AIDS 2012— Turning the Tide Together Emmanuel Njeuhmeli, MD, MPH, MBA Senior Biomedical Prevention Advisor, USAID Washington Co-Chair PEPFAR Male Circumcision Technical Working group In It To Saves Lives Voluntary Male Medical Circumcision for HIV Prevention

Call to Action for VMMC Moderated by Brenda Wilson Male Client Perspective – Mr. Angelo Kaggwa Female Perspective – Her Excellency Dr. Speciosa Wandira – Ms. Hendrica Okongo Cultural aspects of male circumcision – His Excellency Chief Jonathan Mumena Economic Aspects of VMMC – Honorable Dr. Oburu Odinga Leadership in VMMC – Honorable Pr. Christine D. J. Ondoa – Mr. Blessing Chebundo Call to Action – His Excellency Benjamin Mkapa

Champions for HIV-Free Generation His Excellency Benjamin Mkapa, Former President, Tanzania His Excellency Kenneth Kaunda, Former President, Zambia His Excellency Joaquim Chissano, Former President, Mozambique Her Excellency Speciosa Wandira, Former Vice President, Uganda Professor Miriam Were, Former Chairperson of the Kenya National AIDS Council, Kenya

Scientific Evidence Biological plausibility: –Inner surface of the foreskin highly vulnerable to HIV infection –Up to nine times more vulnerable than cervical tissue Over 50 ecological and observational studies: lack of male circumcision associated with higher HIV in men Three RCTs in Kenya, Uganda, and South Africa: 60% protection Longer-term (4–5 years) follow-up of the Kenya and Uganda RCT participants: protective effect sustained/increased Community-level impact evaluation in South Africa (Orange Farm) demonstrated 76% incidence reduction

WHO-UNAIDS Recommendations Male Circumcision Priority Countries

Male circumcision is always part of a package of prevention services: –Provider-initiated HIV counseling and testing, including couples HTC –Screening (and treatment) of STIs –Age-appropriate counseling on risk reduction, including reduced number and concurrency of sexual partners, delaying/abstaining from sex –Provision and promotion of correct and consistent use of condoms (male and female) –Active referral and linkage to HIV care/treatment/support services, including other HIV prevention services –Post-operative clinical care and reinforced education/ counseling Minimum Package of Services

DMPPT Estimate of Number of Adult 15–49 Years VMMC Needed per Countries to Reach 80% Coverage

13 Countries: EIMC, Adolescent and Adult MC Required

Cumulative Number and Percentage of HIV Infections Averted between 2011 to 2025 by Scaling Up VMMC

Challenges for Scaling Up VMMC Risk compensation: – No evidence that men after circumcision adopt riskier sexual behavior Skepticism of science: – Observational studies – RCTs Resumption of sex before wound healing: – If HIV positive men are being circumcised and resume sex without protection before the wound heals there, is an increased risk to transmit HIV to the partner

Total – New HIV Infections Averted

HIV Infections Averted in Men and Women

Net Savings by Scaling Up VMMC US$16.5 Billion (2011 to 2025 in Millions US$)

Number of VMMCs Needed to Prevent 1 Infection

WHO-UNAIDS Joint Strategic Framework for Acceleration of the VMMC Scale-Up 2012–2016 More than 5 years after WHO-UNAIDS recommendations: Neither the elegance of the science nor the strength of the effect predict the ease of implementation. 1.PEPFAR-UNAIDS Recent Publications in PLoS Medicine: Signpost the way forward to accelerate the scaling-up of VMMC service delivery safely and efficiently to reap individual- and population-level benefits 2.PEPFAR-WHO-UNAIDS-BMGF-World Bank collaboration to launch the WHO- UNAIDS Joint Strategy Action Framework for Acceleration of the Scale-Up of VMMC

Number of VMMCs from March 2007 to March 2012

Number of VMMCs Done as of March 2012

Strategy for Achieving Pace and Scale Political will and country ownership Strong leadership and coordination from MOH Effective demand creation strategy with strong community-level buy-in Enough financial resources for service delivery, including some level of dedication of staff time, facility space and commodities Provision of excellent technical support to allow for a good match of demand and supply and an efficient use of the limited resources available in order to reach the maximum number of men possible.

High-Volume, High-Quality Service Delivery Effective Demand Creation Dedicated Commodities Dedicated Human Resources Dedicated Space Efficient VMMC Program

Thank You

Thank you! The sponsors of this satellite would like to acknowledge that the satellite has been made possible because of the Maternal and Child Health Integrated Program (MCHIP). MCHIP is being sponsored by PEPFAR through USAID and managed by Jhpiego. The information provided in this document is not official U.S. Government information and does not necessarily represent the views or positions of USAID or PEPFAR.