1. Office of Global Health and HIV (OGHH) Office of Overseas Programming & Training Support (OPATS) Session: Voluntary Medical Male Circumcision (VMMC)

2. Session Learning Objectives  After this session, participants determine how to work with current mobilization and education activities to support community efforts for VMMC.

3. What is VMMC  Male circumcision is the removal of the foreskin of the penis.  Voluntary medical male circumcision is the voluntary act of having the foreskin removed by a trained medical professional.  VMMC for HIV prevention programs target men (15- 49) in 14 countries in Southern and Eastern Africa.

4. VMMC program goals  UNAIDS, WHO, and PEPFAR have set a target to reach 80% of men in 14 countries by 2015.  Modeling estimated that this would eliminate 20% of all new infections in the region by 2025.  VMMC programs target adult men to get immediate prevention effect. Neonatal circumcision is more straightforward (i.e., not minor surgery) but doesn’t have an immediate impact on HIV.

5. Evidence of VMMC’s Effectiveness  Early observational studies noted lower HIV prevalence rates where rates of male circumcision are high.  Randomized controlled trials in Kenya, Uganda, and South Africa demonstrated that circumcision reduces men’s risk of being infected by upwards of 60% during vaginal intercourse (female to male transmission).

6. VMMC and HIV Prevention  How does circumcision prevent HIV transmission? Theories about physiological change – Uncircumcised men seem to be more likely to have small tears and lesions that allow the virus to enter the body. – There is a high concentration of HIV target cells in the inner foreskin. – Circumcision also demonstrated a reduction in risk for other sexually transmitted infections, which can increase the chance of being infected with HIV.

7. Package of VMMC Services  HIV testing and counseling  Screening and treatment for STIs  Provision of male and female condoms and promotion of their correct and consistent use  Promotion of safer sex practices and risk reduction counseling  MC or surgical removal of the foreskin  Active linkage of HIV-positive client to care and treatment  Also require post operative review (generally seven days later). Bandage can be removed after two days. Must avoid erections for a certain period and abstain from sex for six weeks

8. Limitations of VMMC  Only partial protection – up to 60%. Still have to use condoms.  Does not provide HIV prevention benefit for HIV-positive men.  Only protects insertive partner during heterosexual vaginal sex.

9. National VMMC Strategy  Post adaptation – Include current coverage rates – Include actors, implementers – Review cultural norms around circumcision

10. PCV Support to VMMC Efforts  Conduct information sessions on VMMC.  Support promotion of VMMC, particularly among adult men. Encourage women to support men in going for VMMC.  Provide referrals to local VMMC facilities.  Work with local partners to recruit, train, and select VMMC clients as community advocates.  Educate community on appropriate post-surgical care and appropriate follow up.