Following the recommendation by global health agencies that MC be adopted as one of the critical tools for HIV prevention in high-prevalence generalized heterosexual epidemics [11
], WHO and UNAIDS developed operational guidelines for scaling up MC services [165
]. Programmatic development has, however, been slow, in large part as a consequence of suboptimal funding.
In 2008, researchers argued that the international community was not committing enough resources to MC commensurate with the available evidence on what works [166
]. These authors noted that the 5% allocated for MC, from an overall budget of $3.2 billion that UNAIDS had estimated was needed to achieve universal coverage for HIV programmes by 2010, fell far short of the estimated need and demand for MC, especially given its demonstrated efficacy relative to other interventions. Table summarizes the current state of MC intervention policy strategies, projected cost savings and infections averted, as well as MC provision to date in the 14 priority African countries. It can be seen that programmatic development of MC to date is ongoing in all countries, but differs markedly in extent [13
Design and implementation of MC services for HIV prevention in 14 priority countries in east and southern Africa, 2011
Implementation in Kenya, the first country to commence, was spearheaded by a national task force on MC in 2008 [14
]. Other countries have, or are in the process of developing similar policies, implementation guidelines and strategies. Some, like Kenya and Lesotho, have developed formal MC policies, while others, such as Botswana and Rwanda, have incorporated MC into existing HIV prevention policies. Translating science into policy is often challenging [168
], and we acknowledge that development of documents and programmes through consultative and collaborative processes involving stakeholders in the health ministries, HIV/AIDS agencies, non-governmental organizations, academia and donor partners, as was the case in Kenya, can be time consuming.
It is nevertheless of concern that the numbers circumcised across the various countries three years after policy recommendations are very low relative to targets (Table ). The latest WHO/UNAIDS report indicates cumulative circumcision figures up to 2010 since scale-up started in 2008 at 555,202, i.e., 2.7% of the 20.8 million target [167
]. That 74% (410,904) of these occurred in 2010 alone indicates that the momentum is rising, but needs to accelerate still. As the DMPPT modelling indicates, to achieve the projected outcomes, the 14 countries will need to reach 12 million circumcisions at peak period in 2012 [132
]. Accordingly, five countries (Malawi, South Africa, Tanzania, Uganda and Zimbabwe) would require at least one million circumcisions each in 2012 [132
In most of these countries, MC prevalence varies by region and it is logical that, in the scale-up phase, programmes for MC deliberately target low MC localities, such as is occurring in Ethiopia, Kenya and Namibia. However, many of the current programmes are confined to small or pilot settings. Data available for Lesotho are pre-scale up [169
]; for Zimbabwe, they are from several clinical sites [167
]; and for South Africa, they have scaled-up from Orange Farm [171
], where the RCT in that country was conducted, to over 140 sites [167
]. In Gambella, Ethiopia, services are currently provided in one hospital and seven health centres (personal communication, Hannah Gibson, Country Director Jhpiego, Ethiopia).
With a growing demand for MC services and the potential cost and life savings, it is imperative that scale up be rapidly accelerated [103
]. At the current rate of service provision, 12 million MCs by 2012 across the 14 countries are highly unlikely to be met, so putting in jeopardy many lives and failing to achieve the desired cost savings.
In Kenya, just 232,200 MCs have been completed [167
], the largest number of any country. A speeded-up rapid-results initiative intervention during a 30-day period in 2009 conducted by 95 teams, each of four persons, at a range of 9.6-22.8 circumcisions per team per day, achieved 36,000 circumcisions (Robert Bailey, personal communication). A similar intervention conducted over five weeks during November-December 2010 achieved 51,000 circumcisions (Robert Bailey, personal communication). At these rates, Kenya would need several similar rapid-results initiatives to reach the national goal of one million circumcisions by 2013 [172
]. Nevertheless, Kenya's programme is a model for other African countries and, if adopted, could advance the 2012 goal.
Many challenges stand in the way of implementing MC programmes. These include cost, need for training of health personnel, other health system barriers, the politics surrounding policy development, funding and changing socio-cultural perceptions and beliefs about MC [13
]. In Gambella, Ethiopia, the regional hospital reportedly cannot meet even a small demand of 10 circumcisions per week due to staff shortages and lack of training [173
Currently, the most informative assessment of MC programmes comes from Kenya [164
]. This report reveals that of 81 government health facilities surveyed in Nyanza (the target location of MC services), none had the capacity to implement the full package of voluntary circumcision outlined in the national guidelines [14
]. Challenges included lack of a theatre, MC kits and supplies, medical personnel to perform the procedure, and data monitoring tools. Due to this, most of the reported 230,000 circumcisions were done by partner organizations largely in high-demand settings using mobile teams [164
]. The Kenya programme offers many lessons for other countries.
Health provider training and service models being developed will need to be tailored around specific existing health systems and services infrastructure, HIV epidemiological profiles and determinants, as well as MC prevalence and demand. Reaching the estimated 100,000 men that need to be circumcised in Gambella, Ethiopia, for example, will require a massive increase in trained personnel to conduct the surgical procedure [173
]. Since MC programmes are targeting healthy men, high standards for surgical staff training and post-operative care are essential. This includes strictly following established national and international guidelines for sterile surgical practice [11
To increase the number of health personnel who can perform safe circumcisions, novel service models should be adopted. The rapid-results initiative pursued in Kenya is based on intensive mobilization of resources (human, equipment and financial) in high-demand settings through community approaches [164
]. Models for Optimizing the Volume and Efficiency of MC Services ("MOVE") is an additional approach for meeting demand. Currently practiced in South Africa, it is focused on increasing the efficiency of staff and time by considering alternate surgical methods and modifying facilities for efficient use [174
]. Consideration should also be given to promoting task shifting for nurses and clinical officers as per WHO guidelines [175
]. Already in practice in Kenya [164
] and Zambia [167
], it is a component of proposals in several other countries, such as Namibia, Lesotho [13
In some of the scale-up countries, traditional circumcisers, already used widely [72
], can play a role in meeting demand [176
], but only if they receive adequate certification for acceptable standards of surgical MC. On the other hand, as exemplified by the high (90%) preference among men and women for medical MC in a traditionally circumcising community from northern Tanzania, more efforts should be made to provide this medical service in a culturally appropriate fashion, so encouraging uptake [177
Preliminary data are also becoming available on devices that could facilitate quicker and safer adult circumcision [178
]. These include the Shang Ring [179
] (which produced good results for safety and acceptability in a field test in Kenya [180
]), circumcision template [181
], the recently acclaimed PrePex system [182
], and the Tara KLamp [183
], for which further assessment is needed [178
] after adverse effects were initially reported [184
]. In an important development, WHO has provided a framework for clinical evaluation of devices for adult MC [185
], in addition to those already recommended for infant MC [144