Chapter 9 Voluntary medical male circumcision : A framework analysis of policy and program implementation in eastern and southern Africa

Background: Following confirmation of the effectiveness of voluntary medical male circumcision (VMMC) for HIV prevention, the World Health Organization and the Joint United Nations Programme on HIV/AIDS issued recommendations in 2007. Less than 5 y later, priority countries are at different stages of program scale-up. This paper analyzes the progress towards the scale-up of VMMC programs. It analyzes the adoption of VMMC as an additional HIV prevention strategy and explores the factors may have expedited or hindered the adoption of policies and initial program implementation in priority countries to date. Methods and Findings: VMMCs performed in priority countries between 2008 and 2010 were recorded and used to classify countries into five adopter categories according to the Diffusion of Innovations framework. The main predictors of VMMC program adoption were determined and factors influencing subsequent scale-up explored. By the end of 2010, over 550,000 VMMCs had been performed, representing approximately 3% of the target coverage level in priority countries. The ‘‘early adopter’’ countries developed national VMMC policies and initiated VMMC program implementation soon after the release of the WHO recommendations. However, based on modeling using the Decision Makers’ Program Planning Tool (DMPPT), only Kenya appears to be on track towards achievement of the DMPPT-estimated 80% coverage goal by 2015, having already achieved 61.5% of the DMPPT target. None of the other countries appear to be on track to achieve their targets. Potential predicators of early adoption of male circumcision programs include having a VMMC focal person, establishing a national policy, having an operational strategy, and the establishment of a pilot program. Conclusions: Early adoption of VMMC policies did not necessarily result in rapid program scale-up. A key lesson is the importance of not only being ready to adopt a new intervention but also ensuring that factors critical to supporting and accelerating scale-up are incorporated into the program. The most successful program had country ownership and sustained leadership to translate research into a national policy and program. Please see later in the article for the Editors’ Summary. Citation: Dickson KE, Tran NT, Samuelson JL, Njeuhmeli E, Cherutich P, et al. (2011) Voluntary Medical Male Circumcision: A Framework Analysis of Policy and Program Implementation in Eastern and Southern Africa. PLoS Med 8(11): e1001133. doi:10.1371/journal.pmed. 1001133 Academic Editor: Stephanie L. Sansom, Centers for Disease Control and Prevention, United States of America Received June 2, 2011; Accepted October 19, 2011; Published November 29, 2011 This is an open-access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication. Funding: This work was funded by WHO and PEPFAR through USAID. The funders (WHO and USAID) had roles in the study design, decision to publish, and preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. Abbreviations: DMPPT, Decision Makers’ Program Planning Tool; DOI, Diffusion of Innovations; PEPFAR, United States President’s Emergency Plan for AIDS Relief; RCT, randomized controlled trial; UNAIDS, Joint United Nations Programme on HIV/AIDS; VMMC, voluntary medical male circumcision; WHO, World Health Organization * E-mail: Dicksonk@who.int ¤ Current address: Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America PLoS Medicine | www.plosmedicine. org 1 November 2011 | Volume 8 | Issue 11 | e1001133