IMPLEMENTING THE
                 2017–2021 FRAMEWORK
                 FOR VOLUNTARY MEDICAL
                 MALE CIRCUMCISION

                 27 FEBRUARY–1 MARCH 2017
ISBN : 978-929023405-0
                                     © WHO Regional Office for Africa 2017
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                  Printed in the WHO Regional Office for Africa, Brazzaville, Republic of Congo

List of acronyms                                                                                                                  ii
List of acronyms of organizations                                                                                                 1
    Meeting objectives                                                                                                             3
Presentations, summaries and priority actions	                                                                                    4
    Day 1	                                                                                                                         4
    Day 2                                                                                                                         13
    Day 3                                                                                                                         27
Meeting conclusions             38
Annex 1. – Youth advocacy brief                     39
Annex 2. – List of participants                                                                                                   41

Figure 1: Key milestones in VMMC for HIV prevention                                                                                4
Figure 2: Overview of VMMC implementation progress in 14 countries in eastern and southern Africa                                  5
Figure 3. N
           umber of VMMCs conducted through 2015 in 14 priority African countries, with estimated target number
          required to reach 80% male circumcision                                                                                  5
Figure 4: Decrease in VMMC uptake by age in Tanzania                                                                               7
Figure 5: Malawi national policy documents                                                                                         8
Figure 6: Global HIV targets                                                                                                       9
Figure 7: Relative impact of scaling up VMMC – based on modelling                                                                 10
Figure 8: UNAIDS Fast-Track MC targets                                                                                            10
Figure 9: Years of life lost among men in eastern and southern Africa, according to age group and cause (2013)                   11
Figure 10: Influences and stages of the journey to VMMC                                                                           13
Figure 11: Overview of implementation science studies in Tanzania, Kenya and South Africa                                         14
Figure 12: HIV testing results for VMMC clients at male clinic in Scott Hospital, Lesotho                                         15
Figure 13: Defining and locating the world of work                                                                                16
Figure 14: VMMC among men aged 20–29 years in 2015 and 2016, by priority country in Africa                                        17
Figure 15: Results of policy scans by Sonke Gender Justice                                                                        18
Figure 16: Current activities in the ASRH–VMMC Linkages pilot project, Zimbabwe                                                   20
Figure 17: Successes of the Youth Psychosocial Support Programme in South Africa                                                  23
Figure 18: Scale and sustainability of using soccer to increase uptake of VMMC                                                    24
Figure 19: Community entry model and elements of Lihawu Camps                                                                     25
Figure 20: Key actors for sustainability of VMMC programmes                                                                       29
Figure 21: Conclusions on condoms and VMMC                                                                                        30
Figure 22: Decision-making around the introduction of the human papilloma virus vaccination                                       31
Figure 23: Availability and accessibility of VMMC services based on data from human resource information systems in Mozambique   32
Figure 24: Lessons learnt from VMMC implementation and possible mitigating measures                                               34
Figure 25: Sample data analysis outputs on resource needs and availability by strategic pillar, Zimbabwe                          35

Table 1: Framework for exploring minimum service package in Kenya                                                                 21

     WHO would like to thank the participants and presenters of this
     regional meeting on implementing the 2017–2021 framework for
     voluntary medical male circumcision. The valuable contribution of
     young people is especially recognized.

     WHO would also like to thank Raymond Yekeye who served as
     principal reporter.

     This report was prepared by Raymond Yekeye, Buhle Ncube,
     HIV Prevention Focal Point, WHO AFRO, and Julia Samuelson,
     Department of HIV and Global Hepatitis Programme, WHO, Geneva.

     AA-HA!		     Global Accelerated Action for the Health of Adolescents
     AIDS 		      acquired immunodeficiency syndrome
     ART			antiretroviral therapy
     ASRH			      adolescent sexual and reproductive health
     DMPPT 		     Decision-Makers’ Program Planning Tool
     HIV			       human immunodeficiency virus
     HPV			       human papilloma virus
     MC			male circumcision
     MoH			       ministry of health
     NGO			nongovernmental organization
     NSP			       national strategic plan
     SDGs			      Sustainable Development Goals
     SRH			       sexual and reproductive health
     STI			       sexually transmitted infection
     VMMC		       voluntary medical male circumcision

AFRIYAN 		   African Youth and Adolescent Network on Population and Development
AFRO			      WHO Regional Office for Africa
BMGF 		      Bill and Melinda Gates Foundation
CAPRISA 		   Centre for the AIDS Programme of Research in South Africa
CDC 			      Centers for Disease Control and Prevention
CHAPS 		     Centre for HIV and AIDS Prevention Studies
COSECSA      College of Surgeons of East, Central and Southern Africa
ICAN 			     Infection Control Africa Network
ICAZ 			     Infection Control Association of Zimbabwe
ILO 			      International Labour Organization
JHCCP 		     Johns Hopkins Center for Communication Programs
Jhpiego 		[This is no longer a formal acronym. Jhpiego is an international non-profit
           health organization affiliated with Johns Hopkins University.]
OGAC 		      Office of the US Global Aids Coordinator
PEPFAR 		    United States President’s Emergency Plan for AIDS Relief
PSI 			      Population Services International
SafAIDS 		   Southern Africa HIV and AIDS Information Dissemination Service
UNAIDS 		    Joint United Nations Programme on HIV/AIDS
UNESCO		     United Nations Educational, Scientific and Cultural Organization
UNFPA		      United Nations Population Fund
UNICEF		     United Nations Children’s Fund
USAID 		     United States Agency for International Development
WHO			       World Health Organization

    This report provides an overview of proceedings of a meeting held 27 February–
    1 March 2017 in Durban, South Africa attended by 135 participants from different
    levels of various organizations, including from 14 voluntary medical male circumcision
    (VMMC) priority countries in eastern and southern Africa1. The meeting sought to share
    information on progress, successes, impact and lessons learnt in scaling up national
    VMMC programmes. It also provided a platform for updates on strategy and technical
    aspects of VMMC interventions, including the 2017–2021 framework, new guidance
     and key initiatives for adolescent boys’ and men’s health. The meeting sought to
    identify strategic actions, gaps, challenges and possible solutions for continued VMMC
    programme scale-up and sustainability. A further key objective was to agree on priority
    directions and key country-specific actions for national leadership of programmes.
    Participants included government officials, communication experts, implementation
    researchers, adolescent and young men, women, traditional leaders, and
    representatives from nongovernmental organizations (NGOs), community-based
    organizations, implementing agencies and development partners (see Annex 3
    for a full list of participants).

                                                   1	Botswana, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, South Africa,
                                                      South Sudan, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe.

By end 2016 over 14 million2 men had been                                       With this intention two meetings were held 27 February–
circumcised for HIV prevention in eastern                                       3 March 2017 in Durban, South Africa. The first meeting
and southern Africa.                                                            (27 February–1 March 2017) was attended by all
                                                                                participants (see Annex 3) and the proceedings and
It is estimated that these male circumcisions (MCs)                             main outcomes are summarized in this report. The second
will avert around 500 000 HIV infections through 2030.                          meeting (2–3 March 2017) was attended by 33 participants
Efforts to scale up national VMMC programmes have                               (out of the 135 who took part in the first meeting),
been enabled through the development of national                                including VMMC focal points from the ministries of health
policies on MC, investments in service delivery,                                in the 14 priority countries and from the WHO country
widespread communication and demand generation                                  offices, as well as representatives from WHO headquarters,
along with the engagement of many partners and                                  the WHO Regional Office for Africa and the Intercountry
communities. Experience from VMMC programmes in 14                              Support Team for Eastern and Southern Africa. This second
priority countries in eastern and southern Africa has shown                     meeting was held to provide a forum for further discussion
high uptake among adolescent boys in particular. The men                        of key issues emerging from the first three-day meeting,
and boys reached through VMMC programmes have also                              including technical support needs and the way forwards
been provided with a minimum level of safer sex education,                      in scaling up VMMC.
offered condoms and HIV testing, and been assisted with
the management of sexually transmitted infections.
As a follow-on to the Joint Strategic Action Framework
to Accelerate the Scale-Up of Voluntary Medical                                    Meeting objectives
Male Circumcision for HIV Prevention in Eastern                                    The objectives of the 27 February–
and Southern Africa 2012–2016 UNAIDS and WHO put                                   1 March 2017 meeting were to:
forward new strategic directions with a focus on adolescent
boys and young men in the Framework for Voluntary                                  i.	Share progress, successes, impact and lessons
Medical Male Circumcision: Effective HIV Prevention                                    learnt in scaling up VMMC.
and a Gateway to Improved Adolescent Boys’ and                                     ii.	Provide updates on strategy and technical
Men’s Health in Eastern and Southern Africa by 2021,                                    aspects of VMMC, including the framework,
the targets of which are aligned with the UNAIDS                                        new guidance and key initiatives for adolescent
Fast-Track goals, namely:                                                               males and other men.
i)	90% of males aged 10–29 years will have been                                   iii.	Identify strategic actions, gaps, challenges and
    circumcised in priority settings in sub-Saharan Africa                               possible solutions for continued scale-up and
    as part of integrated sexual and reproductive health                                 sustainability of VMMC.
    services for males;
                                                                                   iv.	Agree on priority directions and country-specific
ii)	90% of males aged 10–29 years will have accessed                                   key actions for national programme leadership.
     age-specific health services tailored to their needs.

Modelling done in 2014–15 showed that an intensified
focus on younger men aged 15–29 years was required
for VMMC programme efficiency and to achieve the most
immediate impact on the HIV epidemic. Efforts have been
underway to expand the evidence on how to operationalize
VMMC services for adolescents while simultaneously
accelerating scale and reach to higher-risk and young
men. Thus, the need was expressed by many stakeholders
to reflect on progress, challenges, lessons learnt and
opportunities to inform future VMMC programmes.

2 	The finalized figure for 2016 is a total of 14.5 million VMMCs performed,
    of which 2.8 million in 2016.

    DAY 1                                                      The official opening ceremony was presided over by
                                                               the WHO Country Representative for South Africa, Dr R.
    OPENING SESSION                                            Chatora, along with Mr C. Bonnecwe and Dr R. Ndaba from
                                                               the South African Department of Health, who work at the
                                                               national and provincial levels respectively.

                                                               The speakers highlighted the main successes achieved to
                                                               date by the VMMC programme in South Africa, which not
                                                               only provides men with access to MC services but also links
                                                               them to other relevant health services. The programme
                                                               has leveraged existing partnerships, particularly with the
                                                               private sector and other health programmes, to facilitate
                                                               the achievement of results. Challenges around data
                                                               collection and data quality, low VMMC uptake by older
                                                               men and the quality of services provided by traditional
                                                               circumcision providers need to be further addressed.

     Share progress, successes, impact and lessons learnt in scaling up VMMC

    Setting the scene (B. Ncube, WHO)
    WHO presented the context for the meeting and made reference to some of the key VMMC milestones that have been
    achieved to date (see Fig. 1).

    Figure 1 Key milestones in VMMC for HIV prevention

       HIV prevention research:                                                       Implementation in 14
       – Observational data                                                           priority countries of
       – Durban IAS2000                                                               East & Southern Africa
       – global consensus to conduct RCTs

       1989       2000           2005 – 2007            2007                   2007 – today

                                  Kenya, Uganda,
                                  South Africa trials

                                   UNAIDS and WHO Global Recommendations

     Almost 12 million VMMC procedures were performed                                                                              452 000 HIV infections by 2030, and the median cost per
     in eastern and southern Africa by end 2015. This figure                                                                       HIV infection averted of US$ 3800 demonstrates the cost-
     increased to more than 14 million3 in 2016, which is almost                                                                   effectiveness of VMMC. Figure 2 provides an overview
     two thirds of the target of 20.8 million MCs set within the                                                                   of the number of VMMCs performed in the 14 priority
     initial VMMC framework in 2011. The more than 12 million                                                                      countries in eastern and southern African in the period
     MCs performed by end 2015 will avert an estimated                                                                             2008–2015.

     Figure 2 Overview of VMMC implementation progress in 14 countries in
     eastern and southern Africa

                                                    Cumulative total: 11 685 591 through 2015
                                3 000
                                                       Botswana             Rwanda

                                                       Ethiopia             South Africa
                                2 500
Number of circumcisions (000)

                                                       Kenya                Zwaziland

                                                       Lesotho              Uganda

                                2 000                  Malawi               United Rep Tanzania

                                                       Mozambique           Zambia

                                                       Namibia              Zimbabwe
                                1 500

                                1 000


                                             2008              2009             2010              2011           2012               2013            2014         2015


     Most countries did not meet the 80% VMMC coverage                                                                             Africa 2012–2016. South Africa, Kenya, Uganda and
     target set within the Joint Strategic Action Framework                                                                        Tanzania contributed the highest number of MC procedures
     to Accelerate the Scale-Up of Voluntary Medical Male                                                                          in 2015 (see Fig. 3).
     Circumcision for HIV Prevention in Eastern and Southern

     Figure 3 Number of VMMCs conducted through 2015 in 14 priority African countries,
     with estimated target number required to reach 80% male circumcision
                                                    VMMCs through 2015
  Millionsof VMMCs


                                                   in ,












                                                 ov ia



                                                                                                                           r ic


                                              P r io p






                                      t sw





                                           lla Eth








     3 	The finalized number for 2016 is a total of 14.5 million VMMCs performed, of which 2.8 million in 2016.

    In the 14 priority African countries, through 2015, 32%        Perspectives and experiences of young
    of VMMCs were performed in the 10–14-year age group.
    These circumcisions alone will contribute to a 16%
                                                                   people (L. Mosooane, AVAC; J. Kayombo,
    reduction in the number of new HIV infections which            AFRIYAN)
    would have occurred through 2030.                              This session provided the floor for young people – who
                                                                   are key for the success of VMMC programmes – to share
    34% of VMMCs through 2015 were performed among
                                                                   their perspectives. AVAC and AFRIYAN highlighted the
    adolescents aged 15-19 years; these will avert an
                                                                   importance of ensuring young people are fully involved in
    estimated 35% of new HIV infections through 2030.
                                                                   consultations as well as in programming/implementation so
                                                                   that VMMC programmes are relevant. In addition, reference
    Lessons learned
                                                                   was made to the critical role played by women and girls in
    Lessons learnt from implementing the Joint Strategic           decision-making around VMMC for adolescent boys/young
    Action Framework to Accelerate the Scale-Up of Voluntary       men. Moreover, during the design and implementation of
    Medical Male Circumcision for HIV Prevention in Eastern        programmes careful consideration needs to be given to
    and Southern Africa 2012–2016 include the importance of        social norms and structures. Experience has shown that
    working within country-specific contexts and investing in      adolescent boys and young men have been left out of
    innovation to increase the scope of success. The centrality    programmes on sexual and reproductive health (SRH) or
    of sustained national leadership for programme success         gender-based violence and gender equality, despite the
    was also recognized. Key lessons further illustrated           fact that they exert a tremendous influence over girls.
    that different demographic groups are influenced in            Interaction between boys and girls is a fundamental
    varying ways, requiring age-specific communication             requirement if there is to be better understanding of
    tools and messaging. Strategic information was critical in     gender equality and sexual violence at the societal level.
    supporting programme implementation and scale-up; thus,        Therefore, it is essential to involve boys and young men
    strong monitoring and evaluation (including collecting         in programmes on gender equality and gender-based
    and analysing disaggregated data) was important for            violence. SRH interventions also need to be designed for
    facilitating informed decision-making. Another lesson          and targeted at both adolescent boys and girls, bearing in
    was that programme success is dependent on strong              mind their similarities and differences. Furthermore, efforts
    multi-stakeholder efforts and coordination, including          should be made to provide timely and correct information
    partnerships with civil society organizations and at all       about SRH to young people. Finally, it was highlighted that
    levels of the national health system.                          programme design and implementation approaches should
                                                                   be built on the understanding that VMMC is a gateway to
    Challenges                                                     other services, for example HIV testing services.
    Key challenges faced in implementing the 2012–2016
    joint strategic action framework were primarily around
    generating demand for VMMC services among men
    aged 24 years and above. Insufficient research has been
    conducted on the barriers to service uptake among this
    population. In addition, leadership at the subnational level
    has been limited – or when available was unsustainable
    – which has affected progress, especially as leadership at
    all levels is fundamental for programme success. Further,
    human resource shortages affected progress, especially
    where programmes were predominantly physician-led,
    compared to those settings where task-sharing efforts
    resulted in the inclusion of other cadres.

  Country presentations (K. Serrem, Kenya Ministry of Health (MoH); Zambia MoH; G. Lija,
  Tanzania MoH; Malawi MoH)
  This session provided perspectives from the VMMC programmes in Kenya, Tanzania, Malawi and Zambia. One common
  observation was that uptake of VMMC decreases with age, as evidenced in Tanzania (see Fig. 4), Malawi and Zambia.

  Figure 4 Decrease in VMMC uptake by age in Tanzania


VMMC/Age group




                           10-14 Yrs   15-19 Yrs   20-24 Yrs      25-29 Yrs     30-34 Yrs     35-49 Yrs      50+ Yrs

                 FY 2014   234699      135887       59581          24360         15581         13747           2834
                 FY 2015   205410      131983       61871          27648         18049         15926          3402

                 FY 2016   177207       99054       45395          20655         12429         10839           2026
                 FY 2017    4954        3534        1640            737           448           358             72

  In all four countries: discrepancies were experienced               innovative demand creation. Data issues – discrepancies
  between partner data and data from district-level health            between partner data and data from district-level health
  information systems; there are plans for the introduction           information systems – have not yet been resolved; and the
  of tetanus mitigation measures; and consideration is being          community VMMC coverage survey planned for 2016 is
  given to providing early infant male circumcision services.         still to be undertaken.

  In summary, the following country-specific progress has           • Zambia: 75% VMMC coverage has been achieved.
  been made:                                                          Success is attributable to good partner coordination and
                                                                      resource leveraging through regular technical working
  • Kenya: although a phased approach to implementation               group meetings and planning; task shifting; robust
    of the national VMMC programme has been adopted,                  community demand generation; involvement of traditional
    there has already been an impact on HIV incidence                 and community leaders and women; harmonization
    as reported in Kenya’s VMMC impact evaluation. This               between partner reporting and data from the national
    success has been attributed to: political engagement and          health information system. However, there have been
    MoH leadership (technical working groups) at all levels;          challenges with competing health priorities, the lack of
    stakeholder engagement, especially cultural and traditional       data disaggregated by age group or data on adverse
    leaders in non-circumcising communities; the availability         events, and inadequate infrastructure.
    of a national strategy with subnational targets; and

    • Tanzania: Successes are attributable to: task shifting,      • Malawi: Successes were attributed to the availability of a
      which has permitted nurses to perform VMMC; large-scale        national policy on VMMC, an operational plan, guidelines
      public awareness campaigns; MoH ownership – with an            and standard operating procedures (see Fig. 5). Challenges
      operational plan through 2017; and partner support for         included an inadequate number of trained providers to
      implementation. Challenges have included: inadequate           routinely offer VMMC services, few implementing partners
      capacity for waste management, especially disposable           to cover all priority districts, seasonality of demand as well
      instruments; implementation in 2015 was only in the            as inadequate infrastructure (limited spaces in facilities
      PEPFAR-supported Scale-Up Districts, which resulted in         and some geographical areas being hard to reach)
      lower numbers of MCs performed; discrepancies between          and data management (limited submission of data by
      data issued by the national health information system          partners to MoH).
      and that used by implementing partners.

    Figure 5 Malawi national policy documents

    Partners panel (C. Toledo, PEPFAR;                             creation. Experience has shown that VMMC is a fast-
                                                                   moving programme, hence there is a need for flexibility
    M. Sundaram, BMGF; A. Kaggwa, AVAC;                            to put in place learning and sharing mechanisms that
    C. Laube, Jhpiego)                                             facilitate rapid scale-up of approaches that are effective.
    This session provided opportunities for reflection by          Appropriate target setting, sustained resource mobilization
    partners on progress made in the implementation of VMMC        and a consistent commitment to implementation are key
    programmes in the 14 priority countries and discussion on      factors for success. The panel recommended ambitious
    the implications of current results on future programming.     VMMC targets be tied to funding, which is necessary to
    The presenters stressed that even though the 80%               provide motivation for intervention success. Challenges
    target set out in the Joint Strategic Action Framework         around financial and technical sustainability were flagged,
    to Accelerate the Scale-Up of Voluntary Medical Male           highlighting the need to further strengthen the capacities
    Circumcision for HIV Prevention in Eastern and Southern        of national VMMC programmes. Sustainability is more
    Africa 2012–2016 had not been reached in most countries,       probable if there is a diversification of the resource base;
    major milestones had still been achieved in mainly difficult   thus, there is a need to strengthen linkages between
    operating environments with competing health priorities.       VMMC programmes and other services and sectors as well
    A key theme that has emerged is that demand creation           as geographic coordination between implementing partners
    is fundamental to programme success. Formative work            to avoid competition.
    and strong partnerships are needed for improved demand

  New strategies and technical updates

UNAIDS targets and strategies in the context                   Three Frees: Start Free, Stay Free, AIDS Free
of the Sustainable Development Goals (SDGs)                    (P. Nary, UNICEF)
and engaging adolescents and men (P.                           It is important that the different United Nations HIV
Somse, UNAIDS)                                                 prevention frameworks work together to avoid duplication
                                                               and to collectively advance towards the goal of zero HIV
VMMC is included in the fourth pillar (Reduce inequality
                                                               infections and an AIDS-free generation. The Three Frees is
in access to services and commodities) of the UNAIDS
                                                               a collaborative agenda between UNAIDS and PEPFAR. It is
2016–2021 Strategy (On the Fast-Track to End AIDS), where
                                                               a fast-track policy and delivery framework for ending AIDS
it is recognized as a game changer. The pillar and related
                                                               among children, adolescents and young women by 2020.
target (90% of women and men, especially young people
                                                               VMMC is part of the Stay Free component. The key next
and those in high prevalence settings, have access to HIV
                                                               steps are to encourage ministers of health and stakeholders
combination prevention and SRH services) provide the basis
                                                               to adopt this framework, align existing resources and
for pursuing sustainability. Technical aspects of programme
                                                               develop implementation plans.
implementation need to be distinguished from nontechnical
components. There is no such thing as a single issue
struggle because we do not live single issue lives.            HIV and AIDS: Framework for Action in
                                                               the WHO African Region 2016–2020
                                                               (F. Lule, WHO/AFRO)
                                                               This framework for action includes five strategic
                                                               directions: i) country ownership, ii) effective partnerships,
                                                               iii) universal health coverage, iv) integration of HIV and AIDS
                                                               in national health systems and strategies, v) a public health
                                                               and people-centred approach. It further includes guidance
                                                               on prioritization – especially high-impact prevention
                                                               interventions, eliminating HIV in infants, expanding
                                                               ational HIV testing services, accelerating the scale-up
                                                               of antiretroviral medicines for treatment and prevention,
                                                               and early detection and treatment of coinfections.

Figure 6 Global HIV targets – Towards the global HIV targets for 2020 and 2030

  Reaching the 2020 targets requires accelerating the integrated public health approach that enabled the achievements of
  the past 15 years. The proposed WHO Global Health Sector Strategy on HIV 2016-2021 charts such a response.

                             2.0 million                               1.2 million                               15.8 million
                                 (2014)                                    (2014)                                (mid-2015)

                                                                       < 500 000
                             < 500 000                                    (2020)
                                (2020)                                                                           � 30 million
                                                                       < 400 000                                      (2020)
                             < 200 000                                    (2030)
                                (2030)                                                                           � 37 million

    Annual number of people newly           Annual number of people dying from              Annual number of people
          infected with HIV                         HIV-related causes                           receiving ART

      Age, risk and geography modelling to inform                                                costs. In 2016 WHO and UNAIDS held a meeting to
                                                                                                 consolidate the findings from the diverse models.
      VMMC strategy and targets (T. Farley,                                                      The models consistently showed that VMMC programmes
      consultant for WHO)                                                                        that reach males aged 15–29 years and males at higher
      Models used earlier to estimate the impact and cost of                                     sexual risk of HIV infection (such as those with multiple
      VMMC programmes have been updated and new models                                           partners) will have the most immediate impact on
      developed. These models use more precise age groups,                                       the AIDS epidemic, followed by boys aged 10–14 years.
      updated HIV incidence estimates and lower HIV treatment

      Figure 7 Relative impact of scaling up VMMC – based on modelling
                                                                                                                                       Reduction in HIV incidence
                                                                                                                                       by age group, 2014–2050.
                                                                                                                                       Each line represents HIV incidence
                                                                                                                                       ratio under scenario in which
                                                                                                                                       only indicated 5-year age group
                                         a                                                                                             circumcised. Marker a represents
     HIV incindence ratio

                                                                                                                                       5-yr period from 2014. Marker
                                                                                                                                       b represents a 15-yr period
                                                       b                                                     Age group                 from 2014.

                            0.6                                                                                          20–24
                            0.5                                                                                          35–39
                                  2013   2018   2023       2028      2033   2038   2043   2048


      VMMC coverage, modelling and translation                                                   Figure 8 UNAIDS Fast-Track MC targets
      of results to inform national strategies (P.                                               Estimated number of circumcisions required by country to
      Stegman, Avenir Health)                                                                    achieve 80% or 90% coverage in 10-29 yr age group by 2020
      The Decision-Makers’ Program Planning Tool (DMPPT),                                         Country                        % in 2015      Target 80%     Target 90%
      developed in 2009 for advocacy purposes, was used to                                        Botswana                       31%            240,000        280,000
      generate initial estimates on HIV infections averted by MC
                                                                                                  Ethiopia (Gambela)             75%            10,000         19,000
      at diverse coverage levels. A second version of the DMPPT,
                                                                                                  Kenya (Nyanza)                 72%            290,000        505,000
      developed in 2011, was used for strategic planning in nine
      African countries with national VMMC programmes and by                                      Lesotho                        69%            55,000         100,000
      the Government of the United States of America (PEPFAR)                                     Malawi                         26%            2.5 million    3.0 million
      in the formulation of country operational plans and for                                     Mozambique                     57%            2.2 million    2.9 million
      monitoring purposes. Achieving the Fast-Track 90–90–90                                      Namibia                        27%            310,000        370,000
      HIV prevention goals requires 90% VMMC coverage among
                                                                                                  Rwanda                         35%            1.3 million    1.6 million
      males aged 10–29 years (see Fig. 8) and health services
                                                                                                  South Africa                   56%            2.7 million    3.9 million
      that are tailored to the needs of specific age brackets.
                                                                                                  South Sudan                    26%            1.8 million    2.1 million
                                                                                                  Swaziland                      32%            150,000        180,000
                                                                                                  Uganda                         53%            3.6 million    4.6 million
                                                                                                  Tanzania                       84%            1.1 million    2.4 million
                                                                                                  Zambia                         37%            2.0 million    2.4 million
                                                                                                  Zimbabwe                       22%            2.2 million    2.6 million
                                                                                                  Total                                         20.4 million   26.8 million

                                                                                                 Source: UNAIDS

 Framework on VMMC: effective HIV                                                           of 90% circumcision coverage among males aged 10–29
                                                                                            years and broadening the range of age-specific health
 prevention and a gateway to improving                                                      services offered to this same age group. How to integrate
 adolescent boys’ and men’s health                                                          VMMC services into broader health and development
 (J. Samuelson, WHO)                                                                        aspirations and systems needs to be determined to ensure
                                                                                            sustainability. The Framework is based on three principles:
 WHO presented on the new landscape in which VMMC
                                                                                            a people-centred approach, gender-based perspective
 implementation is situated and how the new Framework
                                                                                            and enhancing partnerships.
 on VMMC is aligned with the SDGs and other global
 health strategies. It builds on the two Fast-Track targets

 Figure 9 Years of life lost among men in eastern and southern Africa,
 according to age group and cause (2013)
                                eastern Africa                                               southern Africa
                                                                                                                               Other non communicable diseases
                                                                                                                               Other infectious diseases
              70                                                                                                               Alcohol & drug use disorders

                                                                                                                               Interpersonal violence
              40                                                                                                               Self-harm
              30                                                                                                               Unintentional injuries
               0                                                                                                               Tuberculosis
                   10-14   15-19     20-24       25-29       15-49          10-14         15-19   20-24   25-29   15-49
                                     YEARS                                                        YEARS

        Six causes (HIV, tuberculosis, violence, self-harm, injuries and alcohol or drug misuse) contribute more than 80% of
        years of life lost among men aged 15-49 years in southern Africa, and more than 60% in eastern Africa.

 Source: Prepared by the authors, based on the Global Burden of Disease Study 2013 (3).

 The Framework has four strategic directions:                                               3. I nnovations for accelerations and the future.
                                                                                                Health policies need to be established that better
 1. F ocused action for scale-up. Using strategic                                              address the needs of men and boys, including
     information to determine among which population                                            supportive policies from other sectors such as
     groups and geographic areas to focus and tailor VMMC                                       sports and gender. Investing in new coalitions and
     interventions is essential for impact, as noted in the                                     partnerships is essential for programme success.
     modelling results. Age groups should be prioritized,                                       Research on implementation and operations can inform
     especially the age bracket 10–29 years. Priority                                           improvements in service delivery. Creating a culture
     should also be given to males at higher sexual risk                                        of health care seeking behaviour will require learning
     of HIV infection.                                                                          about and changing demand generation approaches,
 2. P
     olicies and services for greatest impact.                                                 including the effective use of relevant media.
    Male-friendly health service delivery approaches                                        4.	Accountability for quality and results. Results must
    must be enhanced along with relevant age- and risk-                                         be evaluated across programmes and sectors, including
    specific packages of services.                                                              the effectiveness of partnerships. Countries need to
                                                                                                put strong national monitoring and quality assurance
                                                                                                systems in place within the next five years and expand
                                                                                                their financial resource portfolios.

     Manual for male circumcision under                                               containing vaccine (two doses sufficiently timed for
                                                                                      protection) should be administered before the elastic
     local anaesthesia, second edition                                                collar compression method (PrePex) is used. WHO also
     (M. Mahomed, Jhpiego)                                                            recommends vaccination programmes add tetanus-toxoid-
     Jhpiego provided a brief overview of the revisions that                          containing vaccines (boosters) for adolescent boys 4.
     will be made in the second edition of the Manual for male                        The WHO schedule for provision of both tetanus-toxoid-
     circumcision under local anaesthesia. These revisions are                        containing vaccines for adolescent boys and girls and
     based on the last 10 years of experience with over 14                            human papilloma virus vaccinations for girls is now aligned
     million MCs performed in eastern and southern Africa.                            to during the ages 9–15 years. Also, awareness should be
     It includes revised and rearranged chapters geared towards                       raised among individuals and communities about clean
     improving quality and safety. WHO recommendations have                           wound care so that substances such as dung, which may
     been incorporated from guidance on infection prevention                          contain spores, are not used. VMMC in general remains
     and control, including hand hygiene and safe injection                           a safe procedure with a low rate of adverse events.
     practices, as well as new surgical recommendations.
                                                                                      Youth advocacy workshop
     VMMC methods, tetanus risk and mitigation                                        Fourteen youth advocates, selected through a nomination
     through tetanus-toxoid-containing                                                process carried out by AFRIYAN, attended the meeting as
     vaccination (J. Samuelson, WHO)                                                  part of their country teams. Their role was to contribute
                                                                                      the perspectives of adolescent boys and young men
     WHO has monitored the safety of MC methods, including                            and advocate for responsive VMMC programming.
     new device-based methods. The PrePex (elastic collar                             In collaboration with AVAC and AFRIYAN, the youth
     compression) and the Shang Ring (collar clamp) have been                         advocates developed key advocacy messages to encourage
     prequalified by WHO for use among males aged 13 years                            policy-makers and programme implementers to give further
     and over. Less than 4% of the more than 14 million VMMCs                         attention to adolescent boys and young men in the HIV
     performed to date were done using devices; the majority                          response and make full use of the opportunity that VMMC
     were performed with conventional surgical methods.                               provides to address their broader health needs. The young
     Between 2012 and mid-year 2016, 16 cases of tetanus                              participants used these messages for advocacy throughout
     were reported. A difference in risk was noted by                                 the three-day meeting. The messages were further
     circumcision method. For example, there was a 30-fold                            developed into an advocacy note for youth organizations
     increased risk of tetanus with the use of the elastic                            to use at the country and international levels. (See Annex 1
     collar compression method. Mitigation of this tetanus                            for a full report on the youth advocacy workshop.)
     risk is possible. The WHO position, issued after two
     advisory group consultations, is that a tetanus-toxoid-

     4 	WHO Weekly Epidemiological Record,10 February 2017, vol. 92, 6 (pp.53–76).

  Evidence, lessons and promising practices to actions

Demand creation (L. Van Lith, JHCCP; C.                                      encouraging implementing partners to focus on age pivots
                                                                             (ages of highest priority for HIV incidence reduction)
Laube, Jhpiego; D. Taljaard, CHAPS; C.                                       through differential reimbursements. Typically, there
Toledo, CDC; A. Machinda, PSI Zambia)                                        are multiple steps in a person’s progression to changed
This session provided an overview of demand creation                         behaviour, thus numerous interactions with a client may be
strategies, including specific strategies for older men.                     required to advance him from baseline to action. At each
                                                                             step, internal (cognitive and emotional) and environmental
Two key approaches to accelerating VMMC uptake among                         (cultural and ethical factors, or issues around service
men were outlined: interpersonal communication and                           delivery) factors can influence an individual’s immediate
community mobilization. The presentation focused on                          VMMC needs and wants, which will govern his subsequent
strategies used for VMMC uptake among males aged 20–                         actions (see Fig. 10). Therefore, different strategies,
29 years in South Africa. These strategies have included:                    messages and sets of tactics might be employed at
focusing on high schools, providing group-based support,                     each interaction.

Figure 10 Influences and stages of the journey to VMMC


                                                                              Cultural and
                                                                             society norms



                                               User-Centric Behavioral Framework

              Unaware    Unaware, Opposition/Apathy        Pre-intention            Intention                Action   Relief

                  Knowledge                Cognitive/Emotional/       CEC + structural          CEC + structural
                   barriers                Cultural (CEC) barrier       barriers and              barriers and
                                              and facilitators          facilitators              facilitators

     The session also focused on the need to invest in                      most immediate impact on HIV incidence. The CDC-
     implementation science research. CDC shared information                supported studies addressed demand and service delivery
     from studies conducted in Tanzania, Kenya and South                    (setting). They showed the need to vary demand creation
     Africa (see Fig. 11). One key issue that has emerged is that           approaches, including messaging, according to the context,
     males aged 20 years and over are not accessing VMMC                    maturity of the VMMC programme and/or target group.
     services as much as younger males. Older men are more                  Some approaches showed modest increases in VMMC
     likely to take part in riskier sexual behaviours, therefore,           uptake among adults.
     circumcising men aged 20–34 years would provide the

     Figure 11 Overview of implementation science studies in Tanzania,
     Kenya and South Africa

      TANZANIA                                       KENYA                                         SOUTH AFRICA

      Research Question

      Does VMMC uptake increase among                Does VMMC uptake increase among               Does VMMC uptake increase among men
      men aged 20-34 years when exposed              men 25-39 years when exposed to               aged 25-49 years when an ‘Exclusive
      to communications and service delivery         interventions addressing barriers?            Intervention Package’ is offered to older
      tailored to older men?                                                                       men?


      • Increase the total number of VMMC clients    • Increase the proportion of men              • Develop tailored VMMC messages
        and the proportion of men aged 20-34 years     aged 25-39 years who accept                   addressing barriers for men aged 25-49
      • Assess relationship between client age and     VMMC compared to men randomized               years.
        reported rick of HIV acquisitions              to routine service delivery and demand      • Evaluate the effectiveness of an ‘Exclusive
                                                       creation activities (including enhanced       Intervention Package’ to men aged 25-49
                                                       interpersonal communication and dedicated     years.
                                                       service outlets).

     Market research combined with behavioural economics
     was shared by PSI as a method used in Zambia to increase
     VMMC uptake. The method includes journey path mapping
     of a man from awareness of VMMC to uptake of the service
     and quantitative market segmentation. This approach
     allows target client archetypes to be developed.

Accessing services (C. Toledo, CDC; V. Kikaya, Jhpiego; K. Hatzold, PSI Zimbabwe;
S. Mabhele, ILO; T. Teka Amero, PEPFAR Ethiopia)
This session offered examples of channels through which                showing that in general Basotho men [men from Lesotho]
adult men may be reached with HIV prevention services,                 have suboptimal health seeking behaviours. Within the
including VMMC.                                                        clinic there is evidence that VMMC is serving as a gateway
                                                                       to other health services (offered at the clinic), including
Jhpiego presented on the VMMC/male clinic in the Scott                 HIV testing, counselling and testing/treatment of other
Hospital in Lesotho, which is a stand-alone facility located           sexually transmitted infections. All VMMC clients at the
away from the main hospital. It is the only male clinic in             clinic were tested for HIV between July 2016 and January
South Africa to be part of a public hospital. The clinic was           2017 (see Fig. 12).
set up based on demographic and health survey evidence

Figure 12 HIV testing results for VMMC clients at male clinic
in Scott Hospital, Lesotho

All Clients tested for HIV in the male clinic, July 2016 to Jan 2017

                               Positive, 150, 14%

                                                                                            Negative, 926, 86%

The ILO presentation on reaching adult men with VMMC                   treatment services and other health services. The example
services through occupational settings highlighted that                provided was that of the South African Clothing and Textile
workplace responses to HIV have an impact on the AIDS                  Workers’ Union: Worker Health Programme, which provides
epidemic and can, therefore, contribute to national AIDS               quality HIV- and tuberculosis-related services to blue collar
responses. The commitment of workplace senior managers                 workers and engages with representatives of employers
and workers’ leaders are driving forces. Engaging worker               and workers through tripartite consultation forums (labour
representatives (trade unions) facilitates the mobilization            advisory councils). It was noted that the public sector often
of workers (particularly men) to access HIV prevention/                employs a larger number of men than the private sector.

     Figure 13 Defining and locating the world of work

                                             Formal/Informal/Self Employment
      People looking for Employment                                                           Interns, Volunteers, Apprentices

                 Public Sector                             Private Sector                             Civil Society

                                                 Organized Employers and Workers

           Government Ministries of                   Private Companies and                 Non-Governmental Organizations
         Public Service or Departments            Business (different sectors and                  and their Coalition
               /Agencies/Offices                    industries of the economy                 (Associations and Networks)

      People who have exited employment                                                    Ex-Mineworkers and other workers

     PEPFAR/Ethiopian Department of Defence gave a                 HIV testing is not mandatory for men who undergo VMMC.
     presentation on reaching adult males with VMMC                The PSI/Zimbabwe presentation on HIV self-testing showed
     services through the military in Ethiopia, where VMMC is      that fear of HIV testing, in particular getting a HIV-
     being offered to new recruits during their training period.   positive result, is a barrier to the uptake of VMMC among
     Approximately 10–15% of new recruits are uncircumcised,       sexually active men. Since HIV self-testing was introduced
     of which around 90–95% accept circumcision. Some              in Zimbabwe, there has been high uptake among men,
     active soldiers also accept circumcision. Because of the      young people and key populations. Among these groups,
     integration of the VMMC programme in the training centres     20–30% are first-time testers. Evidence shows that HIV
     for new recruits, the Ethiopian National Defence Force is     self-testing may help address fears of taking up provider-
     able to achieve its annual VMMC target and there is also      delivered HIV testing services. HIV self-testing will help to
     an opportunity to address the stigma that some men who        link HIV-negative people to appropriate prevention services
     are uncircumcised sometimes face. The Ethiopian National      and identify people living with HIV by providing testing to
     Defence Force has shared its experience of integrating        populations that would otherwise not test due to access
     VMMC services with the militaries in other African            or privacy barriers.
     countries, some of which are now working towards
     this model.                                                   The CDC presentation highlighted that in the period
                                                                   2015–2016 males aged 20–29 years constituted less than
                                                                   30% of all VMMC clients in the 14 priority countries (see
                                                                   Fig. 14). VMMC is one of few preventative health services
                                                                   that caters specifically to males and also provides health
                                                                   screening opportunities, including for noncommunicable
                                                                   diseases. Evidence from Namibia showed that some men
                                                                   were newly diagnosed with hypertension as a result of
                                                                   the screening they received as part of their VMMC service.

Figure 14 VMMC among men aged 20–29 years in 2015 and 2016, by priority country in Africa












         2015 20-29     2015 Total Population   2016 20-29     2016 Total Population

Policies that affect men’s health and                         •M
                                                                en’s health requires urgent attention – for
                                                               everybody’s sake.
address masculinity (D. Peacock, Sonke
Gender Justice)                                               • Improving men’s and boys’ health should enhance –
                                                                not detract from – women’s health and Health for All.
The results of policy scans by Sonke Gender Justice (see
Fig. 15) show that although most national strategic plans     • Women too often blame men for their [men’s] ill health
acknowledge the importance of gender mainstreaming              and absolve themselves of responsibility.
in HIV-related interventions, very few refer to the need      • The low use of health services among men reflects
to engage men; almost all the national strategic plans          prevailing gender norms, structural drivers, poor access
reviewed have a very limited conceptualization of gender        to health services, lack of policies and weak political will.
– seeing it as referring to women only. National strategic
                                                              • A growing number of policies and programmes are
plans are more likely to mention men in relation to efforts
                                                                improving men’s health – in the few countries where
to prevent mother-to-child transmission of HIV and medical
                                                                they exist.
MC. They rarely mention men in terms of policies to affect
their attitudes towards condom use, involving them in         • It is necessary to develop and implement policies and
home-based care or targeting them to increase their uptake      programmes that shift gender norms, improve men’s
of HIV testing and treatment services. Sonke Gender Justice     access to services and address structural drivers of
emphasized the following points:                                men’s ill health.

     Figure 15 Results of policy scans by Sonke Gender Justice

      3. HIV               HIV and       Attempts      Engaging      Men’s          Male       Condoms   Men’s use   Marginalized   Treatment     Home
                           Gender      to challenge     men for    support of   circumcision              of VCT     men & boys                 Based Care
      NSP Gaps                         or transform   prevention     PMTCT
                                          gender        of GBV

      Cote D’Ivoire
      2009 – 2010/11

      2009/10 – 2012/13


      2011 – 2016

      2009 – 2012

      Sierra Leone

      South Africa
      2007 – 2011

      2008 – 2012

      2007/8 – 20011/12

      2011 – 2015

      2011 – 2014

     Key        Adequate             Room for improvement            Inadequate

     Implementation considerations for young                                             in order to encourage uptake of VMMC services among
                                                                                         this population group. There is a need to: include VMMC
     men and high-risk men                                                               within labour policies; create incentives for employers;
     These group work sessions aimed to provide an opportunity                           strengthen private–public funding partnerships; coordinate
     for countries to share their experiences and further explore                        scheduling of VMMC services with/between workplaces.
     the requirements for VMMC reprogramming and key
                                                                                      • Peers, champions and traditional/community influencers
     implementation considerations. The main feedback from
                                                                                        have been successful in generating demand for VMMC
     the working groups was as follows:
                                                                                        services. This approach should be strengthened, while
                                                                                        ensuring links to VMMC services, especially in rural areas,
     Young men                                                                          in order to minimize the time between mobilization
     • Since young men are an economically viable group,                                and the provision of VMMC. In addition, it is necessary
       concerted efforts are needed to engage employers, trade                          to ensure that sites where VMMC services are offered
       unions and medical health insurance companies and                                are ready for increased uptake (staffing, infrastructure
       facilitate their understanding of the benefits of VMMC                           and supplies).

• More use should be made of up-to-date channels of             • Increasing VMMC coverage among men most at risk
  communication, including mass media, interpersonal              will have both programmatic and policy implications
  communication, mid-media and social media.                      and will, therefore, require further significant political
  Additionally, messages should be targeted also at               and resource commitments.
  women as key influencers over men’s health.
                                                                • Innovation is required to generate demand and improve
• More engagement with tertiary institutions is necessary         access to VMMC services among most at risk populations.
  to further leverage opportunities for demand creation.          Suggestions included: providing incentives, flexible
                                                                  services outside of working hours, venue-based outreach,
• In order to better understand what works for young men,
                                                                  couples services and workplace-based strategies. For men
  both in terms of service delivery and demand creation,
                                                                  on the move, suggested reprogramming considerations
  a review of the data collected over the last five years
                                                                  included: health passports, cross-border health service
  is needed to compare VMMC programme experiences
                                                                  access and referrals as well as shared financial and
  in different countries, including the outcomes of pilot
                                                                  political responsibilities between countries.
  initiatives and end-user participation rates.
                                                                • Countries will need to make concerted efforts to obtain
• VMMC should be used as a gateway to address other
                                                                  strategic information on most at risk men since data on
  aspects of young men’s health (the same is true for all
                                                                  this group is often not routinely captured or disaggregated
  age groups). Providing VMMC services through men’s
                                                                  in health information systems and it is important for
  health clinics, which offer screening for and treatment
                                                                  planning and monitoring of VMMC and other services.
  of noncommunicable diseases, including mental health
  and substance misuse, might be less stigmatizing and
  improve VMMC uptake.

High-risk men
• It is important for countries to define which men are
  ‘at high risk’ or ‘most at risk’ and to understand that
  while men in this population will have some common
  characteristics there will also be some differences,
  which has implications for programming. Some countries
  considered the term ‘most at risk’ to apply to: men
  in serodiscordant relationships, those with sexually
  transmitted infections, clients of sex workers, migrants,
  miners, long distance truckers and prisoners.
• Prevention messaging alone is insufficient to increase
  VMMC uptake among men who are most at risk given
  that other concerns and issues drive their risk behaviour.
  Therefore, it is important for VMMC services to provide
  an entry point not only to other HIV prevention services
  but also to additional priority health services, especially
  for men who have limited access to these services.
  The VMMC service package could be broadened to
  include access to pre-exposure prophylaxis for HIV
  prevention, information on family planning, guidance
  on addressing attributes of masculinity that affect health
  seeking behaviours, and screening for conditions such
  as hypertension or substance misuse.

     AA-HA! Adolescent implementation                               Spotlight presentations (S. Mabaya,
     framework – synergies with VMMC2021                            WHO Zimbabwe; E. Njeuhmeli, USAID;
     (T. Desta, WHO)                                                P. Devos, JHCCP)
     WHO presented the AA-HA! guidance, which aims to               WHO Zimbabwe, on behalf of the Zimbabwe MoH,
     provide technical advice to countries to enable them to        presented the Adolescent Sexual and Reproductive Health
     decide what to do and how to do it as they respond to          (ASRH) and VMMC Linkages pilot project, which is being
     the health needs of adolescents. Primary target audiences      implemented to assess the feasibility of creating and
     for the guidance include national-level adolescent health      sustaining linkages between ASRH and VMMC services in
     policy-makers and programme managers in all relevant           Zimbabwe, including related capacity needs. The results of
     sectors. Secondary-level audiences include subnational         the pilot will contribute to guidance on how to effectively
     adolescent health policy-makers and programme                  deliver the two programmes in order to provide sustainable
     managers, international advisors, funders and others.          adolescent services and maintain high VMMC coverage
                                                                    while offering or linking clients to other needed health
     In the same way as the Framework for Voluntary Medical         services. The pilot started in 2014 and has three phases.
     Male Circumcision: Effective HIV Prevention and a Gateway      The first phase (2014) focused on preparatory assessments
     to Improved Adolescent Boys’ and Men’s Health in Eastern       and stakeholder inputs. The second phase (2014–2015)
     and Southern Africa by 2021, AA-HA! identifies VMMC as         focused on implementation by identifying linkages, feasible
     one of a number of priority interventions for countries with   approaches and lessons for scale-up. The third phase
     generalized HIV epidemics. The AA-HA! implementation           (2015–2016) is focused on ongoing implementation (see
     guidance also provides advice to Member States on              Fig. 16) with monitoring embedded in the two programmes
     financing adolescent health interventions through existing     and research conducted to assess effectiveness and costs
     opportunities such as the Global Fund and the Global           in order to inform scale-up by optimizing strategic actions
     Financing Facility investment case. In addition, the AA-       and the delivery of interventions.
     HA! guidance can be used to guide countries in prioritizing
     high-impact national interventions and developing
     coherent national plans for adolescent health in the
     period 2017–2030.

     Figure 16 Current activities in the ASRH–VMMC Linkages pilot project, Zimbabwe

          Advocacy &              Development of         Established            Joint demand            Use of social
          Sensitisation           IEC material           referral & tracking    creation with           media (Whatsapp
          meetings                                       system                 service provision       & Facebook)
                                  Development of
          District review         training materials     Service directories    Service                 U-Report platform
          meetings                                                              integration             for opinion polls
                                  Development of a       Capacity building
          Monthly support         Job Aid                                       Community
          visits                                                                dialogues & Boys
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