Getting men to think about their health can be difficult. Voluntary male medical circumcision (VMMC) programmes can provide an excellent opportunity to reach adolescent boys and young men with health services they might not otherwise access.
This is just one piece of learning in an updated World Health Organization (WHO) manual on HIV and male circumcision, reflecting lessons learnt in getting over 14 million boys and men circumcised across East and Southern Africa.
“The manual has pulled together the huge array of practical experiences and learning from the past 10 years plus, to create a powerful resource for practitioners,” says WHO Coordinator for HIV Key populations and innovative prevention, Rachel Baggaley. “The lessons in the manual can help them maintain high quality of services and reduce surgical risks.”
The WHO has recommended the roll-out of VMMC since 2007, after several trials revealed that male circumcision reduced HIV transmission from women to men by 60% in countries with a high HIV prevalence in the general population. While VMMC is not a HIV prevention ‘silver-bullet’, it is both effective and relatively cheap to implement, and should form part of a comprehensive package that also includes behavioural and structural interventions.
Based on the implementation experience so far, the updated manual calls for a person-centred approach to VMMC programming, with safety as a high priority. But it also highlights an opportunity to talk to men, particularly adolescents.
African adolescents (10-19 years) are among the groups most affected by HIV globally – and one that is growing. For this group, getting circumcised may be the first time they ever visit a health service, so it presents a perfect opportunity to give relevant health messages. These messages could last a lifetime, as many of these adolescents lack basic knowledge about their physical, sexual and mental health.
Depending on how old the target group are, the manual offers age-appropriate considerations for health staff, targeting messages differently for adults and different subgroups of adolescents.
For example, younger adolescents may worry about what their friends may think about them getting circumcised, while older adolescents may only be worried about how long they need to abstain from sex afterwards. Young men may not want to discuss sexual health issues around younger peers, so information about circumcision should be delivered in age-specific groups for the best effects.
Additionally, as more men walk through the door to get circumcised, more will benefit from an expanded package of services, like HIV testing – including self-testing – testing for sexually transmitted infections (STIs) and HPV, and referrals for pre-exposure prophylaxis (PrEP) for high-risk men. They can also be given safer sex information and condoms to use with their partners. Other relevant health issues, such as tuberculosis (TB) and malaria can be screened for, while concerns about substance and alcohol abuse, or even fertility issues can be flagged.
VMMC sites are now also encouraged to implement gender or masculinity education for harmful gender norms that affect women’s risk of HIV. In fact, the intent of all these expanded services will be that women eventually benefit as well.
While circumcision is certainly an entry point for health services for men – it is ultimately a medical intervention and carrying out this procedure safely and with no adverse health effects is a key priority for the WHO. The manual provides advice and information on counselling clients and obtaining informed consent, infection prevention, and key safety principles for male circumcision services.