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Medical male circumcision is now a part of the strategy for HIV prevention in Eastern and Southern Africa. This paper analyses the status of research and recent trends in male circumcision for HIV prevention in thirteen priority countries. A search for the words “male, circumcision, HIV/AIDS, Africa” was done in the free online PubMed Central database of the United States National Library of Medicine (National Institutes of Health). In all the primary studies published over the past two years, the major trends in VMMC include: mathematical confirmation of the protective role of male circumcision in HIV prevention, awareness of and demand for male circumcision, acceptability of male circumcision, male circumcision versus sexual risk compensation, roll-out of male circumcision, and policy environment for adoption and scale-up of male circumcision. The study revealed the need to conduct more studies on male circumcision for HIV prevention especially in countries like Namibia, Malawi, Lesotho, Mozambique, and Zambia. These studies should especially focus on increasing the acceptability and roll-out of voluntary medical male circumcision as well as implementing robust policies and allocating more local resources to this latest strategy of HIV prevention. Uptake of voluntary medical male circumcision should be scaled-up if the benefits of HIV prevention are to be realized.
Article Citation:
Kazhila C. Chinsembu.
A Trends Analysis of Medical Male Circumcision for HIV Prevention In Eastern and Southern Africa.
Journal of Research in Public Health (2012) 1(2): 020-029.
Full Text: http://jhealth.info/documents/PH0009.pdf
Originaltitel
A Trends Analysis of Medical Male Circumcision for HIV Prevention in Eastern and Southern Africa
Medical male circumcision is now a part of the strategy for HIV prevention in Eastern and Southern Africa. This paper analyses the status of research and recent trends in male circumcision for HIV prevention in thirteen priority countries. A search for the words “male, circumcision, HIV/AIDS, Africa” was done in the free online PubMed Central database of the United States National Library of Medicine (National Institutes of Health). In all the primary studies published over the past two years, the major trends in VMMC include: mathematical confirmation of the protective role of male circumcision in HIV prevention, awareness of and demand for male circumcision, acceptability of male circumcision, male circumcision versus sexual risk compensation, roll-out of male circumcision, and policy environment for adoption and scale-up of male circumcision. The study revealed the need to conduct more studies on male circumcision for HIV prevention especially in countries like Namibia, Malawi, Lesotho, Mozambique, and Zambia. These studies should especially focus on increasing the acceptability and roll-out of voluntary medical male circumcision as well as implementing robust policies and allocating more local resources to this latest strategy of HIV prevention. Uptake of voluntary medical male circumcision should be scaled-up if the benefits of HIV prevention are to be realized.
Article Citation:
Kazhila C. Chinsembu.
A Trends Analysis of Medical Male Circumcision for HIV Prevention In Eastern and Southern Africa.
Journal of Research in Public Health (2012) 1(2): 020-029.
Full Text: http://jhealth.info/documents/PH0009.pdf
Medical male circumcision is now a part of the strategy for HIV prevention in Eastern and Southern Africa. This paper analyses the status of research and recent trends in male circumcision for HIV prevention in thirteen priority countries. A search for the words “male, circumcision, HIV/AIDS, Africa” was done in the free online PubMed Central database of the United States National Library of Medicine (National Institutes of Health). In all the primary studies published over the past two years, the major trends in VMMC include: mathematical confirmation of the protective role of male circumcision in HIV prevention, awareness of and demand for male circumcision, acceptability of male circumcision, male circumcision versus sexual risk compensation, roll-out of male circumcision, and policy environment for adoption and scale-up of male circumcision. The study revealed the need to conduct more studies on male circumcision for HIV prevention especially in countries like Namibia, Malawi, Lesotho, Mozambique, and Zambia. These studies should especially focus on increasing the acceptability and roll-out of voluntary medical male circumcision as well as implementing robust policies and allocating more local resources to this latest strategy of HIV prevention. Uptake of voluntary medical male circumcision should be scaled-up if the benefits of HIV prevention are to be realized.
Article Citation:
Kazhila C. Chinsembu.
A Trends Analysis of Medical Male Circumcision for HIV Prevention In Eastern and Southern Africa.
Journal of Research in Public Health (2012) 1(2): 020-029.
Full Text: http://jhealth.info/documents/PH0009.pdf
A Trends Analysis of Medical Male Circumcision for HIV Prevention
In Eastern and Southern Africa
Keywords: Medical, male circumcision, trends, Eastern, Southern, Africa. ABSTRACT:
Medical male circumcision is now a part of the strategy for HIV prevention in Eastern and Southern Africa. This paper analyses the status of research and recent trends in male circumcision for HIV prevention in thirteen priority countries. A search for the words male, circumcision, HIV/AIDS, Africa was done in the free online PubMed Central database of the United States National Library of Medicine (National Institutes of Health). In all the primary studies published over the past two years, the major trends in VMMC include: mathematical confirmation of the protective role of male circumcision in HIV prevention, awareness of and demand for male circumcision, acceptability of male circumcision, male circumcision versus sexual risk compensation, roll-out of male circumcision, and policy environment for adoption and scale-up of male circumcision. The study revealed the need to conduct more studies on male circumcision for HIV prevention especially in countries like Namibia, Malawi, Lesotho, Mozambique, and Zambia. These studies should especially focus on increasing the acceptability and roll-out of voluntary medical male circumcision as well as implementing robust policies and allocating more local resources to this latest strategy of HIV prevention. Uptake of voluntary medical male circumcision should be scaled-up if the benefits of HIV prevention are to be realized. 020-029 | JRPH | 2012 | Vol 1 | No 2 This article is governed by the Creative Commons Attribution License (http://creativecommons.org/ licenses/by/2.0), which gives permission for unrestricted use, non-commercial, distribution and reproduction in all medium, provided the original work is properly cited. www.jhealth.info Journal of Research in Public Health An International Scientific Research Journal Author: Kazhila C. Chinsembu.
Institution: University of Namibia, Faculty of Science, Department of Biological Sciences, P/Bag 13301, Windhoek, Namibia.
Corresponding author: Kazhila C. Chinsembu.
Email: kchinsembu@unam.na
Phone No: +264-61-2063426.
Fax: +264-61-2063791.
Web Address: http://www.jhealth.info/ documents/PH0009.pdf.
Dates: Received: 23 Jul 2012 Accepted: 10 Aug 2012 Published: 18 Sep 2012 Article Citation: Kazhila C. Chinsembu. A Trends Analysis of Medical Male Circumcision for HIV Prevention In Eastern and Southern Africa. Journal of Research in Public Health (2012) 1(2): 020-029 Original Research Journal of Research in Public Health J o u r n a l
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INTRODUCTION Male circumcision (MC), the surgical removal of the foreskin of the penis, is practiced all over the world for medical, religious, and cultural reasons. About 30% of men are circumcised globally (Wilcken et al., 2010). Research has shown that MC can prevent HIV/ AIDS infection (Mwandi et al., 2011). Three randomized controlled trials revealed that MC reduces HIV acquisition from infected women by almost 60% (Auvert et al., 2005; Bailey et al., 2007; Gray et al., 2007). Further to these empirical data, the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) in 2007 recommended that countries should include medical MC in the suite of services for HIV prevention (Mwandi et al., 2011). Thirteen countries in Eastern and Southern Africa (Botswana, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe, and Kenya) were prioritized for scale-up of Voluntary Medical Male Circumcision (VMMC). The objective of this study was to analyze the research status and trends in MC for HIV prevention in Eastern and Southern Africa.
METHODOLOGY The search words male, circumcision, HIV/AIDS, Africa were entered into the free online PubMed Central (PMC) database of the United States National Library of Medicine (National Institutes of Health). The search was performed on March 28, 2012, and was limited to research and review articles published in the two-year period between 2010 and 2012. A total of 157 publications were displayed after the search. Of these, 30 publications were deemed relevant to this systematic review based on the following exclusion and inclusion criteria. Publications that reported studies from outside Africa and those that did not specifically deal with HIV/AIDS and male circumcision were excluded. Review articles and conference abstracts were not included. Only original research articles were incorporated into this study. These were categorised according to the year of publication, country or countries where research was conducted, type of research, and the main focus area of the study (Table 1).
RESULTS Protective effect of male circumcision on HIV acquisition and transmission Fiamma et al. (2010) used a longitudinal dataset obtained during the first male circumcision randomized controlled trial (Orange farm male circumcision trial, ANRS-1265) and demonstrated for the first time that the effect of the intervention could have been approximately estimated by HIV incidence testing applied to blood samples collected at the final follow-up visit. Using rigorous theoretical and statistical formulae (intention-to-treat effect, 95% confidence intervals, and bootstrap resampling), the results of Fiamma et al. (2010) verified the previously reported (in survival analysis) HIV protective effect of 60% conferred by male circumcision. Also, using data from Kenya and Zimbabwe, Hallett et al. (2011) mathematically modeled that circumcision may confer a 46% reduction in the rate of HIV transmission from circumcised men to their female partners. They projected that the protective impact of circumcision on the spread of HIV is substantially increased for women, and that an increase in the risk of acquisition and transmission of HIV during circumcision wound healing is unlikely to have a major effect on the population-level impact of circumcision interventions.
Chinsembu,2012 021 Journal of Research in Public Health (2012) 1(2): 020-029 Although it was previously expected that women would benefit modestly from male circumcision implementation (as fewer of their sexual partners would be infected), the projections of Hallett et al. (2011) showed that women could also receive a direct benefit from male circumcision. These authors posited that if their estimate about the long-term effect of circumcision on male-to-female HIV transmission was correct, then women in stable partnerships with infected men would receive a degree of protection from circumcision similar to that received by men in partnerships with infected women. Awareness of and demand for male circumcision In Uganda, adults were more aware of male circumcision than youth (Wilcken et al., 2010). Awareness increased with educational level. Marital status, religion, geographical location, ethnicity, employment status, and circumcision status were not determinants of awareness of male circumcision for HIV prevention in youth (Wilcken et al., 2010). Preference for circumcision in a traditionally non-circumcising Luo community in Kisumu, Kenya, was increased by the knowledge that circumcised men are less likely to become infected with HIV (Westercamp et al., 2010). In order to enhance demand for voluntary medical male circumcision, key informants in Eastern and Southern Africa stated that effective communication channels for demand creation should include the mass media, print materials (small media), and outreach/mobilization (Bertrand et al. 2011). However, there were variations in the cost of demand creation activities by the country and the programme, decisions about the quality and comprehensiveness of programming, and the lack of data on critical elements needed to trigger the decision to voluntarily seek medical circumcision services among eligible men. Thus, Bertrand et al. (2011) cautioned that a standard package of core demand creation elements would not be universally applicable to all countries. This finding underscored the importance of tailoring demand creation strategies and cost estimates to specific country contexts. Acceptability of male circumcision Among Rwandan men, half of the study participants were willing to be circumcised and 79% accepted circumcision for their sons (Gasasira et al., 2012). The main drivers of male circumcision were benefits in HIV prevention and improved hygiene. Men who were old did not favour male circumcision. Acceptability of male circumcision increased with younger age (adolescents and young adults were more willing to be circumcised), living in the Eastern Province and with the factors marriage, and knowledge of the protective role of circumcision (Gasasira et al., 2012). Mugwanya and co-workers, working in Uganda, found that circumcision for male children was favoured as a future risk reduction strategy for HIV infection. Men preferred 6 months while women preferred 2 months as the preferred ages for circumcision of their infant sons (Mugwanya et al., 2011). Among Tanzanian parents, medical pre-pubertal circumcision was accepted along ethnic lines (Wambura et al., 2011). Preference for pre-pubertal male circumcision was associated with the non-Kurya ethnic group. In Kenya, Herman-Roloff et al. (2011) documented that male circumcision uptake was facilitated by the need for hygiene, social pressure, protection from HIV infection, and increased sexual performance and satisfaction. They also found several barriers to male circumcision: culture, religion, fear of adverse events, and post-surgical abstinence. Chinsembu,2012 Journal of Research in Public Health (2012) 1(2): 020-029 022
Herman-Roloff et al. (2011) recommended that the activities which may increase male circumcision uptake should dispel misconceptions around male circumcision; increase the involvement of religious leaders, womens groups, and peer educators; and enhance the significance of male circumcision among men who are already using an HIV/AIDS prevention strategy. Chinsembu,2012 023 Journal of Research in Public Health (2012) 1(2): 020-029 Year of Publication Country Research type Research Problem Reference 2010 Uganda Cross-sectional Awareness of MC Wilcken et al., (2010) 2010 South Africa Cross-sectional/ qualitative studies Feasibility of roll-out of AMC Lissouba et al.,(2010) 2010 South Africa Secondary analysis of longitudinal data/ laboratory analyses Effect of MC on HIV acquisition Fiamma et al. (2010) 2010 Kenya Randomized controlled trial Risks for self-reported penile injuries versus MC Mehta et al., (2010) 2010 Kenya Qualitative: Interviews/ FGDs Examining sexual risk compensation in circumcised men Riess et al. (2010) 2010 Kenya Population-based survey Beliefs about male circumcision in a traditionally non-circumcising community Westercamp et al., (2010) 2010 Botswana Cross-sectional study Acceptability of EIMC Plank et al., (2010) 2011 Uganda Cross-sectional Acceptability of EIMC Mugwanya et al., (2011) 2011 Tanzania Cross-sectional Acceptability of MC Wambura et al., (2011) 2011 Swaziland Situation analysis Logistics, commodities, and waste management Edgil et al. (2011) 2011 Tanzania Qualitative: Interviews Acceptability/policy environment Mwanga et al., (2011) 2011 Eastern and Southern Africa Modelling Impact and cost of scale-up of adult VMMC Njeuhmeli et al. (2011) 2011 Kenya/ Zimbabwe Modelling Population impacts of MC on HIV transmission Hallett et al. (2011) 2011 Kenya Situation analysis of secondary and primary data Challenges, responses, and lessons from national VMMC Herman-Roloff et al. (2011) 2011 Eastern/ Southern Africa Secondary analysis of data based on DOI and Expand Net frameworks Progress towards scale-up of VMMC: factors/ policies for adoption and implementation Dickson et al. (2011) 2011 Lesotho Cross-sectional study Concordance of MC self- reported status with physical examination status Thomas et al., (2011) 2011 Kenya Qualitative: FGDs Acceptability of MC among uncircumcised men Herman-Roloff et al., (2011) 2011 Eastern/ Southern Africa Qualitative: Interviews of 7 key informants Challenges of demand creation for VMMC Bertrand et al. (2011) 2012 Rwanda Cross-sectional Perception and determinants of MC Gasasira et al., (2012) 2012 Zimbabwe Qualitative: FGDs Acceptability of EIMC Mavhu et al., (2012) EIMC = Early Infant Male Circumcision; DOI= Diffusion of Innovation; MC= Male Circumcision; VMMC = Voluntary Medical Male Circumcision Table 1: Summary of primary studies used in the trends analysis In Botswana, medical male infant circumcision was acceptable especially within the first 6 weeks to 1 year after birth (Plank et al., 2010). Many respondents (92%) stated they would accept infant circumcision if the procedure was available in a clinical setting, primarily to prevent future HIV infection, and 85% stated the infant's father must participate in the decision (Plank et al., 2010). Among Zimbabweans, despite their poor knowledge of male circumcision, acceptance of infant male circumcision was high regardless of ethnicity (Mavhu et al., 2012). However, many expressed cultural concerns about the motive for mass male circumcision, and the disposal of the foreskin. Older Zimbabweans spoke against early infant male circumcision because it depreciated adolescent initiation ceremonies and allowed mothers to nurse the wound; the latter is considered taboo. Sexual risk compensation Riess et al. (2010) examined sexual risk compensation in circumcised Kenyan men. Their results showed that a minority of circumcised men reported higher risk behaviours by either not using condoms or increasing the number of casual sexual partners. The increased risky sexual behavior may be attributed to the fact that circumcised respondents described being able to perform more rounds of sex and experienced less penile coital trauma (cuts on the penis during sex). The risk of coital injury (soreness, scratches, abrasions, bleeding) is lower for circumcised than uncircumcised men (Mehta et al., 2010). On the other hand, a majority of circumcised Kenyan men did not report any increased changes in risky sexual behaviours after circumcision. The results of this study by Riess et al. (2010) illustrated that male circumcision does not necessarily lead to risk compensation as long as one is aware of sexual risky behaviours, undergoes HIV/male circumcision counseling and education, takes HIV testing, and maintains a desire to remain HIV negative. Roll-out of male circumcision Within a South African poor setting, the feasibility to roll-out high quality adult male circumcision according to UNAIDS/WHO operational guidelines was confirmed by Lissouba et al. (2010). Using an innovative surgical organization, Lissouba and colleagues documented that 150 adult male circumcisions were performed per day under local anaesthesia by one medical circumciser and 5 nurses. Using the Decision Makers Programme Planning Tool (DMPPT), researchers modeled the impact and cost of scaling up adult voluntary medical male circumcision in Botswana, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe, and Nyanza Province in Kenya. According to Njeuhmeli et al. (2011), the cost of one voluntary medical male circumcision ranged from US$65.85 to US$95.15. Njeuhmeli et al. (2011) estimated that scaling up voluntary medical adult male circumcision to reach 80% coverage in the 13 countries by 2015 entailed performing 20.34 million circumcisions between 2011 and 2015 and an additional 8.42 million between 2016 and 2025 (to maintain the 80% coverage). This scale-up was expected to avert 3.36 million new HIV infections through 2025. The same authors calculated that the scale-up programme would cost a total of US$2 billion between 2011 and 2025. However, they maintained that voluntary medical male circumcision would also rake in net savings amounting to US$16.51billion due to averted HIV/AIDS treatment and care costs. Their Chinsembu,2012 Journal of Research in Public Health (2012) 1(2): 020-029 024 findings corroborate that rapid medical male circumcision scale-up in Eastern and Southern Africa is justified given its likely impact on the regions HIV epidemics and the resultant cost savings. Further to the cost estimates derived by Njeuhmeli et al. (2011), a situational cost analysis to inform the planning of voluntary medical male circumcision services was carried out in Swaziland. Edgil et al. (2011) found that an additional per cost of US$60 is required for supply chain and waste management, HIV counselling and testing, and treatment of sexually transmitted infections. This additional US$60 is required over and above the US$65.85 to US$95.15 needed to perform one medical male circumcision. Therefore, the overall cost of one voluntary medical male circumcision would likely range between US$125.85 and US$155.15 in Eastern and Southern Africa. Policy environment for adoption and scale-up of male circumcision Using the diffusion of innovation model, Dickson et al. (2011) studied the adoption of voluntary medical male circumcision in Eastern and Southern Africa. Their findings reveal that the innovators (Kenya) started performing voluntary medical male circumcisions in or before 2008 and reached a cumulative total of 232,287 voluntary medical male circumcisions by 2010. South Africa, Zambia, and Swaziland (early adopters) started in or before 2008, but by 2010 had cumulative totals of 145,475, 81,849, and 24,315 voluntary medical male circumcisions, respectively (Dickson et al. 2011). Countries in the category of early majority started in 2009 and achieved the following voluntary medical male circumcisions by 2010: Botswana (11,197), Zimbabwe (13,977), Tanzania (29,443), Namibia (1,987), and Mozambique (7,733).
The late majority (Uganda and Rwanda) started in 2010 and did 9,052 and 1,694 voluntary medical male circumcisions, respectively. By the end of 2010, the laggards (Malawi and Lesotho) did 300 and 219 circumcisions, respectively. In Lesotho, there were self-reports of false male circumcisions. Approximately 27% of adult males self-reported being circumcised but only 50% of these men had complete male circumcision as determined by a physical examination (Thomas et al., 2011). Given this low male self-report accuracy, countries scaling up voluntary medical male circumcision should obtain physical-exam-based male circumcision data to guide service delivery and cost estimates (Thomas et al., 2011). Overall, Dickson et al. (2011) found that at the end of 2010, only 550,000 voluntary medical male circumcisions had been performed, representing a paltry 3% of the target coverage level in the 13 priority Eastern and Southern African countries. The early adopter countries developed national voluntary medical male circumcision policies and implemented the programme soon after the release of the WHO recommendations in 2007. However, based on modeling using the Decision Makers Programme Planning Tool (DMPPT), Dickson et al. (2011) contend that only Kenya will achieve the DMPPT-estimated 80% coverage goal by 2015, having already achieved 61.5% of the DMPPT target. None of the other countries appear to be on track to achieve their targets. According to Dickson and co-workers, potential predicators of early adoption of male circumcision programmes include having a voluntary medical male circumcisions focal person, establishing a national policy, having an operational strategy, and the establishment of a pilot programme (Dickson et al. 2011).
Chinsembu,2012 025 Journal of Research in Public Health (2012) 1(2): 020-029 In Kenya, implementation of voluntary medical male circumcision faced staff shortages, and government had to endorse trained nurses to roll-out the service (Herman-Roloff et al., 2011). Voluntary counseling and testing (VCT) was also replaced with provider-initiated testing and counseling (PITC) and subsequently doubling the proportion of VMMC clients tested for HIV. A study in Tanzania (Mwanga et al., 2011) also urged the government to make improvements in the health system at all levels to ensure availability of adequate trained personnel, infrastructure, equipment, and supplies for male circumcision scale up, and insisted on the involvement of different male circumcision stakeholders as key components in effective roll out of medically performed male circumcision.
DISCUSSION This study analyzed key trends in VMMC in Eastern and Southern Africa. Six key trends were observed in all the studies published over the past two years: mathematical confirmation of the protective role of MC for HIV prevention, awareness of and demand for MC, acceptability of MC, MC versus sexual risk compensation, roll-out of MC, and policy environment for adoption and scale-up of MC. Recent data collection protocols, analyses, and models have corroborated the efficacy of MC in preventing HIV acquisition and transmission. Given the strong evidence that exists, the role of MC in preventing HIV infection is undoubtedly defensible. We therefore foresee no further practical need for research in this area, unless it is for academic purposes only. This study did not find convincing evidence for universal awareness of MC as a preventive strategy for HIV/AIDS. This lack of awareness is quite prevalent in culturally non-circumcising communities, and also among older people. Several factors that hinder demand for VMMC also exist. It is recommended that locale-specific communicative programmes that should trigger decisions towards MC should be increased if universal awareness of MC as an HIV measure is to be achieved. The cost of such awareness programmes will also differ from country to country. Despite the overwhelming evidence that MC protects against HIV/AIDS, VMMC is not yet universally accepted. Studies to ascertain the acceptability of VMMC should be carried out in countries such as Namibia, Malawi, Lesotho, Mozambique, South Africa, and Zambia. Several barriers to MC should exist: ethnicity, culture, religion, fear, misconceptions, and gate-keepers such as older persons and fathers. Increasing the roll-out of VMMC will have to overcome these barriers. It is proposed that peer-educators can help MC programme implementers secure the buy-in of gate-keepers. A key concern is that promoting MC may lead circumcised men to develop a false sense of complete protection against HIV and engage in risk compensation by halting or decreasing previous protective behaviors such as condom use or partner reduction, causing the protective effects of MC to be reduced or negated. This is a major concern especially that MC increases coital activity and satisfaction. To reduce sexual risk compensation, there is need to counsel circumcised sexually active adolescents and adults that MC does not totally protect an individual from HIV/AIDS infection. There is evidence that roll-out of VMMC can be achieved in poor settings. The total cost of VMMC was estimated to be less than US$155.15. Although the scale-up of VMMC in Eastern and Southern Africa was estimated at US$2 billion, this cost is overshadowed by Chinsembu,2012 Journal of Research in Public Health (2012) 1(2): 020-029 026
the savings that accrue from treatment and care of HIV/AIDS patients. Therefore, in the long term, using VMMC to prevent HIV infections will become a much cheaper option than treatment and care. One regrettable trend identified in this study is that the adoption of VMMC been slow in countries with high HIV/AIDS prevalence rates. There is also mis-reporting of MC. Notwithstanding the progress made by Kenya, the total coverage of MC in Eastern and Southern Africa is still very low (3%). There is an urgent need to devise national policies and implementation programmes that promote VMMC in Eastern and Southern Africa. Without a clear policy direction and implementation agencies, the benefits of MC for HIV prevention will not be realized in the near future.
CONCLUSIONS AND RECOMMENDATIONS There is need to conduct more studies on MC for HIV prevention especially in countries like Namibia, Malawi, Lesotho, Mozambique, and Zambia. Throughout Eastern and Southern Africa, VMMC is very low. Therefore, uptake of VMMC should also be scaled-up if the benefits of HIV prevention are to be realized. Specifically, there is an urgent need to use Information, Education and Communication (IEC) as well as Behaviour Change Communication (BCC) strategies to increase the uptake of VMMC. Such strategies should centre around increasing the acceptability of VMMC by breaking cultural barriers against VMMC. Governments should also devise and implement robust policies to roll- out VMMC. For example, governments must commit more local resources to scale-up VMMC. This should include robust programmes to train circumcisers and bring VMMC services closer to the community.
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