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 . 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.