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Age Targeting VMMC for best HIV prevention practices: lessons from Swaziland

Voluntary medical male circumcision (VMMC) for HIV prevention has been a priority for Swaziland since 2009. To understand the implications of age targeting, the Ministry of Health undertook a modeling exercise.

Swaziland reduced the minimum age for VMMC to 10 years, given the demand. Photo credit: Flickr ow.ly/KPNT30cPmtj

Introduction
Voluntary medical male circumcision (VMMC) has been shown to reduce female-to-male transmission of HIV by 60% and is a recommended HIV prevention strategy in countries with high HIV prevalence and low levels of male circumcision. Swaziland is one of 14 countries in eastern and southern Africa scaling up VMMC for HIV prevention following the recommendations of the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS). With an HIV prevalence of 31% and HIV incidence of 2.4% among adults ages 18–49 years, Swaziland has the highest HIV prevalence and incidence in the world. At the same time, with a male circumcision rate of 8.2% in its most recent Demographic and Health Survey, Swaziland has one of the lowest levels of male circumcision among the 14 VMMC priority countries.

In 2008, Swaziland developed the Policy on Safe Male Circumcision for HIV Prevention and the Strategy and Implementation Plan for Scaling up Safe Male Circumcision for HIV Prevention 2009–2013. According to the strategy, a key objective was to provide VMMC services to 144,688 HIV-negative males during the period 2009–2013 (111,688 males ages 15–24, and 33,000 neonates). Males ages 15–24 were selected as the primary population, because they were believed to be at greatest risk of infection. In 2011, the Accelerated Saturation Initiative (ASI), also known as Soka Uncobe (meaning circumcise and conquer in SiSwati), was launched with the goal of circumcising 80% of males ages 15–49 within one year. While the ambitious ASI target was not met, important lessons were learned, especially about demand creation and the need to have strong community engagement and government leadership and coordination. Routine program data revealed important variation in demand for VMMC by age. Even though the program targeted 15- to 49-year-old males, there was significant demand for circumcisions among 10- to14-year-olds. Whereas clients ages 10–24 years comprised 75% of the client population between the start of the program in 2009 and the end of 2014, clients ages 25 years and above made up a lower proportion of clients than would be expected, based on the age distribution of uncircumcised males in the overall population. Fewer than 5% of clients were above the age of 35. In response to the demand for circumcision among 10- to 15-year-olds, the Ministry of Health decided to reduce the minimum age for VMMC from 15 to 10 years in 2012.

The Swaziland Ministry of Health (MOH) was interested in understanding the implications of focusing VMMC service delivery on specific age groups and aligning their VMMC targets with their implementation experience highlighting the heterogeneous demand among different age groups. In 2013/2014, the Decision Makers’ Program Planning Tool, Version 2.0 (DMPPT 2.0) was applied in Swaziland to assess the impact and cost of circumcising specific client age groups, and to inform the development of the country’s Male Circumcision Strategic and Operational Plan for HIV Prevention, 2014–2018. This paper describes the modeling done and the key policy decisions made based on the modeling results.

Palladium's Melissa Schnure, Health Practice Associate, contributed to this article in Plos One. To view the article in full, please click here