20,000 HIV Infections Averted

SMC Small LogoThe SMC Programme in Uganda started in the second half of 2010. In the twelve months October 2010 to September 2011, a total of 40,000 SMCs were performed. From October 2011 to September 30th, 2012, PEPFAR reports a total of 348,000; which is a significant year-on-year increase. So, to date, the SMC programme in Uganda has reached a total of 388,000.

In 2011, DMPPT modelling for Uganda showed that in order to reach the target 80% prevalence of adult males circumcised by 2015, it needed to perform 4.25m circumcisions and an additional 2.1m in the years 2016 to 2025 to maintain that degree of prevalence. The total discounted cost of doing so was estimated at just over $350m. The number of SMCs required to avert one future infection varies from country to country; this modelling indicated that Uganda needs 19. This suggests that such a programme would avert 350,000 new infections, 25% of the total expected over that 14 year period, at a cost of $1,408 for each HIA, which in turn would generate future savings of $5,992.

In summary, 6.35m SMCs over the years 2011 – 2025, at a discounted cost of $350m, could generate total future savings of $1.52 billion.

The country still has a long way to go in the national scale-up of the programme. It has set a challenging target of 1m SMCs for the 12 months to the end of September 2013, a 250% increase in the current rate of output.

The good news is that these 388,000 SMCs may potentially avert some 20,000 new HIV infections, saving the country more than $100m in the cost of future treatments.

SMC is not an invisible condom, it is only partially protective against infection (60%) and men must continue to be serious about protecting themselves and their partner(s).

Factors Influencing SMC Scale-Up

Each day some 45 health centres are reporting the number of medical male circumcisions performed at that centre in the previous day. It’s clear even from a very quick skim of these numbers that there is still a long way to go in scaling up the SMC Programme.

These numbers alone of course will not tell us if a particular centre is able to increase its daily output, there is no reported measure of centre utilisation.

The opportunity to increase output and utilisation will depend upon three key factors. The first is the availability of trained staff and whether these can be dedicated to performing SMCs or if they will do these together with their normal duties. Second will be the space available within the centre for each of the different parts related to SMC; these include initial counselling, testing for HIV, screening for STIs, performing the circumcision, recovery and discharge. Efficiency of the centre will then depend upon ensuring an adequate flow of clients, which will depend upon successful community engagement and mobilisation. Some of the usual barriers may of course apply to SMC, as to other health services and health seeking behaviour. Whilst the service is being offered free of charge, the men attending will still need to take some time off work and travel to that centre. Loss of income and cost of transport may become real barriers to attendance.

Those tasked with considering how to scale-up will need to carefully consider each of the above as part of programme planning.

Uganda’s ABC Strategy Revisited

During this last week or so I’ve been reading about the history of HIV/AIDS in Uganda. The international charity Avert has an excellent webpage which discusses this and how strategies such as the ABC campaign helped to significantly reduce the rate of HIV infection.

This ABC campaign started in 1987 and encouraged people to Abstain from sex and to delay the age at which a young person first has sex or Be Faithful to a lifelong partner and if you are unable to do these, then use a Condom.

The good news is that some 25 years later the most recent AIDS survey shows that more than 9 out of 10 women and 8 of every 10 men can still tell you that remaining faithful and using condoms are the best ways to avoid becoming infected with HIV.


UNAIDS Executive Director Michel Sidibé said at the recent AIDS 2012 conference in Washington:

Let us not forget that the condom remains the cheapest and highly effective method we have to stop the spread of HIV… It is time for all of us to condomize!

However this same survey also shows that during the last 12 months for those that had more than one partner, only 1 in 8 used a condom the last time they had sexual intercourse. Condoms can be very effective but only if used correctly and consistently.

Condomize deflated

So it seems that Public Health professionals cannot solely rely upon people behaving as they know they should and we cannot rely solely on the correct and consistent using of barrier methods such as condoms. We need to combine these together with biomedical methods of prevention such as earlier treatment of those already infected, treating more of those who are infected, treatment for the non-infected partner in a discordant couple, eliminating Mother to Child transmission and voluntary male medical circumcision.

I enjoyed reading an article about this same issue by Andrew Green in Voice of America last month.

Reaching Men with a Minimum Package

Removal of the foreskin is only one element of a comprehensive SMC Programme. PEPFAR and other donors have a ‘minimum package’ of services that programme implementers must provide.

This starts with community engagement and mobilisation during which we have a great opportunity to reach men with a broad public health message, whilst of course focussing on many aspects of reproductive health. Men are very often not present at other ‘outreaches’ that may be more focussed on water and sanitation, malaria or family planning and child health.

Men registering for circumcision are first offered voluntary HIV counselling and testing. Knowing your status is essential and for many of these men this may be the first time they have been tested. Those who test positive are enrolled onto treatment programmes.

The men have a chance to learn more about how to avoid HIV and other sexually transmitted infections. They are offered STI screening and provided with any necessary treatment and care.

Men are informed about the correct and consistent use of condoms and why this is such an important part of prevention both before and after circumcision.

All of these services are provided free of charge.

VMMC – An HIV Prevention Priority for PEPFAR

A paper authored by Reed, J., Njeuhmeli, E., Thomas, A., et al. has been published in the JAIDS journal. It outlines the background to the development of Voluntary Medical Male Circumcision (VMMC) as part of a comprehensive HIV prevention package and moves on to discuss some of the challenges being faced in programme scale-up. In it the authors note that President Obama has committed PEPFAR to provide funding and technical support to help 13 countries in Africa to achieve 4.7m procedures by 2014. This in itself is a step towards a previously set target of 20.8m VMMCs by 2015.

The WHO formally recommended VMMC as part of its HIV prevention strategy in 2007. Between October 2009 and March 2012, PEPFAR has supported the delivery of 901,900 VMMCs at a cost of more than $250m. This financial support has been alongside more than $140m from the Bill and Melinda Gates Foundation since 2001.

The 901,900 represents just 4.3% of the overall 2015 target. The paper shows relative performance across all 13 countries. Kenya, so far, has shown most progress in overall numbers performed (295,800) and also in progress towards meeting its national target (34%). Uganda follows 2nd, having so far performed 149,400 VMMCs, but this is just 3.5% of its 4.2m national target.

Clearly these National programmes need to be scaled-up if the 2014 and 2015 targets are to be achieved:

The Challenge

The authors discuss a number of issues that need to be managed if scale-up is to be achieved.

VMMC is a one-time, relatively low-cost, quick and effective intervention. Protection against HIV infection can be more than 60% and such protection is permanent; the procedure does not need to be repeated again and again, nor does it rely on user adherence. Modelling shows that if we can reach a significant prevalence rate of male circumcision (80%) then millions of new infections could be averted, saving billions of dollars in the cost of future care and treatment; but these benefits take some years to accrue and health care professionals may prefer to use scarce resources on other health interventions that are more immediate and in which the benefits are more easily, more quickly, seen.

There is an interesting note that perhaps some countries have already seen the ‘early adopters’ with the implication that reaching these early numbers has been relatively easy. In the next phase as countries seek to scale-up the programmes there will need to be a greater emphasis on community engagement and mobilisation to ensure that not just the targeted numbers are achieved, but that we also focus more on the most at risk groups.

Two other matters will be essential for successful scale-up:

  1. Acceptance at Policy level that VMMC can be task-shifted to lower credentialed, specifically trained staff
  2. Inclusion of non-surgical (device) methodology, with full WHO approval and agreed funding support from PEPFAR and other donors.

Studies are currently on-going in a number of the 13 countries to evaluate both of these innovations.


Reed, J.B. et al., 2012. Voluntary Medical Male Circumcision : An HIV Prevention Priority for PEPFAR. JAIDS, 60(August), pp.88–95. Available at: http://bit.ly/Pcq8QP
[Accessed August 22, 2012].

Make Voluntary Medical Male Circumcision a Priority

Earlier this week Christine Ondoa, Uganda Minister of Health, called on all leaders – political and traditional leaders, religious and community leaders, youth and women leaders, professional and business leaders – to support VMMC. (text link here)

Five years ago UNAIDS and WHO recommended VMMC scale-up in countries with low male circumcision coverage and high HIV prevalence. Emmanuel Njeuhmeli et al published a paper in November 2011 which showed the need to perform more than 20m circumcisions across 14 countries in eastern and southern Africa to reach a male circumcised prevalence rate of 80% by the end of 2015. They estimated that doing so would cost about $2b but could save more than $16b in treatment and care costs by preventing more than 3.36m new HIV infections.

However since then progress has been very slow. A report issued last month by AVAC shows, as of March 2012, just 1.5m VMMCs have been completed, less than 8% of the 20m target. Uganda has completed 204,000 of its 4.2m target which, whilst reflecting slow progress, may already be contributing to averting more than 10,000 new infections. (PDF Summary here)


There is a need for all implementers to scale-up their operations and, as one potential solution, there is growing interest in the use of innovative non-surgical devices.

Alison and Michelle Raise more than £3,300

Alison and Michelle

Alison and Michelle raised more than £3,300 from their family and friends who sponsored their recent marathon in Edinburgh.

These funds will be used to continue supporting the STI clinic in Makindye division, Kampala. This clinic provides counselling, testing and treatment, free of charge, to those that could not otherwise afford to access such care.

The clinic is an integral part of our Touch Namuwongo Programme which also provides counselling, testing and treatment for HIV/AIDS and TB. We are currently planning to extend these services to include safe male circumcision.

In recent years about 20,000 adults living in Makindye division have accessed services from the Touch programme.

Our thanks also to Helen for her continued support for the STI clinic.

Uganda Aids Indicator Survey 2011–Preliminary Report

Uganda MoH has released a preliminary report of its findings from the Aids Indicator survey. Data were collected between February and September 2011.

This survey was designed to enable data to be compared with those collected during the previous survey in 2004-5.

Male Circumcision

The prevalence of male circumcision, 23%, has not changed since the last survey and there are only small variations in the data by age groups. This indicates that there is little change in the practice of MC over time. The prevalence of MC for reasons of faith, culture or tradition continues as before.

There are wide variances of MC prevalence across the country and across wealth quintiles, men in the higher wealth quintiles are more likely to be circumcised. About 35% of men in Kampala are circumcised whereas prevalence is less than 6% of men living in the north of Uganda.

Knowledge of HIV Transmission

About 75% of adults are able to say that remaining faithful to one uninfected partner and always using a condom are ways of reducing the risk of becoming infected with the AIDS virus, HIV.

The survey also identified the numbers of those with misconceptions about how HIV is transmitted. Just less than 50% of adults think that HIV can be transmitted by mosquito bites and up to a quarter think that you might become infected by sharing food with a person living with HIV.

Comprehensive knowledge measures those that can state the two means of reducing HIV infection, know that a health-looking person can have HIV and can also reject the two most common misconceptions. Interestingly the survey shows that less than 40% can be counted as having comprehensive knowledge; so there is still room for improvement in the way in which we are delivering the prevention message.

Stigma and Discrimination

There is a section in the survey which attempts to uncover attitudes towards people living with HIV. Stigma and discrimination are still issues that will need to be addressed. These can lead people to stay in denial and refuse to come forward for counselling and testing, an essential first step in the prevention campaign. Others may keep their infection secret from others, which in turn may lead to further transmission.

Sexual Behaviour

The most likely mechanism for transmission of HIV in Uganda is through unprotected sexual intercourse with an infected partner (heterosexual). There are growing concerns about the increasing prevalence of those with multiple concurrent partners, MCP.

The survey asks a number of different questions related to this. I think the most interesting result is that less than 16% reported using a condom during their last sexual intercourse, which when combined with the admitted numbers of multiple partners is a worrying trend. This presents an interesting dichotomy between what people state as knowledge (be faithful and use a condom) and actual behaviour.

HIV Prevalence

Prevalence rates might be increasing, this survey indicates the overall rate to be 6.7%, which is higher than the previous 6.4% but this movement may not be statistically significant. Prevalence among women is higher, 7.7%, than in men, 5.5%.

A later press release by the MoH stated the prevalence rate as 7.3%, which means as many as 1 in every 13 adults in Uganda are HIV positive.

You can access the survey report here: http://t.co/98S1RkUe

1 in 13 Ugandans are HIV+ and Reactions to my SMC Post

We received a number of comments after my initial posting about the Safe Male Circumcision Programme at IMG.

It’s true that SMC (MMC, VMMC) has its detractors. There are some that do not consider this procedure desirable and others who are concerned that circumcision may in fact lead to an increase in HIV infections and the spread of STIs.

Some have called into question the validity of the initial three research studies, often quoted as the reasons for these national SMC programmes. We welcome further research studies, designed to ensure that these concerns are addressed. As we embark on this programme in Uganda, we are keeping research and evaluation right at the heart of what we do.

When the BBC reported the news that in Zimbabwe MPs were coming forward for SMC, it noted these concerns:

But it is not the whole solution. Promoting safe sex, providing people with HIV testing services and encouraging the use of male and female condoms are all seen as equally important.

Some experts also say there is a danger in sending out a message that circumcision can protect against HIV because it could lead to an increase in unprotected sex.

We agree, it is essential that SMC is made an integral part of a comprehensive prevention programme. We are ensuring that both men and women understand that male circumcision does not give full protection and other preventive measures must still be taken, in particular continued use of condoms and knowing your partner’s status.

TNP ABC - Put it on like this

We are using the SMC programme as a unique opportunity to reach men who are often not present at our other community health outreaches. We are combining each of the reproductive health messages with the SMC message, covering e.g. HIV, STIs, Family Planning, PMTCT, the need for and importance of ante-natal visits and attended delivery. In that way we hope that both men and women will gain a better, more complete, understanding of all these related matters.

These programmes are hugely important in Uganda. Just this week the Ministry of Health reported new data showing that HIV/AIDS is on the increase:

The number of Ugandans infected with the HIV virus has increased by 100 per cent in the last seven years, it was announced yesterday. Results from the 2011 Uganda AIDS Indicator Survey show that one in every 13 Ugandan adults has HIV. The prevalence rate has surged from 6.4% in 2005 to 7.3%.

Joshua Businge from the AIDS control Program from the Ministry of Health attributed the incidence to multiple sexual partnerships (MCP) and failure to use condoms as one of the major reasons why the figures were going up.

You can read more about this announcement here and here.

Male Circumcision Programme in Tanzania reaches 100,000

The Maternal and Child Integrated Programme, MCHIP, announced this week that its safe male circumcision programme in Tanzania had now provided services to 100,000 clients. You can read the original press release by clicking on the image below.


Estimations show that 16,000 future HIV infections will be averted between now and 2025 as a result of these 100,000 circumcisions. If accurate this means that for every one pound or one dollar invested in the SMC programme, about 14 will be saved in future treatment costs.

I shared this news with our own team and here’s the reply back from Francis, the in-charge at Hope Clinic Lukuli:

This is extremely very good news for East Africans. Overall, I think the success in TZ can be attributed to the immense family support for men going for VMMC as the article does note. For example, a son and his mother accompanying a father to the VMMC CENTRE and also availing himself (son) for the VMMC is extremely awesome. Also, not forgetting the hard work of the local medical team, the nurses.

For Uganda, there is a lot to learn from TZ especially how can we have full family support for men in Uganda to get the numbers we desire for VMMC? Also can we have work places support the VMMC so that men who work can benefit fully from this? Can registering, HCT and STI treatment and carrying out the procedure in one day work better than giving appointments? Lastly, why do some men register and never show up?

VMMC – voluntary medical male circumcision

SMC – safe male circumcision

These are the same, just referred to differently in different places.

HCT – this is the counselling and testing for HIV, an integral part of an SMC programme and sometimes also referred to as VCT.