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).

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].

Toward an AIDS-Free Generation

U.S. Chargé d’Affaires, Virginia Blaser made a statement recently about the on-going support by the USA for healthcare in Uganda and for the fight against HIV/AIDS in particular. You can read the statement in full here.

This statement of support comes at an interesting point in time. The Uganda Ministry of Health has just recently announced that a recent survey shows the prevalence of HIV has increased to 7.3% of adults, that’s about 1.2m people, more than double the number estimated 7 years ago.

In Uganda, with the support of Target TB, Touch Namuwongo (IMF) has improved access to health education and HIV testing in the community through outreach work. Here a fully trained community healthworker undertakes blood tests at a mobile clinic.

In June the Government of Uganda announced that the allocation of national budget to the Healthcare sector would be reduced from 9.8% in 2011/12 to just 7.6% this year. Depending on the exchange rate this is equivalent to about $307m.

In her statement, Blaser starts by reminding us that since 2004, the American people have invested over $1.7 billion in support of the national HIV response in Uganda. Most of this has been channelled through PEPFAR, for which we should always give a note of thanks to former President George W. Bush.

In 2003, Bush launched the President’s Emergency Plan for AIDS Relief (PEPFAR), pledging $15 billion to end the suffering and save lives threatened by the AIDS epidemic. In 2008, Congress agreed to provide $38 billion more.

In Uganda an estimated 600,000 people living with HIV need to be treated with ARVs but only 330,000 are currently receiving these life-saving drugs and of those the USA directly supports funding for 314,000. Antiretroviral treatment, ART, means that a person living with HIV can expect to live as long as their fellow countrymen who are HIV infection free.

We know that ensuring early and sustained access to ART for all those that need it will be a very significant intervention in the fight to reduce the growing numbers of new infections. So it is good to hear Blaser state:

the PEPFAR program in Uganda will review its programs to ensure that we prioritise treatment expansion to ensure all who need ART receive it

On July 5th Blaser stated that $425m will be given in Aid to boost Uganda’s health sector. This is more than 60% of the total Aid being given by USA to Uganda and is some 40% more than the GoU budget allocation.

That budget allocation is coming under increasing scrutiny. Blaser urges the GoU to increase the allocation to the 15% committed in the Abuja Declaration. Whether or not the country can afford to reach that target, it should perhaps be a little more circumspect before revealing that it spends some $150m to send VIPs overseas for healthcare treatment.

It is clear to me that fighting HIV is more than just about GoU budget or Aid from USA. That budget and Aid need to be used more effectively, we need to focus our attention on proven interventions that we know will work. Implementation will involve many different partners from all parts of the health sector and as Blaser says:

By working together, we can free Uganda from this terrible epidemic.  Let us all fight together for an “AIDS-free generation.”