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Circumcising millions: plans and outomes

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Targets and reported number of men circ’d

In 14 targeted countries in Africa, WHO proposed to increase the percentage of men aged 15-49 years who are circ’d to 80% by 2016.[1] WHO estimated this would require VMMC (Voluntary Medical Male Circ’n) programs to circ 20.4 million men.

Against this target, WHO reports VMMC programs circ’d 14.54 million men by end-2016. However, about 40% of these circ’s were performed on boys aged 10-14 years, who were outside the target population. Excluding these boys, the program circ’d 8.7 million men aged 15-49 years — 43% of the target:

Table 1: Reported targets and achieved circ’s in VMMC programs

Country Target: 80% of men 15-49 years to be circ’d [1] Achievement[2] Achievement as % of target
14 countries 20.4 million 14.54 million (8.7 million excluding men aged 10-14 years) 71% (43% excluding men aged 10-14 years)
Botswana 345,244 180,543 52%
Ethiopia 40,000 71,235 178%
Kenya 377,788 1,377,617 365%
Lesotho 376,795 144,858 38%
Malawi 2,101,566 396,151 19%
Mozambique 1,059,104 1,010,297 95%
Namibia 330,218 64,119 19%
Rwanda 1,746,052 730,059 42%
South Africa 4,333,134 2,844,413 66%
Swaziland 183,450 100,803 55%
Tanzania 1,373,271 2,210,026 161%
Uganda 4,245,184 3,115,110 73%
Zambia 1,949,292 1,484,899 76%
Zimbabwe 1,912,595 807,060 42%

Reported VMMC circ’s vs changes in the percent of men circ’d by country

Reported VMMC achievements in at least some countries might be exaggerated: VMMC programs may be circ’ing men who would get circ’d anyways, according to their custom; such men may take advantage of VMMC’s free circ’s. That may be the case in at least some of the targeted countries. In Zimbabwe, for example, WHO reports VMMC circ’d 507,000 men from 2008 through half of 2015 – more than double the increase in numbers of circ’d men during that time based on national surveys (Table 2). WHO similarly reports VMMC programs circ’d more men in Uganda, Zambia, and Rwanda than can be estimated from national surveys. In some other countries, reported VMMC circ’s are less than numbers circ’d based on survey data (Table 2). In other words, data are unreliable…

Table 2: Comparing reported numbers of men circ’d in VMMC programs to survey data on percentages of men circ’d

Country Change in numbers of circ’d men in the population Number of men circ’d in VMMC programs between survey years (1,000s)*
Last survey before VMMC[3]

 

Last survey after VMMC  began[3] change in % of men circ’d between surveys number of men  aged ≥15 years during the last survey year[5,6] increase in number of circ’d men between survey years (1,000s)
A B C = A x B D
Ethiopia 2005 2016 -0.8 26,587 -213 66
Kenya 2003 2014 9.1 13,680 1,245 671
Malawi 2004 2015-16 7.5 5,481 411 266
Mozambique 2009 2015 11.3 7,591 858 658
Rwanda 2005 2014-15 8.5 3,746 318 455
Swaziland 2006-7 2011[4] 8.0 409 33 31
Tanzania 2003-4 2011-12 2.4 13,858 332 139
Uganda 2004 2016 20.4 11,465 2,339 2,909
Zambia 2007 2013-14 9.2 4,338 399 635
Zimbabwe 2005-6 2015 4.5 4,269 192 507
All countries 5,914 6,337

*The table considers circ’s reported to the mid-point of survey years; eg, if the survey year was 2014, the table sums half the circ’s reported for 2014.

Ambitious new VMMC targets

Undaunted by lagging achievements and unreliable data, WHO and UNAIDS propose to circ 27 million men during 2016-21. After 2.9 million circs in 2016, the remaining 24 million would require 4.8 million circs/year, far more than reported in any year to date.[2]

References

1. Currran K, Njeuhmeli E, Mirelman A, et al. Voluntary medical male circumcision: strategies for meeting the human resource needs of scale-up in southern and eastern Africa. PLoS 2011; 8: e1001129. Available at  http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001129 (accessed 10 April 2018).

2. WHO. Progress brief. 2017. Available at: http://apps.who.int/iris/bitstream/handle/10665/258691/WHO-HIV-2017.36-eng.pdf?sequence=1 (accessed 10 April 2018).

3. DHS, available at: https://dhsprogram.com/.

4. Swaziland HIV Incidence Measurement Survey, available at: https://www.k4health.org/sites/default/files/SHIMS_Report.pdf);

Column D: population from Wikipedia at 5. https://en.wikipedia.org/wiki/List_of_countries_by_past_and_future_population.

6. http://en.worldstat.info/Africa.

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