monitoring, learning, and evaluation played a significant role in study design, analysis, decision to publish, or platform. preparation of the manuscript. Disclaimer: The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the Bill & Melinda Gates Foundation, the Office of the Global AIDS Coordinator, the US Agency for International Development, the Centers for Disease Control and Prevention, the US Department of Defense, or the US Introduction Government. Voluntary medical male circumcision (VMMC) has been shown Competing Interests: The authors have declared that no competing interest exist. to be effective in reducing the sexual transmission of HIV from Abbreviations: JSAF, Joint Strategic Action Framework; MC, male circumcision; PEPFAR, United States President’s Emergency Plan for AIDS Relief; UNAIDS, Joint United Nations Programme on HIV/AIDS; VMMC, voluntary medical male Collection Review articles synthesize in narrative form the best available evidence circumcision. on a topic. Submission of Collection Review articles is by invitation only, and they * E-mail: Sema.Sgaier@gatesfoundation.org are only published as part of a PLOS Collection as agreed in advance by the PLOS Medicine Editors. Provenance: Not commissioned. Submitted as part of a PLOS Collection; externally reviewed. PLOS Medicine | www.plosmedicine.org 1 May 2014 | Volume 11 | Issue 5 | e1001641 demand for circumcision. While at a broad level the program is Summary Points increasing its outputs each year (Figures 2 and 3), the current growth rate of the program is not sufficient to reach the JSAF’s Large-scale implementation of voluntary medical male circumcision (VMMC) in 14 priority countries of Eastern goal of 80% coverage by 2016 (Figure 4). and Southern Africa has the potential to significantly This collection of research and review articles, ‘‘Voluntary reduce heterosexual transmission of HIV to males, saving Medical Male Circumcision for HIV Prevention: Improving lives, averting suffering, and avoiding health care costs. Quality, Efficiency, Cost Effectiveness, and Demand for Services Resource and capacity constraints pose a serious during an Accelerated Scale-up,’’ presents new research that challenge to the ability of the priority countries to reach underscores both the challenges and the opportunities for the their goals for VMMC scale-up. accelerated scale-up of VMMC (Box 1). This review article The 13 papers in this collection examine issues of service synthesizes and briefly describes the findings, which focus on four quality, demand creation, cost, and efficiency faced by key areas of the VMMC program: (1) quality of services, (2) governments, donors, and programs. demand creation, (3) cost, and (4) efficiencies for service delivery. Building on these findings, we propose a set of priority focus areas Systematic, evidence-based management of programs and a dynamic culture of learning are proposed to help for the global VMMC program and for the governments of the meet the challenges of VMMC scale-up. priority countries, and we highlight new areas of opportunity to accelerate scale-up. Recommendations include greater prioritization and funding of VMMC, strategic targeting and demand creation, a focus on programmatic efficiencies, and Quality of VMMC Services exploration of new technologies. Ensuring safe and efficient execution of the VMMC procedure Further recommendations are for strengthened data use, N and high-quality pre- and post-procedure services, even as improving governments’ program management capac- programs expand rapidly, is essential in order to realize the full ity, strategizing for sustainability, and maintaining a impact of VMMC, reduce program costs, and increase and sustain flexible scale-up strategy. demand for the service. While most previous quality assessments focused on adverse events in clients [9], two papers in this collection examine facility preparedness for providing quality to provide continuous benefits. VMMC has political support at surgical services using data across two years of program scale-up. both the global and national levels. Most of the 14 priority Jennings and colleagues undertook a comparative assessment of countries have developed strategic plans and established infra- facility preparedness and surgery in Kenya, South Africa, structure to implement the plans and scale up VMMC interven- Tanzania, and Zimbabwe through direct observation [10]. Results tions. (These efforts are referred to collectively in this paper as ‘‘the for facility preparedness were mixed: in some settings, improve- VMMC program’’ or ‘‘the program.’’) ments were seen over time, while in others, early problems that Nevertheless, the VMMC strategy faces challenges at multiple went uncorrected prior to expansion were amplified system-wide levels. The goals set out in the Joint Strategic Action Framework at scale. Rech and colleagues explored in further detail the (JSAF) are highly ambitious: to circumcise 20.2 million men in five implications of scale-up in South Africa [11]. They assessed years (2012–2016) across 14 African countries [6]. Furthermore, readiness to provide quality services and quality of surgical care in the choice to be circumcised involves deep-seated values, beliefs, 2011 and 2012. Rapid scale-up in South Africa led to human and motivational factors that vary with ethnic, religious, and resources being stretched too thinly, with negative effects on cultural identities, and must be addressed effectively to generate quality overall. These studies, and a further study of surgical Figure 1. Timeline and key milestones of the voluntary medical male circumcision program in 14 priority countries. 6 million circumcisions listed in 2013 is an estimate by PEPFAR and the Bill & Melinda Gates Foundation. RCTs, randomized controlled trials; TWG, technical working group; TAG, technical advisory group; MOVE, Models for Optimizing the Volume and Efficiency of MC services. doi:10.1371/journal.pmed.1001641.g001 PLOS Medicine | www.plosmedicine.org 2 May 2014 | Volume 11 | Issue 5 | e1001641 Figure 2. Scale-up of voluntary medical male circumcision program and coverage in 14 priority countries, aggregate, 2008–2013. Number of circumcisions completed each year in millions. Source of 2008–2012 data is the WHO 2012 VMMC report [38]. 2013 numbers have been estimated using data from PEPFAR and the Bill & Melinda Gates Foundation. *CAGR, compound annual growth rate, calculated based on the average 1/(tn 2 to) proportional growth each year. CAGR (t ,t ) = (V(t /V(t )) 21, where V(t ) is the start value and V(t ) is the finish value and t 2 t is the 0 n n) 0 0 n n 0 number of years. doi:10.1371/journal.pmed.1001641.g002 Figure 3. Scale-up of voluntary medical male circumcision program and coverage in 14 priority countries, 2008–2012. Totals reflect progress through 2012. Percentage figures represent the achieved proportion of the target of 80% coverage among males ages 15–49, but totals include circumcisions done for all age groups, regardless of the age-range target. Data obtained from WHO 2012 VMMC report [38]. doi:10.1371/journal.pmed.1001641.g003 PLOS Medicine | www.plosmedicine.org 3 May 2014 | Volume 11 | Issue 5 | e1001641 Figure 4. Scale-up of voluntary medical male circumcision program and coverage in 14 priority countries: growth scenarios, 200822016. Source of 2008–2012 data is the WHO 2012 VMMC report [38]; 2013 figures are estimates, and 2014–2016 figures are projections. In the ‘‘no growth’’ scenario, the program continues to perform the same numbers of circumcisions each year as in 2013. In the ‘‘current growth’’ scenario, the program continues the trend of historical growth rate. doi:10.1371/journal.pmed.1001641.g004 efficiencies and quality of surgical technique in VMMC in Kenya, it is also necessary to improve initial and refresher training for South Africa, Tanzania, and Zimbabwe [12], remind us that while providers on all aspects of the VMMC service package, strengthen ongoing quality and performance assessments, reinforce supervi- it is possible to maintain high standards of surgical care during rapid scale-up (Zimbabwe is a good example), there is always a sion and mentoring, and create functional systems to continuously assess and improve service quality. need to manage adverse events by proactively following up with clients and facilitating postoperative services. As programs expand, Demand Creation There is general agreement among the authors about the need to foster greater demand among men for VMMC in order to Box 1. Scope of the Collection achieve the desired reduction in HIV incidence [6]. Although The PLOS Collection ‘‘Voluntary Medical Male Circumcision most programs aim to reach men aged 15–49, those over 25 are for HIV Prevention: Improving Quality, Efficiency, Cost underrepresented thus far in the scale-up [13]. Two studies have Effectiveness, and Demand for Services during an Accel- explored barriers to and facilitators of demand [14], and three erated Scale-up’’ includes 13 research papers and an papers in this collection specifically address men aged 25 and overview that highlight key findings from several countries above, a group for whom the reasons for low demand are not well that have moved to high-volume VMMC services, explore understood, and whose contribution to HIV prevalence is challenges faced, and offer recommendations for pro- currently being evaluated by new modeling work. grams as they scale up VMMC services. It focuses on the Macintyre and colleagues examined barriers to and facilitators following: of demand in Turkana County, Kenya, a traditionally non- circumcising community [15]. Older married men did not Quality and efficiency of VMMC services – results of the consider themselves at risk of acquiring HIV, and they echoed Systematic Monitoring of the Voluntary Medical Male the findings of other literature on acceptability in viewing Circumcision Scale Up (SYMMACS) facility-based survey circumcision as more appropriate for younger men, whom they conducted in Kenya, South Africa, Tanzania, and perceived as being at higher risk of HIV [16–20]. The authors Zimbabwe argue that promoting circumcision as a modern, biomedical Costing and Impact – findings from three studies by procedure rather than as a cultural practice (which may be PEPFAR through the USAID funded Health Policy Project associated with other tribal groups or young men’s rites of passage) of interest to decision-makers determining allocation of will be an important demand-creation message in this particular HIV prevention resources setting. Demand Creation – studies from Kenya, Zimbabwe, and In Zimbabwe, Hatzold and colleagues conducted quantitative Tanzania highlight importance of tailoring demand- and qualitative studies to explore barriers to and motivating factors creation interventions and service delivery models to for VMMC and to assess the use of existing VMMC communi- specific age group of clients cation channels to promote VMMC [21]. A large majority of the PLOS Medicine | www.plosmedicine.org 4 May 2014 | Volume 11 | Issue 5 | e1001641 respondents had heard about VMMC, mainly through radio. Efficiencies Prevention of HIV was the most cited motivator for circumcision, Several papers in this collection explore improvements in the but men were also motivated by prospects for improved hygiene. efficiency of service delivery, with specific emphasis on efficiencies Non-HIV-related benefits could be part of the messaging for around the surgical procedure, using data from Kenya, South demand-creation activities. Only 11% of all the men surveyed had Africa, Tanzania, and Zimbabwe [9]. None of the four countries been circumcised, and among male respondents expressing an surveyed had adopted all six elements of surgical efficiency tracked unwillingness to become circumcised, fear of pain was the most by the data, which were (1) use of multiple surgical beds, (2) use of frequently cited reason. The paper does not directly identify the pre-bundled surgical supply kits, (3) task-shifting, (4) task-sharing, reasons why men who expressed a willingness to undergo VMMC (5) use of forceps-guided surgical method, and (6) use of had not yet done so, and further research on this would be useful. electrocautery. The use of the forceps-guided surgical method However, three primary predictors of VMMC uptake were was the only element adopted by all countries. Rech and identified: self-efficacy (the belief that one can make the decision colleagues found that innovative human resource models such as oneself to be circumcised), social support from friends, and the sharing of tasks among a coordinated team of clinicians, as well availability of VMMC services. as electrocautery and the use of multiple beds, reduced the overall The study of the modality and intensity of service delivery in procedure time and increased the number of clients served by the Tanzania and Zimbabwe by Adamu and colleagues [22] shows primary surgeon in a given period of time [12]. An encouraging that campaigns conducted during school holidays lead to higher finding was that the quality of surgical technique was not attendance by younger clients, an effect enhanced in Tanzania by compromised by reducing the amount of time the primary the cultural preference for circumcision at a younger age [23]. provider spent with each client, meaning that quality was This underscores the importance of considering cultural prefer- maintained in high-service-volume settings. In fact, in South ences and service delivery timing when designing demand-creation Africa, reduced operating time was associated with higher surgical approaches. quality, which the authors suggest might be the result of experienced providers being more skilled and working more Costs efficiently. While modeling showed that scaling up VMMC to 80% While these papers focus on efficiencies that could be gained at coverage among men aged 15–49 in the 14 priority countries the site level, an assessment of efficiency gains at the macro level of could result in savings of US$16.5 billion in treatment costs, the overall program delivery is also needed, as discussed below. resources required to achieve this are substantial—an estimated Mavhu and colleagues found that providers held positive US$2 billion [7,8,24]. Three papers in this collection undertake attitudes toward the six recommended elements of surgical unit cost analyses to identify the cost drivers and explore where efficiency in countries where national policies were supportive efficiency gains are possible. Bollinger and colleagues (data from [29]. This study highlights the value of consulting with those who Kenya, Namibia, South Africa, Tanzania, Uganda, and Zambia) will implement policies at the service-delivery level. The finding and Menon and colleagues (data from three regions of Tanzania) that national policy bodies in South Africa and Zimbabwe did not use programmatic and financial data (including direct and indirect adopt task-shifting—even though providers supported it—is costs) from VMMC facilities to determine the unit cost of a significant, because task-shifting could alleviate the human surgical VMMC [24,25]. Both studies illustrate that the two largest resources constraint that is a major challenge to the scale-up of cost drivers are personnel (36% of costs) and commodities (28%), VMMC in these countries. with ranges varying by country and model of service delivery. Perry and colleagues identified factors associated with provider An economies-of-scale analysis suggests that further cost burnout (physical or emotional exhaustion as a result of prolonged reductions will be seen as the supply side of the program plateaus stress or frustration) and explored a possible relationship between [24]. These studies highlight the possibility of further efficiency burnout and job satisfaction [30]. In 2012, more than three- gains in the personnel and consumables components of the fourths of providers surveyed in Kenya, South Africa, Tanzania, program by maximizing efficiencies in human and material and Zimbabwe reported that providing VMMC was personally resources and technology. fulfilling. Providers’ median work span in VMMC was longest in Three independent modeling studies, including one in this issue, Kenya (31 months), but the proportion of providers who reported using different starting assumptions, have forecast little if any cost that they were starting to experience burnout was much higher savings with the initial use of circumcision devices such as PrePex there (67%) than in the other three countries. However, the and Shang Ring [26–28]. Njeuhmeli and colleagues note that the study failed to identify any correlates associated with burnout in single greatest determinant of unit cost was site utilization, with Kenya. underutilization doubling the per-procedure price, regardless of whether circumcision was device-based or surgical [28]. Device- Discussion based circumcision has yet to be provided as a routine procedure under efficiency conditions, as surgical circumcision is currently The VMMC program is an ambitious public health interven- provided. If device-based service models function closer to tion. While it is estimated that close to 6 million circumcisions had maximum capacity, decreased unit costs could be realized. been completed by the end of 2013, against a goal of 20.2 million However, there will always be a need for national programs to by 2016, this progress should be viewed within the context of the provide surgical circumcision for men who are not eligible for recent and rapidly developing understanding of the importance of devices or who prefer surgery. VMMC as an HIV prevention intervention (Figure 1). Less than A major limitation of the cost studies in this collection is that three years after a consensus was reached to recommend VMMC they do not include the costs of demand creation nor analyze how as an additional HIV prevention intervention in countries with increased spending on demand creation might affect the actual high HIV prevalence and low MC rates [6], 11 of the 14 priority demand for services. This is partly because of limitations in the countries had approved national VMMC strategies and opera- available data. In future studies, it will be important to address this tional plans. The program has been scaling up in many countries knowledge gap. since then, with the result that the number of circumcisions PLOS Medicine | www.plosmedicine.org 5 May 2014 | Volume 11 | Issue 5 | e1001641 performed each year, which in 2008 had been only 0.02 million, maximize the impact of scale-up (Figure 5). These enabling grew to an estimate of at least 2.8 million in 2013, representing a factors—leadership, policy, and to a certain extent funding—are compound annual growth rate of 166% (Figure 2). largely in place both globally and in VMMC priority countries. Despite the rapid implementation and scale-up of VMMC Increased funding for VMMC is needed to meet the growing programs and the doubling of the cumulative total VMMC targets and outputs of the program. Given that PEPFAR is the procedures in the past year (from 3.2 million by the end of 2012 to predominant donor, getting other donors and governments to an estimated 5.8–6 million by the end of 2013), progress at the contribute is essential. In addition, the levers for scale identified in country level has varied widely (Figure 3) and the year-on-year Figure 5 (government program management capacity, use of data rate of growth in the number of VMMCs performed is declining for decision-making, and technologies) require further strengthen- (Figures 2 and 4). This is due to a combination of factors: the JSAF ing in order to match supply and demand. This challenge may be goal of reaching 80% of uncircumcised men by 2016 did not fully met by incorporating principles of managing large-scale enter- take into account country-specific constraints that have tempered prises such as standardization of service delivery and training, the pace of scale-up, lack of sufficient demand, and insufficient market segmentation, and data-driven management [31]. Building funding from a broad base of international donors (the United on the findings presented in this collection, we propose below a set States President’s Emergency Plan for AIDS Relief [PEPFAR] has of actions for the VMMC community. funded more than 80% of circumcisions to date). Modeling suggests that even if the current growth rate is maintained and Action Recommendations adequate funds are forthcoming, the number of VMMCs Continue advocating for prioritization and funding for completed by 2016 would fall about 3 million short of the JSAF VMMC. The program faces increasing competition for declin- goal of 20.2 million (Figure 4). ing funding for HIV prevention and treatment. The funding need This collection provides an opportunity to reflect on ways to for VMMC remains significant, and continued evidence-based maximize the potential of the VMMC program during the advocacy is necessary to secure funds for accelerated scale-up from remainder of the accelerated scale-up period (until 2016) (Box 2). a broad base of donors. One way to do this is to evaluate the This means prioritizing strategies that can improve programmatic population-level impact of those VMMC programs that have impact and efficiency in order to avert the greatest possible already been scaled up. Another is to continue to draw number of HIV infections through VMMC within realistic cost comparisons between VMMC and other HIV prevention and capacity constraints, as well as taking into account funds programs, highlighting specifically that if VMMC coverage available for VMMC. reaches the JSAF goal of 80%, it will prove the most cost-effective We believe it is essential to take a systematic approach to and cost-saving HIV prevention intervention in Eastern and improving the design, implementation, and evaluation of the Southern Africa. In addition, it does not require sustained program. Several enabling factors and levers may accelerate and adherence, and there is evidence that referrals made from the VMMC program increase HIV-positive males’ access to treatment [32]. Box 2. Key Points from the Collection Increase program efficiency by identifying and prioritizing those most at risk of acquiring Quality of services: It is possible to maintain and even HIV. Circumcisions performed on those males most at risk of improve service quality, especially surgical performance, as VMMC is scaled up, but improved provider training is acquiring HIV will have the greatest epidemiological impact in needed to strengthen quality of pre- and postoperative terms of HIV infections averted [7]. There is an opportunity to care and infection control. strategically prioritize subpopulations (for example, by age and Costs: Personnel and consumables are the largest cost geography) to maximize the program’s impact and efficiency drivers, but costs may be reduced as programs scale up within the required time period, while also ensuring that VMMC and economies of scale are achieved, as well as by is available to all males who want it. Given what is known about improving service efficiency. Underutilization of service the relatively low uptake of VMMC among men aged 25 and capacity increases unit costs more than any other above [14,23], we also recommend more modeling to ascertain the variable, highlighting the importance of predictable relative contribution of this subgroup to overall infections averted demand and nimble service platforms so that sites are in the short and long terms. consistently performing as close to capacity as possible. Focus on program efficiency and quality at all levels, and Responsible public-sector pricing strategies for devices on matching supply with demand. While a large portion of have the potential to reduce overall unit costs, and this collection focuses on surgical efficiency or quality [9–12], the further discounts should be negotiated as procurement bigger challenge is overall programmatic efficiency. The challenge volumes increase. of scale-up can be approached as a management challenge that Demand creation: Messaging must be tailored to requires addressing each element of the delivery value chain (the different age groups and to the cultural norms of specific activities that deliver the end product to the user), using different communities. Men aged 25 and above are less time and resources appropriately, and matching supply with motivated to undergo VMMC. Studies suggest that we demand for VMMC services while working to increase both. need to go beyond simple HIV messaging and present Human resource constraints must be addressed in some places VMMC in terms of hygiene, appearance, attractiveness to (e.g., through the sharing of clinical tasks [33]), while mechanisms partners, peer group norms, and modernity. to monitor the quality and safety of the rapidly expanding Efficiencies: Adoption of various elements of surgical programs must also be enhanced [11,12]. Advocacy for including efficiency is variable between countries studied. Task- surgical circumcision within the scope of practice for nurses (task- sharing, sharing, bundling of surgical instruments, and shifting) should be sustained in those countries that have not yet electrocautery are associated with surgical efficiency adopted it. Supply of VMMC services must be calibrated to meet outcomes, and surgical quality need not be compro- demand and located in areas where it will reach the prioritized mised by measures to reduce operating time. populations. PLOS Medicine | www.plosmedicine.org 6 May 2014 | Volume 11 | Issue 5 | e1001641 Figure 5. Enabling factors and levers to achieve scale and impact for the voluntary medical male circumcision program. Strong enabling factors of leadership, policy, and financing are needed to accelerate and maximize the impact of scale-up of the VMMC program. The levers for scale—government management capacity, use of data for decision-making, and technologies—are needed to match supply and demand. doi:10.1371/journal.pmed.1001641.g005 Explore the role technologies, especially devices, can play demand; and information on seasonal fluctuations in demand in accelerating scale-up. The cost of circumcision devices and [35]. other supply chain costs must be brought down considerably if We recommend that systems and tools be developed to devices are to reduce overall program costs. This will require empower and enable managers to use data for day-to-day advocacy as well as negotiation with manufacturers and suppliers decision-making and to adjust services in real time. Useful lessons in tandem with demand-creation activities. We recommend may be learned from other programs (e.g., the Avahan India HIV further study to ascertain whether devices make circumcision prevention program), including the use of micro-planning [36]. more attractive to men and to understand whether devices could There is a related need for continual analysis of cost drivers to see assist with balancing supply and demand to help achieve needed where efficiency gains are possible [24]. However, cost analysis programmatic efficiencies. It is also important to tailor demand- should look at the overall program—not just the cost of individual creation activities for devices in order to reach those who may procedures—and should include management, the cost of already be aware of circumcision’s benefits but who have avoided demand-creation activities, and the opportunity cost of underuti- conventional surgical methods. lized services sites. Rethink demand creation through market segmentation Strengthen government capacity to manage and and insights from other disciplines. More needs to be done coordinate programs. We recommend exploring ways to not only to stimulate demand for VMMC [15,21,22], but also to support the program management capacity of national and normalize it, or at least to better forecast the fluctuations in subnational governments to coordinate multiple donors and demand that are apparent in many places [15]. Barriers and implementers [37], manage competition for limited human facilitators to uptake of services must be understood, with male resources and health infrastructure, and avoid duplication of populations properly segmented demographically to make best use efforts. Governments must also lead in strategic planning, of limited resources. To date little research has looked at the male including target-setting, geographic prioritization, quality assur- population as a market of consumers of an intervention with ance, and monitoring and evaluation. Related to this is the need to multiple benefits. A market research approach, along with insights support government capacity for streamlined data collection using from diverse fields such as behavioral economics and anthropol- tracking systems that are standardized across implementers. ogy, can provide new tools to inform the development of new Strategize for the sustainability phase of the program. It approaches. More funding should be allocated to systematically is important to begin strategizing for the sustainability phase that evaluate the effectiveness of the many approaches to creating and should follow the present ‘‘catch-up’’ activities. It will take time to mobilizing demand. Those that show positive results should be determine the best approach to sustaining high MC prevalence in taken to scale. each country, develop global and national frameworks, secure Gather and use standardized, high-quality data for resources, and implement long-term programs. Since the cohorts Abroad program management and decision-making. prioritized in the sustainability phase will likely be some range of data should be collected and reported on a frequent combination of uncircumcised boys (aged 10214 years) and and regular basis and used by program managers at all levels to infants (aged 0260 days), it will also be important to explore how analyze program constraints and manage supply and demand best to reach young adolescents and parents of infants, taking into [34]. Examples of such data include the performance of a site account impact, cost, the feasibility of scale-up, cultural accept- (i.e., the number of VMMCs performed) against its functional ability, and other factors. capacity and projected demand; the demand-creation Keep strategy dynamic, informed by a strong monitoring, channels that bring individuals to specific VMMC sites; evaluation, and learning platform. Our final recommenda- daily outputs of community members engaged to generate tion is that ministries of health, donors, program planners, and PLOS Medicine | www.plosmedicine.org 7 May 2014 | Volume 11 | Issue 5 | e1001641 having heterosexual sex. In the 14 priority countries of Eastern Box 3. What Needs to Be Done to Accelerate and Southern Africa, the prospective gains through lives saved, Scale-up and Impact of the VMMC Program? suffering averted, and health care costs avoided make VMMC Continue advocating for prioritization and funding for programs a crucial intervention in the struggle against HIV and VMMC. AIDS. This realization is reflected in the considerable progress already made in scaling up VMMC programs; but resource and Increase program efficiency by identifying and prioritiz- ing those most at risk of acquiring HIV. capacity constraints pose a serious challenge to the ability of the priority countries to reach the goal set out in the JSAF. Focus on program efficiency and quality at all levels, and This challenge, readily acknowledged by the countries them- on matching supply with demand. selves, is also reflected in a growing body of research that examines Explore the role that technologies, especially devices, the complexity of designing, implementing, scaling up, and can play in accelerating scale-up. evaluating VMMC programs. We believe that many of these Rethink demand creation through market segmentation challenges can be addressed through systematic, evidence-based and insights from other disciplines. management of the programs and a dynamic culture of learning. Gather and use standardized, high-quality data for The papers in this collection add further to our understanding of program management and decision-making. issues of cost, demand creation, efficiency, and service quality. Strengthen government capacity to manage and coor- They represent a significant contribution to our knowledge and dinate programs. help point the way toward the achievement of the VMMC Strategize for the sustainability phase of the program. program’s ambitious goals. Keep strategy dynamic, informed by a strong monitor- ing, evaluation, and learning platform. Acknowledgments We would like to acknowledge Naomi Bock for her contribution to the development of this manuscript. We would also like to acknowledge implementers strive to maintain a dynamic strategy and evidence- Elizabeth Gold, Jane Bertrand, Tigitsu Adamu, Lori Bollinger, Delivette based programs that are agile and able to correct their course Castor, Kim Ahanda, and James Baer for their invaluable contributions to when necessary. This is crucial because of the constantly the preparation of this manuscript; Maaya Sundaram for her help with the developing understanding of the complexities and challenges of data analysis and exhibits; and Elizabeth Thompson for editing and managing VMMC supply and demand, dealing with new formatting this manuscript. technologies, managing costs, and improving efficiency and quality. For this reason too, investment in disseminating and Author Contributions incorporating lessons learned, informed by monitoring and Analyzed the data: SS JR AT EN. Wrote the first draft of the manuscript: evaluation data, should also be prioritized (Box 3). SS EN. Contributed to the writing of the manuscript: SS JR AT EN. ICMJE criteria for authorship read and met: SS JR AT EN. Agree with Conclusion manuscript results and conclusions: SS JR AT EN. Large-scale implementation of VMMC has the potential to significantly reduce the incidence of HIV infection among men References 1. 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(2014) Surgical circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. efficiencies and quality in the performance of voluntary medical male Lancet 369: 657–666. circumcision procedures in Kenya, South Africa, Tanzania, and Zimbabwe. 4. Weiss HA, Quiqley MA, Hayes RJ (2000) Male circumcision and risk of HIV PLoS ONE 9: e84271. infection in sub-Saharan Africa: a systematic review and meta-analysis. AIDS 13. Onyango T (2011) Male Circumcision Consortium, Monitoring and Evaluation 14: 2361–2370. Office. 5. WHO, UNAIDS (2007) New data on male circumcision and HIV prevention: 14. Djimeu Wouabe E (2013) Scoping report on interventions for increasing the Policy and programme implications. WHO/UNAIDS Technical Consultation demand for voluntary medical male circumcision. Washington (D.C.): on Male Circumcision and HIV Prevention: Research Implications for Policy International Initiative for Impact Evaluation (3IE). and Programming. Geneva: WHO. 15. Macintyre K, Andrinopoulos K, Moses N, Bornstein M, Ochieng A, et al. (2014) 6. WHO (2011) Joint Strategic Action Framework to Accelerate the Scale-Up of Attitudes, perceptions and potential uptake of male circumcision among older Voluntary Medical Male Circumcision for HIV Prevention in Eastern and men in Turkana County, Kenya using qualitative methods. PLoS ONE 9: e83998. Southern Africa, 2012-2016. Geneva: WHO. 16. Herman-Roloff A, Otieno N, Agot K, Ndinya-Achola J, Bailey RC (2011) 7. Njeuhmeli E, Forsythe S, Reed J, Opuni M, Bollinger L, et al. (2011) Voluntary Acceptability of medical male circumcision among uncircumcised men in Kenya medical male circumcision: modeling the impact and cost of expanding male one year after the launch of the national male circumcision program. PLoS circumcision for HIV prevention in eastern and southern Africa. PLoS Med 8: ONE 6: e19814. e1001132. 17. Westercamp N, Bailey RC (2007) Acceptability of male circumcision for 8. Hankins C, Forsythe S, Njeuhmeli E (2011) Voluntary medical male prevention of HIV/AIDS in sub-Saharan Africa: a review. AIDS Behav 11: circumcision: an introduction to the cost, impact, and challenges of accelerated 341–355. scaling up. PLoS Med 8: e1001127. 18. Gasasira RA, Sarker M, Tsague L, Nsanzimana S, Gwiza A, et al. (2012) 9. Herman-Roloff A, Bailey R, Agot K, Ndinya-Achola J (2010) Medical male Determinants of circumcision and willingness to be circumcised by Rwandan circumcision for HIV prevention in Kenya: a study of service provision and men, 2010. BMC Public Health 12: 134. adverse events [abstract]. XVIII International AIDS Conference; Vienna, 19. Westercamp M, Agot KE, Ndinya-Achola J, Bailey RC (2012) Circumcision Austria; 18–23 July 2010. Available: http://www.iasociety.org/Abstracts/ preference among women and uncircumcised men prior to scale-up of male A200736968.aspx. Accessed 15 October 2013. circumcision for HIV prevention in Kisumu, Kenya. AIDS Care 24: 157–166. PLOS Medicine | www.plosmedicine.org 8 May 2014 | Volume 11 | Issue 5 | e1001641 20. Plotkin MK, Curran J, Mziray K, Prince H, Mahler J, et al. (2011) The unpeeled 29. Mavhu W, Frade S, Yongho A, Farrell M, Hatzold K, et al. (2014) Provider mango: a qualitative assessment of views and preferences of voluntary medical attitudes toward the voluntary medical male circumcision scale-up in Kenya, male circumcision in Iringa Region, Tanzania. Dar es Salaam, Tanzania: South Africa, Tanzania and Zimbabwe. PLoS ONE 9: e82911. Jhpiego. 30. Perry L, Rech D, Mavhu W, Frade S, Machaku MD, et al. (2014) Work 21. Hatzold K, Mavhu W, Jasi P, Chatora K, Cowan FM, et al. (2014) Barriers and experience, job-fulfillment and burnout among VMMC providers in Kenya, motivators to voluntary medical male circumcision uptake among different age South Africa, Tanzania and Zimbabwe. PLoS ONE 9: e84215. groups of men in Zimbabwe: results from a mixed methods study. PLoS ONE 9: 31. (2008) Avahan—The India AIDS Initiative: The business of HIV prevention at e85051. scale. New Delhi: Bill & Melinda Gates Foundation. 22. Adamu Ashengo T, Hatzold K, Mahler H, Rock A, Kanagat N, et al. (2014) 32. Kikaya V, Skolnik L, Garcıa MC, Nkonyana J, Curran K, et al. (2014) Voluntary medical male circumcision (VMMC) in Tanzania and Zimbabwe: Voluntary medical male circumcision programs can address low HIV testing and service delivery intensity and modality and their influence on the age of clients. counseling usage and ART enrollment among young men: lessons from Lesotho. PLoS ONE 9: e83642. PLoS ONE 9: e83614. 23. Plotkin M, Castor D, Mziray H, Ku ¨ ver J, Mpuya E, et al. (2013) ‘‘Man, what 33. WHO (2010) Considerations for implementing models for optimizing the took you so long?’’ Social and individual factors affecting adult attendance at volume and efficiency of male circumcision services. Field testing edition. voluntary medical male circumcision services in Tanzania. Glob Health Sci Geneva: WHO. Pract 1:108–116. 34. Sgaier SK, Claeson M, Gilks C, Ramesh BM, Ghys PD, et al. (2012) Knowing 24. Bollinger L, Adesina A, Forsythe S, Godbole R, Reuben E, et al. (2014) Cost your HIV/AIDS epidemic and tailoring an effective response: how did India do drivers for voluntary medical male circumcision using primary source data from it? Sex Transm Infect 88: 240–249. sub-Saharan Africa. PLoS ONE 9: e84701. 35. Bertrand JT, Rech D, Omondi Aduda D, Frade S, Loolpapit M, et al. (2014) 25. Menon V, Gold E, Godbole R, Castor D, Mahler H, et al. (2014) Costs and Systematic monitoring of voluntary medical male circumcision scale-up: impacts of scaling up voluntary medical male circumcision in Tanzania. PLoS adoption of efficiency elements in Kenya, South Africa, Tanzania, and ONE 9: e83925. Zimbabwe. PLoS ONE 9: e82518. 26. Bratt JH, Zyambo Z (2013) Comparing direct costs of facility-based Shang Ring 36. (2013) Micro-planning in peer led outreach programs—a handbook. New Delhi: provision versus a standard surgical technique for voluntary medical male Bill & Melinda Gates Foundation. circumcision in Zambia. J Acquir Immune Defic Syndr 63: e109–112. 37. Sgaier SK, Ramakrishnan A, Dhingra N, Wadhwani A, Alexander A, et al. 27. Duffy K, Galukande M, Wooding N, Dea M, Coutinho A (2013) Reach and (2013) How the Avahan HIV prevention program transitioned from the Gates cost-effectiveness of the PrePex device for safe male circumcision in Uganda. Foundation to the Government of India. Health Affairs 32: 1265–1273. PLoS ONE 8:e63134. 38. WHO/AFRO (2013) Progress in scaling up voluntary medical male circumci- 28. Njeuhmeli E, Kripke K, Hatzold K, Reed J, Edgil D, et al. (2014) Cost analysis sion for HIV prevention in East and Southern Africa, January – December of integrating the PrePex medical device into a voluntary medical male 2012. Brazzaville: WHO/AFRO. circumcision program in Zimbabwe. PLoS ONE 9: e82533. PLOS Medicine | www.plosmedicine.org 9 May 2014 | Volume 11 | Issue 5 | e1001641 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png PLoS Medicine Public Library of Science (PLoS) Journal

Achieving the HIV Prevention Impact of Voluntary Medical Male Circumcision: Lessons and Challenges for Managing Programs

PLoS Medicine , Volume 11 (5) – May 6, 2014

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Collection Review Achieving the HIV Prevention Impact of Voluntary Medical Male Circumcision: Lessons and Challenges for Managing Programs 1,2 3 4 5 Sema K. Sgaier *, Jason B. Reed , Anne Thomas , Emmanuel Njeuhmeli 1 Integrated Delivery, Global Development Program, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America, 2 Department of Global Health, University of Washington, Seattle, United States of America, 3 Office of the U.S. Global AIDS Coordinator, Washington (DC), United States of America, 4 Naval Health Research Center, US Department of Defense, San Diego, California, United States of America, 5 United States Agency for International Development, Washington (DC), United States of America women to men (Figure 1) [1–4]. Fourteen countries in Eastern and Abstract: Voluntary medical male circumcision (VMMC) is Southern Africa with high HIV prevalence and low levels of male capable of reducing the risk of sexual transmission of HIV circumcision (MC) are following the recommendations of the from females to males by approximately 60%. In 2007, the World Health Organization (WHO) and the Joint United Nations WHO and the Joint United Nations Programme on HIV/ Programme on HIV/AIDS (UNAIDS) to expand VMMC services AIDS (UNAIDS) recommended making VMMC part of a as an HIV prevention strategy [5,6]. These countries are comprehensive HIV prevention package in countries with Botswana, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, a generalized HIV epidemic and low rates of male Namibia, Rwanda, South Africa, Swaziland, Uganda, the United circumcision. Modeling studies undertaken in 2009–2011 Republic of Tanzania, Zambia, and Zimbabwe. Modeling studies estimated that circumcising 80% of adult males in 14 done in 2009–2011 showed that in these 14 priority countries, priority countries in Eastern and Southern Africa within achieving 80% circumcision prevalence among males aged 15–49 five years, and sustaining coverage levels thereafter, could within five years (‘‘catch-up’’), and maintaining this coverage rate avert 3.4 million HIV infections within 15 years and save in subsequent years (‘‘sustainability’’), could avert 3.4 million new US$16.5 billion in treatment costs. In response, WHO/ UNAIDS launched the Joint Strategic Action Framework HIV infections within 15 years and generate treatment and care for accelerating the scale-up of VMMC for HIV prevention savings of US$16.5 billion [7,8]. VMMC is a highly cost-effective in Southern and Eastern Africa, calling for 80% coverage HIV prevention strategy for both generalized and high-prevalence of adult male circumcision by 2016. While VMMC HIV epidemics [7]. It differs from most other prevention methods programs have grown dramatically since inception, they (e.g., pre-exposure prophylaxis, sexual behavior change, or appear unlikely to reach this goal. This review provides an condom use) in that it only requires a one-time action in order overview of findings from the PLOS Collection ‘‘Voluntary Medical Male Circumcision for HIV Prevention: Improving Quality, Efficiency, Cost Effectiveness, and Demand for Citation: Sgaier SK, Reed JB, Thomas A, Njeuhmeli E (2014) Achieving the HIV Prevention Impact of Voluntary Medical Male Circumcision: Lessons and Services during an Accelerated Scale-up.’’ The use of Challenges for Managing Programs. PLoS Med 11(5): e1001641. doi:10.1371/ devices for VMMC is also explored. We propose empha- journal.pmed.1001641 sizing management solutions to help VMMC programs in Published May 6, 2014 the priority countries achieve the desired impact of averting the greatest possible number of HIV infections. This is an open-access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for Our recommendations include advocating for prioritiza- any lawful purpose. The work is made available under the Creative Commons CC0 tion and funding of VMMC, increasing strategic targeting public domain dedication. to achieve the goal of reducing HIV incidence, focusing on Funding: The United States President’s Emergency Plan for AIDS Relief (PEPFAR) programmatic efficiency, exploring the role of new supported the manuscripts included in this collection through the US Agency for technologies, rethinking demand creation, strengthening International Development (USAID). This collection was funded by PEPFAR data use for decision-making, improving governments’ through USAID’s Maternal and Child Health Integrated Program (MCHIP), under Cooperative Agreement #GHS-A-00-08-00002-000 and AIDS Support and program management capacity, strategizing for sustain- Technical Assistance Resources (AIDSTAR-One) Project, Sector I, Task Order 1 ability, and maintaining a flexible scale-up strategy under contract number GHH-I-00-07-00059-00. Staff from the funding bodies informed by a strong monitoring, learning, and evaluation played a significant role in study design, analysis, decision to publish, or platform. preparation of the manuscript. Disclaimer: The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the Bill & Melinda Gates Foundation, the Office of the Global AIDS Coordinator, the US Agency for International Development, the Centers for Disease Control and Prevention, the US Department of Defense, or the US Introduction Government. Voluntary medical male circumcision (VMMC) has been shown Competing Interests: The authors have declared that no competing interest exist. to be effective in reducing the sexual transmission of HIV from Abbreviations: JSAF, Joint Strategic Action Framework; MC, male circumcision; PEPFAR, United States President’s Emergency Plan for AIDS Relief; UNAIDS, Joint United Nations Programme on HIV/AIDS; VMMC, voluntary medical male Collection Review articles synthesize in narrative form the best available evidence circumcision. on a topic. Submission of Collection Review articles is by invitation only, and they * E-mail: Sema.Sgaier@gatesfoundation.org are only published as part of a PLOS Collection as agreed in advance by the PLOS Medicine Editors. Provenance: Not commissioned. Submitted as part of a PLOS Collection; externally reviewed. PLOS Medicine | www.plosmedicine.org 1 May 2014 | Volume 11 | Issue 5 | e1001641 demand for circumcision. While at a broad level the program is Summary Points increasing its outputs each year (Figures 2 and 3), the current growth rate of the program is not sufficient to reach the JSAF’s Large-scale implementation of voluntary medical male circumcision (VMMC) in 14 priority countries of Eastern goal of 80% coverage by 2016 (Figure 4). and Southern Africa has the potential to significantly This collection of research and review articles, ‘‘Voluntary reduce heterosexual transmission of HIV to males, saving Medical Male Circumcision for HIV Prevention: Improving lives, averting suffering, and avoiding health care costs. Quality, Efficiency, Cost Effectiveness, and Demand for Services Resource and capacity constraints pose a serious during an Accelerated Scale-up,’’ presents new research that challenge to the ability of the priority countries to reach underscores both the challenges and the opportunities for the their goals for VMMC scale-up. accelerated scale-up of VMMC (Box 1). This review article The 13 papers in this collection examine issues of service synthesizes and briefly describes the findings, which focus on four quality, demand creation, cost, and efficiency faced by key areas of the VMMC program: (1) quality of services, (2) governments, donors, and programs. demand creation, (3) cost, and (4) efficiencies for service delivery. Building on these findings, we propose a set of priority focus areas Systematic, evidence-based management of programs and a dynamic culture of learning are proposed to help for the global VMMC program and for the governments of the meet the challenges of VMMC scale-up. priority countries, and we highlight new areas of opportunity to accelerate scale-up. Recommendations include greater prioritization and funding of VMMC, strategic targeting and demand creation, a focus on programmatic efficiencies, and Quality of VMMC Services exploration of new technologies. Ensuring safe and efficient execution of the VMMC procedure Further recommendations are for strengthened data use, N and high-quality pre- and post-procedure services, even as improving governments’ program management capac- programs expand rapidly, is essential in order to realize the full ity, strategizing for sustainability, and maintaining a impact of VMMC, reduce program costs, and increase and sustain flexible scale-up strategy. demand for the service. While most previous quality assessments focused on adverse events in clients [9], two papers in this collection examine facility preparedness for providing quality to provide continuous benefits. VMMC has political support at surgical services using data across two years of program scale-up. both the global and national levels. Most of the 14 priority Jennings and colleagues undertook a comparative assessment of countries have developed strategic plans and established infra- facility preparedness and surgery in Kenya, South Africa, structure to implement the plans and scale up VMMC interven- Tanzania, and Zimbabwe through direct observation [10]. Results tions. (These efforts are referred to collectively in this paper as ‘‘the for facility preparedness were mixed: in some settings, improve- VMMC program’’ or ‘‘the program.’’) ments were seen over time, while in others, early problems that Nevertheless, the VMMC strategy faces challenges at multiple went uncorrected prior to expansion were amplified system-wide levels. The goals set out in the Joint Strategic Action Framework at scale. Rech and colleagues explored in further detail the (JSAF) are highly ambitious: to circumcise 20.2 million men in five implications of scale-up in South Africa [11]. They assessed years (2012–2016) across 14 African countries [6]. Furthermore, readiness to provide quality services and quality of surgical care in the choice to be circumcised involves deep-seated values, beliefs, 2011 and 2012. Rapid scale-up in South Africa led to human and motivational factors that vary with ethnic, religious, and resources being stretched too thinly, with negative effects on cultural identities, and must be addressed effectively to generate quality overall. These studies, and a further study of surgical Figure 1. Timeline and key milestones of the voluntary medical male circumcision program in 14 priority countries. 6 million circumcisions listed in 2013 is an estimate by PEPFAR and the Bill & Melinda Gates Foundation. RCTs, randomized controlled trials; TWG, technical working group; TAG, technical advisory group; MOVE, Models for Optimizing the Volume and Efficiency of MC services. doi:10.1371/journal.pmed.1001641.g001 PLOS Medicine | www.plosmedicine.org 2 May 2014 | Volume 11 | Issue 5 | e1001641 Figure 2. Scale-up of voluntary medical male circumcision program and coverage in 14 priority countries, aggregate, 2008–2013. Number of circumcisions completed each year in millions. Source of 2008–2012 data is the WHO 2012 VMMC report [38]. 2013 numbers have been estimated using data from PEPFAR and the Bill & Melinda Gates Foundation. *CAGR, compound annual growth rate, calculated based on the average 1/(tn 2 to) proportional growth each year. CAGR (t ,t ) = (V(t /V(t )) 21, where V(t ) is the start value and V(t ) is the finish value and t 2 t is the 0 n n) 0 0 n n 0 number of years. doi:10.1371/journal.pmed.1001641.g002 Figure 3. Scale-up of voluntary medical male circumcision program and coverage in 14 priority countries, 2008–2012. Totals reflect progress through 2012. Percentage figures represent the achieved proportion of the target of 80% coverage among males ages 15–49, but totals include circumcisions done for all age groups, regardless of the age-range target. Data obtained from WHO 2012 VMMC report [38]. doi:10.1371/journal.pmed.1001641.g003 PLOS Medicine | www.plosmedicine.org 3 May 2014 | Volume 11 | Issue 5 | e1001641 Figure 4. Scale-up of voluntary medical male circumcision program and coverage in 14 priority countries: growth scenarios, 200822016. Source of 2008–2012 data is the WHO 2012 VMMC report [38]; 2013 figures are estimates, and 2014–2016 figures are projections. In the ‘‘no growth’’ scenario, the program continues to perform the same numbers of circumcisions each year as in 2013. In the ‘‘current growth’’ scenario, the program continues the trend of historical growth rate. doi:10.1371/journal.pmed.1001641.g004 efficiencies and quality of surgical technique in VMMC in Kenya, it is also necessary to improve initial and refresher training for South Africa, Tanzania, and Zimbabwe [12], remind us that while providers on all aspects of the VMMC service package, strengthen ongoing quality and performance assessments, reinforce supervi- it is possible to maintain high standards of surgical care during rapid scale-up (Zimbabwe is a good example), there is always a sion and mentoring, and create functional systems to continuously assess and improve service quality. need to manage adverse events by proactively following up with clients and facilitating postoperative services. As programs expand, Demand Creation There is general agreement among the authors about the need to foster greater demand among men for VMMC in order to Box 1. Scope of the Collection achieve the desired reduction in HIV incidence [6]. Although The PLOS Collection ‘‘Voluntary Medical Male Circumcision most programs aim to reach men aged 15–49, those over 25 are for HIV Prevention: Improving Quality, Efficiency, Cost underrepresented thus far in the scale-up [13]. Two studies have Effectiveness, and Demand for Services during an Accel- explored barriers to and facilitators of demand [14], and three erated Scale-up’’ includes 13 research papers and an papers in this collection specifically address men aged 25 and overview that highlight key findings from several countries above, a group for whom the reasons for low demand are not well that have moved to high-volume VMMC services, explore understood, and whose contribution to HIV prevalence is challenges faced, and offer recommendations for pro- currently being evaluated by new modeling work. grams as they scale up VMMC services. It focuses on the Macintyre and colleagues examined barriers to and facilitators following: of demand in Turkana County, Kenya, a traditionally non- circumcising community [15]. Older married men did not Quality and efficiency of VMMC services – results of the consider themselves at risk of acquiring HIV, and they echoed Systematic Monitoring of the Voluntary Medical Male the findings of other literature on acceptability in viewing Circumcision Scale Up (SYMMACS) facility-based survey circumcision as more appropriate for younger men, whom they conducted in Kenya, South Africa, Tanzania, and perceived as being at higher risk of HIV [16–20]. The authors Zimbabwe argue that promoting circumcision as a modern, biomedical Costing and Impact – findings from three studies by procedure rather than as a cultural practice (which may be PEPFAR through the USAID funded Health Policy Project associated with other tribal groups or young men’s rites of passage) of interest to decision-makers determining allocation of will be an important demand-creation message in this particular HIV prevention resources setting. Demand Creation – studies from Kenya, Zimbabwe, and In Zimbabwe, Hatzold and colleagues conducted quantitative Tanzania highlight importance of tailoring demand- and qualitative studies to explore barriers to and motivating factors creation interventions and service delivery models to for VMMC and to assess the use of existing VMMC communi- specific age group of clients cation channels to promote VMMC [21]. A large majority of the PLOS Medicine | www.plosmedicine.org 4 May 2014 | Volume 11 | Issue 5 | e1001641 respondents had heard about VMMC, mainly through radio. Efficiencies Prevention of HIV was the most cited motivator for circumcision, Several papers in this collection explore improvements in the but men were also motivated by prospects for improved hygiene. efficiency of service delivery, with specific emphasis on efficiencies Non-HIV-related benefits could be part of the messaging for around the surgical procedure, using data from Kenya, South demand-creation activities. Only 11% of all the men surveyed had Africa, Tanzania, and Zimbabwe [9]. None of the four countries been circumcised, and among male respondents expressing an surveyed had adopted all six elements of surgical efficiency tracked unwillingness to become circumcised, fear of pain was the most by the data, which were (1) use of multiple surgical beds, (2) use of frequently cited reason. The paper does not directly identify the pre-bundled surgical supply kits, (3) task-shifting, (4) task-sharing, reasons why men who expressed a willingness to undergo VMMC (5) use of forceps-guided surgical method, and (6) use of had not yet done so, and further research on this would be useful. electrocautery. The use of the forceps-guided surgical method However, three primary predictors of VMMC uptake were was the only element adopted by all countries. Rech and identified: self-efficacy (the belief that one can make the decision colleagues found that innovative human resource models such as oneself to be circumcised), social support from friends, and the sharing of tasks among a coordinated team of clinicians, as well availability of VMMC services. as electrocautery and the use of multiple beds, reduced the overall The study of the modality and intensity of service delivery in procedure time and increased the number of clients served by the Tanzania and Zimbabwe by Adamu and colleagues [22] shows primary surgeon in a given period of time [12]. An encouraging that campaigns conducted during school holidays lead to higher finding was that the quality of surgical technique was not attendance by younger clients, an effect enhanced in Tanzania by compromised by reducing the amount of time the primary the cultural preference for circumcision at a younger age [23]. provider spent with each client, meaning that quality was This underscores the importance of considering cultural prefer- maintained in high-service-volume settings. In fact, in South ences and service delivery timing when designing demand-creation Africa, reduced operating time was associated with higher surgical approaches. quality, which the authors suggest might be the result of experienced providers being more skilled and working more Costs efficiently. While modeling showed that scaling up VMMC to 80% While these papers focus on efficiencies that could be gained at coverage among men aged 15–49 in the 14 priority countries the site level, an assessment of efficiency gains at the macro level of could result in savings of US$16.5 billion in treatment costs, the overall program delivery is also needed, as discussed below. resources required to achieve this are substantial—an estimated Mavhu and colleagues found that providers held positive US$2 billion [7,8,24]. Three papers in this collection undertake attitudes toward the six recommended elements of surgical unit cost analyses to identify the cost drivers and explore where efficiency in countries where national policies were supportive efficiency gains are possible. Bollinger and colleagues (data from [29]. This study highlights the value of consulting with those who Kenya, Namibia, South Africa, Tanzania, Uganda, and Zambia) will implement policies at the service-delivery level. The finding and Menon and colleagues (data from three regions of Tanzania) that national policy bodies in South Africa and Zimbabwe did not use programmatic and financial data (including direct and indirect adopt task-shifting—even though providers supported it—is costs) from VMMC facilities to determine the unit cost of a significant, because task-shifting could alleviate the human surgical VMMC [24,25]. Both studies illustrate that the two largest resources constraint that is a major challenge to the scale-up of cost drivers are personnel (36% of costs) and commodities (28%), VMMC in these countries. with ranges varying by country and model of service delivery. Perry and colleagues identified factors associated with provider An economies-of-scale analysis suggests that further cost burnout (physical or emotional exhaustion as a result of prolonged reductions will be seen as the supply side of the program plateaus stress or frustration) and explored a possible relationship between [24]. These studies highlight the possibility of further efficiency burnout and job satisfaction [30]. In 2012, more than three- gains in the personnel and consumables components of the fourths of providers surveyed in Kenya, South Africa, Tanzania, program by maximizing efficiencies in human and material and Zimbabwe reported that providing VMMC was personally resources and technology. fulfilling. Providers’ median work span in VMMC was longest in Three independent modeling studies, including one in this issue, Kenya (31 months), but the proportion of providers who reported using different starting assumptions, have forecast little if any cost that they were starting to experience burnout was much higher savings with the initial use of circumcision devices such as PrePex there (67%) than in the other three countries. However, the and Shang Ring [26–28]. Njeuhmeli and colleagues note that the study failed to identify any correlates associated with burnout in single greatest determinant of unit cost was site utilization, with Kenya. underutilization doubling the per-procedure price, regardless of whether circumcision was device-based or surgical [28]. Device- Discussion based circumcision has yet to be provided as a routine procedure under efficiency conditions, as surgical circumcision is currently The VMMC program is an ambitious public health interven- provided. If device-based service models function closer to tion. While it is estimated that close to 6 million circumcisions had maximum capacity, decreased unit costs could be realized. been completed by the end of 2013, against a goal of 20.2 million However, there will always be a need for national programs to by 2016, this progress should be viewed within the context of the provide surgical circumcision for men who are not eligible for recent and rapidly developing understanding of the importance of devices or who prefer surgery. VMMC as an HIV prevention intervention (Figure 1). Less than A major limitation of the cost studies in this collection is that three years after a consensus was reached to recommend VMMC they do not include the costs of demand creation nor analyze how as an additional HIV prevention intervention in countries with increased spending on demand creation might affect the actual high HIV prevalence and low MC rates [6], 11 of the 14 priority demand for services. This is partly because of limitations in the countries had approved national VMMC strategies and opera- available data. In future studies, it will be important to address this tional plans. The program has been scaling up in many countries knowledge gap. since then, with the result that the number of circumcisions PLOS Medicine | www.plosmedicine.org 5 May 2014 | Volume 11 | Issue 5 | e1001641 performed each year, which in 2008 had been only 0.02 million, maximize the impact of scale-up (Figure 5). These enabling grew to an estimate of at least 2.8 million in 2013, representing a factors—leadership, policy, and to a certain extent funding—are compound annual growth rate of 166% (Figure 2). largely in place both globally and in VMMC priority countries. Despite the rapid implementation and scale-up of VMMC Increased funding for VMMC is needed to meet the growing programs and the doubling of the cumulative total VMMC targets and outputs of the program. Given that PEPFAR is the procedures in the past year (from 3.2 million by the end of 2012 to predominant donor, getting other donors and governments to an estimated 5.8–6 million by the end of 2013), progress at the contribute is essential. In addition, the levers for scale identified in country level has varied widely (Figure 3) and the year-on-year Figure 5 (government program management capacity, use of data rate of growth in the number of VMMCs performed is declining for decision-making, and technologies) require further strengthen- (Figures 2 and 4). This is due to a combination of factors: the JSAF ing in order to match supply and demand. This challenge may be goal of reaching 80% of uncircumcised men by 2016 did not fully met by incorporating principles of managing large-scale enter- take into account country-specific constraints that have tempered prises such as standardization of service delivery and training, the pace of scale-up, lack of sufficient demand, and insufficient market segmentation, and data-driven management [31]. Building funding from a broad base of international donors (the United on the findings presented in this collection, we propose below a set States President’s Emergency Plan for AIDS Relief [PEPFAR] has of actions for the VMMC community. funded more than 80% of circumcisions to date). Modeling suggests that even if the current growth rate is maintained and Action Recommendations adequate funds are forthcoming, the number of VMMCs Continue advocating for prioritization and funding for completed by 2016 would fall about 3 million short of the JSAF VMMC. The program faces increasing competition for declin- goal of 20.2 million (Figure 4). ing funding for HIV prevention and treatment. The funding need This collection provides an opportunity to reflect on ways to for VMMC remains significant, and continued evidence-based maximize the potential of the VMMC program during the advocacy is necessary to secure funds for accelerated scale-up from remainder of the accelerated scale-up period (until 2016) (Box 2). a broad base of donors. One way to do this is to evaluate the This means prioritizing strategies that can improve programmatic population-level impact of those VMMC programs that have impact and efficiency in order to avert the greatest possible already been scaled up. Another is to continue to draw number of HIV infections through VMMC within realistic cost comparisons between VMMC and other HIV prevention and capacity constraints, as well as taking into account funds programs, highlighting specifically that if VMMC coverage available for VMMC. reaches the JSAF goal of 80%, it will prove the most cost-effective We believe it is essential to take a systematic approach to and cost-saving HIV prevention intervention in Eastern and improving the design, implementation, and evaluation of the Southern Africa. In addition, it does not require sustained program. Several enabling factors and levers may accelerate and adherence, and there is evidence that referrals made from the VMMC program increase HIV-positive males’ access to treatment [32]. Box 2. Key Points from the Collection Increase program efficiency by identifying and prioritizing those most at risk of acquiring Quality of services: It is possible to maintain and even HIV. Circumcisions performed on those males most at risk of improve service quality, especially surgical performance, as VMMC is scaled up, but improved provider training is acquiring HIV will have the greatest epidemiological impact in needed to strengthen quality of pre- and postoperative terms of HIV infections averted [7]. There is an opportunity to care and infection control. strategically prioritize subpopulations (for example, by age and Costs: Personnel and consumables are the largest cost geography) to maximize the program’s impact and efficiency drivers, but costs may be reduced as programs scale up within the required time period, while also ensuring that VMMC and economies of scale are achieved, as well as by is available to all males who want it. Given what is known about improving service efficiency. Underutilization of service the relatively low uptake of VMMC among men aged 25 and capacity increases unit costs more than any other above [14,23], we also recommend more modeling to ascertain the variable, highlighting the importance of predictable relative contribution of this subgroup to overall infections averted demand and nimble service platforms so that sites are in the short and long terms. consistently performing as close to capacity as possible. Focus on program efficiency and quality at all levels, and Responsible public-sector pricing strategies for devices on matching supply with demand. While a large portion of have the potential to reduce overall unit costs, and this collection focuses on surgical efficiency or quality [9–12], the further discounts should be negotiated as procurement bigger challenge is overall programmatic efficiency. The challenge volumes increase. of scale-up can be approached as a management challenge that Demand creation: Messaging must be tailored to requires addressing each element of the delivery value chain (the different age groups and to the cultural norms of specific activities that deliver the end product to the user), using different communities. Men aged 25 and above are less time and resources appropriately, and matching supply with motivated to undergo VMMC. Studies suggest that we demand for VMMC services while working to increase both. need to go beyond simple HIV messaging and present Human resource constraints must be addressed in some places VMMC in terms of hygiene, appearance, attractiveness to (e.g., through the sharing of clinical tasks [33]), while mechanisms partners, peer group norms, and modernity. to monitor the quality and safety of the rapidly expanding Efficiencies: Adoption of various elements of surgical programs must also be enhanced [11,12]. Advocacy for including efficiency is variable between countries studied. Task- surgical circumcision within the scope of practice for nurses (task- sharing, sharing, bundling of surgical instruments, and shifting) should be sustained in those countries that have not yet electrocautery are associated with surgical efficiency adopted it. Supply of VMMC services must be calibrated to meet outcomes, and surgical quality need not be compro- demand and located in areas where it will reach the prioritized mised by measures to reduce operating time. populations. PLOS Medicine | www.plosmedicine.org 6 May 2014 | Volume 11 | Issue 5 | e1001641 Figure 5. Enabling factors and levers to achieve scale and impact for the voluntary medical male circumcision program. Strong enabling factors of leadership, policy, and financing are needed to accelerate and maximize the impact of scale-up of the VMMC program. The levers for scale—government management capacity, use of data for decision-making, and technologies—are needed to match supply and demand. doi:10.1371/journal.pmed.1001641.g005 Explore the role technologies, especially devices, can play demand; and information on seasonal fluctuations in demand in accelerating scale-up. The cost of circumcision devices and [35]. other supply chain costs must be brought down considerably if We recommend that systems and tools be developed to devices are to reduce overall program costs. This will require empower and enable managers to use data for day-to-day advocacy as well as negotiation with manufacturers and suppliers decision-making and to adjust services in real time. Useful lessons in tandem with demand-creation activities. We recommend may be learned from other programs (e.g., the Avahan India HIV further study to ascertain whether devices make circumcision prevention program), including the use of micro-planning [36]. more attractive to men and to understand whether devices could There is a related need for continual analysis of cost drivers to see assist with balancing supply and demand to help achieve needed where efficiency gains are possible [24]. However, cost analysis programmatic efficiencies. It is also important to tailor demand- should look at the overall program—not just the cost of individual creation activities for devices in order to reach those who may procedures—and should include management, the cost of already be aware of circumcision’s benefits but who have avoided demand-creation activities, and the opportunity cost of underuti- conventional surgical methods. lized services sites. Rethink demand creation through market segmentation Strengthen government capacity to manage and and insights from other disciplines. More needs to be done coordinate programs. We recommend exploring ways to not only to stimulate demand for VMMC [15,21,22], but also to support the program management capacity of national and normalize it, or at least to better forecast the fluctuations in subnational governments to coordinate multiple donors and demand that are apparent in many places [15]. Barriers and implementers [37], manage competition for limited human facilitators to uptake of services must be understood, with male resources and health infrastructure, and avoid duplication of populations properly segmented demographically to make best use efforts. Governments must also lead in strategic planning, of limited resources. To date little research has looked at the male including target-setting, geographic prioritization, quality assur- population as a market of consumers of an intervention with ance, and monitoring and evaluation. Related to this is the need to multiple benefits. A market research approach, along with insights support government capacity for streamlined data collection using from diverse fields such as behavioral economics and anthropol- tracking systems that are standardized across implementers. ogy, can provide new tools to inform the development of new Strategize for the sustainability phase of the program. It approaches. More funding should be allocated to systematically is important to begin strategizing for the sustainability phase that evaluate the effectiveness of the many approaches to creating and should follow the present ‘‘catch-up’’ activities. It will take time to mobilizing demand. Those that show positive results should be determine the best approach to sustaining high MC prevalence in taken to scale. each country, develop global and national frameworks, secure Gather and use standardized, high-quality data for resources, and implement long-term programs. Since the cohorts Abroad program management and decision-making. prioritized in the sustainability phase will likely be some range of data should be collected and reported on a frequent combination of uncircumcised boys (aged 10214 years) and and regular basis and used by program managers at all levels to infants (aged 0260 days), it will also be important to explore how analyze program constraints and manage supply and demand best to reach young adolescents and parents of infants, taking into [34]. Examples of such data include the performance of a site account impact, cost, the feasibility of scale-up, cultural accept- (i.e., the number of VMMCs performed) against its functional ability, and other factors. capacity and projected demand; the demand-creation Keep strategy dynamic, informed by a strong monitoring, channels that bring individuals to specific VMMC sites; evaluation, and learning platform. Our final recommenda- daily outputs of community members engaged to generate tion is that ministries of health, donors, program planners, and PLOS Medicine | www.plosmedicine.org 7 May 2014 | Volume 11 | Issue 5 | e1001641 having heterosexual sex. In the 14 priority countries of Eastern Box 3. What Needs to Be Done to Accelerate and Southern Africa, the prospective gains through lives saved, Scale-up and Impact of the VMMC Program? suffering averted, and health care costs avoided make VMMC Continue advocating for prioritization and funding for programs a crucial intervention in the struggle against HIV and VMMC. AIDS. This realization is reflected in the considerable progress already made in scaling up VMMC programs; but resource and Increase program efficiency by identifying and prioritiz- ing those most at risk of acquiring HIV. capacity constraints pose a serious challenge to the ability of the priority countries to reach the goal set out in the JSAF. Focus on program efficiency and quality at all levels, and This challenge, readily acknowledged by the countries them- on matching supply with demand. selves, is also reflected in a growing body of research that examines Explore the role that technologies, especially devices, the complexity of designing, implementing, scaling up, and can play in accelerating scale-up. evaluating VMMC programs. We believe that many of these Rethink demand creation through market segmentation challenges can be addressed through systematic, evidence-based and insights from other disciplines. management of the programs and a dynamic culture of learning. Gather and use standardized, high-quality data for The papers in this collection add further to our understanding of program management and decision-making. issues of cost, demand creation, efficiency, and service quality. Strengthen government capacity to manage and coor- They represent a significant contribution to our knowledge and dinate programs. help point the way toward the achievement of the VMMC Strategize for the sustainability phase of the program. program’s ambitious goals. Keep strategy dynamic, informed by a strong monitor- ing, evaluation, and learning platform. Acknowledgments We would like to acknowledge Naomi Bock for her contribution to the development of this manuscript. We would also like to acknowledge implementers strive to maintain a dynamic strategy and evidence- Elizabeth Gold, Jane Bertrand, Tigitsu Adamu, Lori Bollinger, Delivette based programs that are agile and able to correct their course Castor, Kim Ahanda, and James Baer for their invaluable contributions to when necessary. This is crucial because of the constantly the preparation of this manuscript; Maaya Sundaram for her help with the developing understanding of the complexities and challenges of data analysis and exhibits; and Elizabeth Thompson for editing and managing VMMC supply and demand, dealing with new formatting this manuscript. technologies, managing costs, and improving efficiency and quality. For this reason too, investment in disseminating and Author Contributions incorporating lessons learned, informed by monitoring and Analyzed the data: SS JR AT EN. Wrote the first draft of the manuscript: evaluation data, should also be prioritized (Box 3). SS EN. Contributed to the writing of the manuscript: SS JR AT EN. ICMJE criteria for authorship read and met: SS JR AT EN. Agree with Conclusion manuscript results and conclusions: SS JR AT EN. Large-scale implementation of VMMC has the potential to significantly reduce the incidence of HIV infection among men References 1. 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