Voluntary Medical Male circumcision has been proven to be an evidence based route of HIV prevention . Its also envisaged that the cost of HIV treatment in the next ten year can be reduced by tenth fraction with an elaborate VMMC performed in two years. The uptake of VMMC is still not impressive in sub-saharan Africa. This slides present the evidence for the efficiency of VMMC in HIV prevention.

1. A.A.ADENIJI.
MB,BS; Mmed (stell); FCFP(sa).
Acting Family Physician
Bishop Lavis Day Hospital.

3. VMMC for HIV prevention

4.  Biological plausibility:
Inner surface of the
foreskin highly vulnerable
to HIV infection (Hussain LA,
Lehner T. Comparative investigation of
Langerhans cells and potential receptors
for HIV in oral, genitourinary and rectal
epithelia. Immunology. 1995;85:475–484.)
 A multi-country study* found
HPV infection was lower in
circumcised men and, as long
suspected, cervical cancer rates
were higher in the female
partners of uncircumcised men.
(New Engl J Med 2002, 346: 1105–1112.)
VMMC for HIV prevention

5. VMMC for HIV prevention
Low circumcision rate (<20% circumcised) High circumcision rate (>80% circumcised)
Country HIV prevalence Country HIV prevalence
Sub-Saharan Africa
Botswana 24.1 Benin 1.8
Malawi 14.1 Cameroon 5.4
Mozambique 16.1 Democratic Republic of Congo 3.2
Namibia 19.6 Gabon 7.9
Rwanda 3.1 Gambia 2.4
Swaziland 33.4 Ghana 2.3
Zambia 17.0 Guinea 1.5
Zimbabwe 20.1 Kenya 6.1
Liberia 5.9
Nigeria 3.9
Sierra Leone 1.6
South and Southeast Asia
Cambodia 1.6 Bangladesh <0.1
India 0.9 Indonesia 0.1
Myanmar 1.3 Pakistan 0.1
Nepal 0.5 Philippines <0.1
Thailand 1.4
.

6. VMMC for HIV prevention
Countries with low
prevalence of male
circumcision have
a higher prevalence
of HIV

7.  Study population: 3,274 HIV-negative men,
aged 18 to 24, in Orange Farm. Half assigned
to immediate circumcision.
 Results: Male circumcision reduced the risk
that men would contract HIV through
intercourse with infected women by about
61%.
Auvert B, Taljaard D, Lagarde E, et al. Randomized, controlled intervention
trial of male circumcision for reduction of HIV infection risk: The ANRS
1265 trial. PLoS Medicine 2005; 2(11): e298.
VMMC for HIV prevention

8.  Study population: 2,784 men aged 18–24
years in Kisumu, Kenya, randomly assigned
to intervention or control group.
 Results: Protective effect: 59%
 Adverse events rare: 1.5% experienced an event,
all resolved quickly
 No change in prevalence of risky behavior
observed.
Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV
prevention in young men in Kisumu, Kenya: A randomised
controlled trial. The Lancet 2007; 369: 643-656
VMMC for HIV prevention

9.  Study population: 4,996 uncircumcised, HIV-
negative men aged 15–49 years in Rakai,
Uganda, randomly assigned to immediate or
delayed procedure.
 Results: Protective effect: 51%
 HIV incidence was lower in intervention group in all
socio-demographic, behavioural, and STI symptom
subgroups.
 Moderate or severe adverse events occurred in 84
(3.6%) circumcisions; all resolved with treatment.
Gray, RH, Kigozi G, Serwadda D,et al. 2007. Male circumcision for HIV
prevention in men in Rakai, Uganda: A randomised trial. The Lancet; 369: 657-
666
VMMC for HIV prevention

10. WHO/UNAIDS technical consultation on male
circumcision and HIV prevention recommendations
 The 3 RCTs showed that male circumcision was safe
and reduced the risk of acquiring HIV infection by
approximately 60% and therefore:
 Male circumcision should now be recognized as an
efficacious intervention for HIV prevention.
 Male circumcision should be recognized as an additional,
important strategy for the prevention of HIV infection in
men.
 In 14 countries with generalized HIV epidemics (i.e., where
>1% of the population is HIV-positive) and low male
circumcision prevalence* prioritize scale-up of VMMC for HIV
prevention
VMMC for HIV prevention

11. VMMC for HIV prevention

12. WHO Minimum Package of VMMC Services
VMMC for HIV prevention

13.  VMMC integrated with other services
 Training and certification, with monitoring and
evaluation of programmes
 Full adherence to medical ethics and human
rights principles, including informed consent,
confidentiality, and absence of coercion.
VMMC for HIV prevention

14.  Target age groups at
highest risk of
acquiring HIV
(younger)
 Provide VMMC
services free of charge
or at lowest possible
cost
 More research needed.
VMMC for HIV prevention
PROPORTION OF HIV INFECTIONS AVERTED (2009-
2030) ATTRIBUTABLE TO VMMCs PERFORMED IN
EACH AGE GROUP AND PROPORTION OF VMMCS
PERFORMED IN EACH AGE GROUP

15.  Longer-term (4-5 years) follow-up of the Kenya and
Uganda RCT participants: Protective effect
sustained/increased
(Mehta SD, Moses S, Agot K, Odoyo-June E, Li H, Maclean I, Hedeker D, Bailey RC. The
long term efficacy of medical male circumcision against HIV acquisition. AIDS. 2013. doi:
10.1097/01.aids.0000432444.30308.2d)
 Community-level impact evaluation in South Africa
(Orange Farm) demonstrated 76% incidence reduction
 Rise of circumcision rate from 12% to 53% over 10 years
 HIV prevalence 19% lower for men in the
community,16.9% lower for women with circumcised
partner.
(Auvert B, Taljaard D, Rech D, Lissouba P, Singh B, Bouscaillou J, Peytavin G, Mahiane SG,
Sitta R, Puren A, Lewis D. Association of the ANRS-12126 Male Circumcision Project with
HIV Levels among Men in a South African Township: Evaluation of Effectiveness using
Cross-sectional Surveys. PLoS Med. 2013;10(9):e1001509. doi:
10.1371/journal.pmed.1001509)
VMMC for HIV prevention

16. VMMC for HIV prevention
 PLOS Collection 2011:the cost and impact of
scaling up VMMC: The potential cost savings
of scale-up are clear.
 An initial investment of US$1.5 billion
between 2011 and 2015 to achieve 80%
coverage of VMMC services in 14 countries
could result in net savings of US$16.5 billion
between 2011 and 2025

17.  The highly vascularized foreskin mucosa, which
is prone to tearing or bleeding during
intercourse (especially with the “dry sex”
practices common in Southern Africa), facilitates
HIV infection in uncircumcised men.
 Inner surface of the foreskin highly vulnerable to
HIV infection due to presence of HIV target cells
 Also, ulcerative STIs like HSV-2, chancroid and
syphilis, which are more prevalent in
uncircumcised men, facilitate HIV infection.
 Bacteria under foreskin raises risk of HIV
VMMC for HIV prevention

18. Prevention of Herpes
Simplex Virus-2 (-25%)
and Human
Papillomavirus (HPV) (-
35%):
 Inner foreskin micro-
tears and lightly
keratinized skin layer
facilitate virus entry.
 Moist environment
facilitates virus
survival.
VMMC for HIV prevention

19. VMMC for HIV prevention
Lack of
circumcision
Increased risk of
HIV
Increased risk of
STIs

20. VMMC for HIV prevention

21. . International Journal of Science and Research (IJSR)
 ISSN (Online): 2319-7064
 Index Copernicus Value (2016): 79.57 | Impact Factor (2015): 6.391
 Volume 7 Issue 2, February 2018
 www.ijsr.net
 Licensed Under Creative Commons Attribution CC BY
 Book Review: Circumcision: A History of the
 World’s Most Controversial Surgery
 (ISBN10:0465026532/ISBN13:9780465026531, Published by Basic books, New York, USA; 2001, cost: $14.00)
 Adeloye Amoo Adeniji
 Brackenfell -7560, Western Cape, Cape Town, South Africa
 This ten chaptered, fully referenced book was written by a celebrated American medical historian “David Gollaher”. The
 strength of this book lies in its ability to explore the various cultural, religious, mythical and anthropological concepts of
 circumcision. Gollaher discusses the pre-historic origins of the procedure as a religious sacrifice, cultural rite of passage from
 adolescence to manhood, ritual for virility or fertility, protection from evil, emblem of higher social status or a sexual
 punishment. During history several cultures and religions have embraced circumcision, such as ancient Egypt, the Jewish faith
 and Islam.
 Gollaher also discusses the current ethical dilemmas surrounding the act of circumcision by exploring the views of opponents
 and advocates of circumcision in modern medicine.
 Gollaher is unable to keep his stand as an opponent of male circumcision for long. He argues his point from the social and
 cultural values placed on genital markings for both male and female in chapter six. He sees the unequal criticism placed on
 both markings as elements of paradigm shift which is socially unacceptable. He, however, is unable to equate both markings
 from the context of scientific benefits.
 As a specialist in family medicine, I have performed well over a thousand medical male circumcisions in South Africa. Many
 of my patients often ask the question: When should I bring my child for the operation? This question is often asked with
 mixed feelings ranging from guilt of coming too late to the joy of being circumcised after all. This book provides no answer to
 why the uptake of male circumcision is still unimpressive even in this twenty first century medicine, when the health benefits
 of the procedure are so obvious and voluntary medical circumcision is hugely promoted in southern Africa.
 This volume deserves a wide readership by the medical community

22.  These information is an excerpt from work of
JPS Africa and other articles that are therein
referenced.
 The author will not take responsibility for
misuse or misinterpretation of the information
provided.