Voluntary Medical Male Circumcision to Reduce HIV Acquisition and Transmission

Abstract

Purpose of Review

This commentary introduces the special Global Health Section on the state of voluntary medical male circumcision (VMMC) programs and current knowledge as to role of VMMC prevention of HIV infection acquisition in men and, indirectly, women.

Recent Findings

Since the first clinical trial of VMMC in Africa was published in 2005, implementation of programs has depended on illuminating best practices and key obstacles in the effort to expand VMMC in areas of high HIV prevalence to reduce HIV acquisition among men, with consequent benefits that uninfected men will not infect others. Global efforts are focused on sub-Saharan Africa, given the favorable expected impact of VMMC deployment where HIV incidence is high and circumcision rates are low.

Summary

With estimated field effectiveness estimated to exceed 60%, reduced HIV risk for circumcised men in sub-Saharan Africa based on a once-only minor surgical intervention provides extraordinary preventive benefits. Where high VMMC rates have been achieved, declining HIV incidence rates may be partially or substantially attributed to VMMC, but this remains to be investigated. Articles in this special section address achievements, obstacles and risks, and plans for future progress in partnership with affected communities.

The global effort to find an HIV vaccine has made progress, but no licensed vaccine is available. An ideal vaccine would be at least 60% efficacious, would need just one vaccine to cover all subtypes, and would require a single dose with lifetime protection [1–3]. Hence, the HIV field celebrates voluntary medical male circumcision (VMMC) that is more than 60% efficacious in clinical trials and has comparable effectiveness in real world deployment. VMMC protects against all HIV subtypes and requires a single minor surgical procedure to convey protection over decades. VMMC is an anatomical intervention with immunological consequences that make it a powerful component of the HIV prevention portfolio. That VMMC has features of an ideal vaccine suggests that more implementation science research investments are needed [4].

This issue of Current HIV AIDS Reports is devoted to the VMMC agenda. The issue starts with an overview article by Zhang et al to introduce key issues within a global context, including the need to maximize VMMC success by creating demand from men and women in vulnerable communities [5]. Kaul et al explore the mechanisms of putative action for prevention in men [6]. The most notable programmatic successes in VMMC coverage and impact on HIV incidence are from western Kenya; Agot et al described this region as a positive case study [7]. Mehta addressed the benefits of VMMC on female partners’ sexual and reproductive health, including reducing risks for sexually transmitted infections (STI) [8]. Lucas et al describe the adverse events reporting within the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) Voluntary Medical Male Circumcision Program, highlighting strategies for adverse event notification and the quality improvement feedback loops that use these data to improve programs [9].

Gao et al examine concerns that circumcised heterosexual men may increase risk behaviors (risk compensation) [10], building upon their 2021 systematic review and meta-analysis [11]. Lin et al examine evidence for the utility of VMMC for men who have sex with men (MSM) [12]. Bershteyn et al highlight mathematical models as a tool to assess both need for, and impact of VMMC programs in eastern and southern Africa [13], especially interesting in the context of a favorable 2020 impact assessment based on a systematic review and meta-analysis [14]. Finally, Peck et al look to the future in presenting their perspectives on the direction of VMMC programs and research priorities, including priority actions that can be expected to make a substantial difference in VMMC deployment [15].

Broad themes across the studies include insuring safety and quality of circumcisions with suitable health systems strengthening, how to create community demand for services and reduce stigma, and overall health benefits in sexual health including reduced STI incidence (Table). We do not have definitive data as to the VMMC benefits to MSM and indirect benefits to women (Table). We still need vigilance and effective educational approaches to reduce risk compensation, and we face a myriad of policy, geopolitical, and funding complexities (Table). Issues around neonatal circumcision whose impact on HIV will be decades hence, ethical arguments made against circumcision by persons who deny a parent’s right to choose for the male infant, and religious issues in some societies have been highlighted elsewhere [refs].

Table:

Key issues in voluntary medical male circumcision for HIV prevention

Key issues in circumcision	Outstanding research questions	References
Building safe surgery programs	Use of non-physician providers; Best techniques; Reduction of complications	[4,5,7,9,12–15]
Demand creation among men, women, and couples	Community education; Stigma reduction; Best incentives and outreach strategies	[5,7,12,13–15]
Overall benefits to sexual health and reduced risks	Impact on all reproductive tract infections; Effects on male/female sexual satisfaction;	[4–15]
Benefits to men who have sex with men	Strong observational evidence, but no clinical trial confirmations	[5,12]
Magnitude of benefits to women	Field evidence for benefits as suggested in transmission models for HIV/STI	[5–8,13,15]
Potential of increased behavioral risk-taking	Evidence for risk compensation and how to mitigate this with education and support	[10,11]
Uses of best practice models to inform programs	Policy and practice strategies most suitable for a particular sociopolitical milieu	[7,13–15]

Notes: HIV-human immunodeficiency virus; STI- sexually transmitted infections

Despite concerns about unresolved challenges and research questions, VMMC is valuable in the arsenal of HIV prevention strategies, particularly relevant for global efforts. Just as future vaccines will be beneficial only insofar as they are made available, are acceptable, and are widely deployed [16–22], VMMC is only helpful when enough vulnerable men avail themselves of the minor surgery to reduce lifelong HIV risk of HIV acquisition. Partners’ and spouses’ roles are vital in encouraging men to be circumcised and best-practice strategies at the community and family level for education and advocacy are needed. The editors hope that this special issue will be useful in discussions, teaching, and programmatic development in expanded VMMC in high HIV incidence venues where circumcision rates are suboptimal, spurring this vital strategy in global HIV prevention.