CDC-Supported Male Circumcisions for HIV Prevention in 13 African Countries, 2017–2021

In 2007 the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) endorsed voluntary medical male circumcision (VMMC) after it was found to be associated with approximately a 60% reduction in the risk of HIV passing from women to men. The U.S. President's Emergency Plan for AIDS Relief (PEPFAR), through CDC, the Department of Defense and the U.S. Agency for International Development, then began supporting VMMC in prioritized countries of eastern and southern Africa. From 2010 to 2016, CDC supported 5,880,372 procedures in 12 countries.

This report updates the program for 2017–2021, using PEPFAR monitoring data reported each quarter. The goal is the UNAIDS 2025 target of 90% of males aged 15–59 having access to VMMC in prioritized countries, to help end the AIDS epidemic by 2030.

The program

VMMC is part of each country's HIV prevention services, which also include voluntary HIV testing, risk-reduction education, screening and treatment for sexually transmitted infections, and linkage to care for anyone who tests positive. In 2017–2021 CDC supported programs in 13 countries — Botswana, Eswatini, Ethiopia, Kenya, Malawi, Mozambique, Namibia, Rwanda, South Africa, Tanzania, Uganda, Zambia and Zimbabwe — though not all for the whole period: Eswatini gained CDC support in 2019, and Namibia's support moved to another agency in 2020.

What happened, 2017–2021

• 8,497,297 CDC-supported circumcisions were performed.
• Numbers grew each year from 2017 to 2019, by a mean of 13.5% a year, then fell 31.8% in 2020 — from 2,120,797 in 2019 to 1,447,147 — mainly because of COVID-19 disruptions, and fell further in 2021.
• Age: in 2017–2019, 43.8% of procedures were in boys aged 10–14 and 45.7% in males aged 15–29; the 15–29 share rose to 61.0% in 2020 and 86.6% in 2021.
• HIV testing: 74.2% of clients were tested for HIV at VMMC sites, though the share fell from 86.4% in 2017 to 48.7% in 2021. Of 5,595,239 tested, 44,745 (0.8%) were HIV-positive, ranging from 0.4% in 2020 to 1.2% in 2021.
• Follow-up: 90.8% returned for a check within 14 days, rising in every country from 86.2% in 2017 to 96.7% in 2021 — above the recommended 80%, which helps catch complications early.
• Devices: 2% (166,475) of circumcisions used a device instead of surgery; the share peaked at 3.8% in 2017, fell to 1.1% in 2019 and 2020, then rose to 2.2% in 2021.

CDC-supported voluntary medical male circumcisions by year in 13 countries, 2017–2021. CDC.

Behind the trends

• Growing experience and continued priority from health ministries and global partners drove the scale-up.
• COVID-19 measures caused the 2020 drop. To limit spread, many countries switched to virtual follow-up visits, an approach PEPFAR backed in 2021.
• The age shift: 2015–2018 data showed certain severe adverse events, while very rare, were more common in boys aged 10–14 (2.9 per 100,000 procedures) than in those 15 and older (1.6 per 100,000), so in 2020 PEPFAR raised the minimum age to 15.
• Less testing in 2020 and 2021 likely reflected PEPFAR's 2019 move toward targeted testing of higher-risk clients. VMMC sites remain an important entry point to HIV testing for men who might otherwise go undiagnosed.
• Devices are still mostly being piloted. Their use fell after practitioners phased out the PrePex device in 2016–2018, following reports of tetanus in patients circumcised with it, and programs had little experience scaling up the ShangRing device instead; more programs expanded device use in 2021.

Why it matters

Modeling estimates that the 26.8 million PEPFAR-supported circumcisions performed in 2008–2019 prevented 340,000 new HIV infections, a figure projected to reach 1.8 million by 2030 because the protection lasts a lifetime. Focusing on uncircumcised males in high-incidence areas and those at highest risk can make the most of VMMC's contribution to controlling HIV.

Limits

Only CDC-supported procedures are counted, so the true total is higher; the monitoring data can contain reporting and entry errors; and they cannot directly measure progress toward the 90% access target.

Sources

Based on Peck ME, Ong KS, Lucas T, et al., "Voluntary Medical Male Circumcisions for HIV Prevention — 13 Countries in Eastern and Southern Africa, 2017–2021," MMWR Vol. 72, No. 10, CDC; a work of the United States government in the public domain.