Number of males circumcised as part of the minimum package of MC for HIV prevention services

Export Indicator

Number of males circumcised as part of the minimum package of MC for HIV prevention services
What it measures

For maximal population impact, uptake of male circumcision should be as high and as rapid as safely possible and aligned with national policy. The total number of males circumcised indicates either change in the supply of or demand for MC services. Additionally, disaggregated information may be useful to evaluate whether prioritized services have been successful, set targets have been achieved, and modeling inputs should be adjusted.

Rationale

Three randomized controlled clinical trials in sub-Saharan Africa demonstrated a 60% reduction in risk of female-to-male HIV transmission among men randomized to receive circumcision (compared to uncircumcised controls).2,3,4 This evidence is supported by long-standing ecologic and observational data. Elective surgical male circumcision confers a partially protective effect against HIV acquisition for HIV-negative men at risk for acquiring HIV from HIV-positive female sexual partners, and may be particularly beneficial in populations where HIV prevalence is high and male circumcision prevalence is low.

Numerator

Number of males circumcised as part of the minimum package of MC for HIV prevention services per national standards and in accordance with the WHO/UNAIDS/Jhpiego Manual for Male Circumcision Under Local Anesthesia

Denominator
Calculation
Method of measurement

The numerator can be generated by summing the clients documented as having received MC within the reporting period in MC Registries or clients’ medical records maintained by programs.

Explanation: While services must be provided within the context of the minimum MC package, only males who have received a circumcision surgery in accordance with the WHO/UNAIDS/Jhpiego Manual for Male Circumcision Under Local Anesthesia1 and per national standards by funded programs/sites in the reporting period meet the definition for the numerator.

Other services within the MC minimum package (i.e. Testing, Behavioral Change, counseling, or training of health professionals) should not be counted here, but may be captured under separate but appropriate indicators found in this document.

PEPFAR does not provide funding to perform male circumcision under general anesthesia, and cases of MC under general anesthesia should not be paid for by PEPFAR and should not be counted in the indicator. Children may receive PEPFAR-funded MC as long as the procedure is performed using local anesthesia and in accordance with the WHO/UNAIDS/Jhpiego Manual for Male Circumcision Under Local Anesthesia.1 MC using local anesthesia should be deferred if the maturity level of the child precludes use of local anesthesia.

Programs should focus on compiling data for the numerator from MC Registers or client medical records maintained by funded programs/sites. A program site is a fixed or mobile facility that is able to provide all components of the minimum package of MC for HIV prevention services. The MC minimum package of services must include elective surgical male circumcision using local anesthesia provided after education and consent and delivered in the context of comprehensive HIV prevention messages/services that include: on-site pre-operative HIV counseling and testing (offer of); active exclusion of symptomatic STIs and syndromic treatment when indicated; post-operative wound care and abstinence instructions; age-appropriate counseling on risk reduction, reducing number and concurrency of sexual partners, and delaying/abstaining from sex; and provision and promotion of correct and consistent use of male and/or female condoms.

It is anticipated that some programs may establish formal referral relationships with voluntary counseling and testing (VCT) services to provide the HIV testing components of the MC minimum package of services. In these cases, a repeat HIV test ‘on-site’ may not be necessary, if the MC program and VCT service have agreed upon what constitutes ‘certifiable results.’ Though it is not possible to mandate a specific length of time before the MC surgery that an HIV test must have been done, it is suggested that the HIV test be done within the prior 3 months. Clients who present without a ‘certifiable result’ and wishing to defer HIV testing are not able to self-report their result. Such clients should be counted in the ‘unknown/refused HIV test’ recommended disaggregation category.

Clients circumcised in a fixed/permanent location, such as a hospital or clinic, should be counted in the ‘fixed/permanent location’ recommended disaggregation category. Those circumcised in a school, tent, mobile facility, or in any location intended for use as another purpose but temporarily established for MC, should be counted in the ‘temporary (including mobile) location’ recommended disaggregation category.

Disaggregation:
Essential/Reported: Recommended for in-country partner level tracking: Recommended for in country partner level tackng: HIV positive by test(s) on site; HIV negative by test(s) on site; HIV indeterminate result by test(s) on site; Unknown/refused HIV test; Documented H

Measurement frequency

Continuously

Disaggregation

Age group: (greater than) 15 years

Explanation of the numerator
Explanation of the denominator
Strengths and weaknesses

Programs are required to report on the actual number of males circumcised in accordance with the WHO/UNAIDS/Jhpiego Manual for Male Circumcision Under Local Anesthesia1 so that the overall uptake and delivery of the PEPFAR-funded MC minimum services package in the country can be monitored, outcomes evaluated, and impact of MC on HIV incidence at a population level can be modeled. Comparing current and previous values may indicate newly implemented service delivery or changes in supply or demand volume. When the number of male circumcisions is disaggregated by age and HIV status, it will be possible to adjust inputs used in models to determine impact of male circumcision programs on HIV incidence. Disaggregation by age may be particularly helpful is determining whether age-specific communication strategies are working to create demand. Disaggregation by service delivery location/setting may allow for evaluation of resource allocations. Non-PEPFAR funded providers also performing MCs within the reporting period will not be captured by this indicator, and any broader evaluations of population-level uptake will need to be interpreted accordingly.

Further information