Program Expansion Supplement: Provision of Male Medical Circumcision (MMC) in South Africa under PEPFAR

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This Funding Opportunity Announcement (FOA) seeks to provide additional funds to The South African Clothing and Textile Workers Union (SACTWU – GH000265), Jhpiego (GH000237) and Population Services International (PSI- GH000248) for the purpose of scale-up of voluntary medical male circumcision (VMMC) services to 27 high-burden districts, as well as sub-districts with low male circumcision (MC) prevalence. VMMC is a one-time procedure that reduces men’s risk of acquiring HIV from heterosexual exposure for a lifetime. Three randomized controlled trials (RCT) demonstrated that VMMC reduces men’s risk of HIV acquisition by approximately 60%, making it one of the most effective HIV prevention interventions known. Extended follow-up of participants in the Uganda and Kenya RCTs through five and six years post-trial indicated that the protective effect was sustained or increased at 67-73% and 58%, respectively (Gray, 2012) (Mehta, 2013). WHO/UNAIDS issued normative guidance in March 2007, recognizing that VMMC is an additional important intervention to reduce the risk of male heterosexually acquired HIV infection, (World Health Organization, 2007) and subsequently issued the Joint Strategic Action Framework to Accelerate the Scale-Up of Voluntary Medical Male Circumcision for HIV Prevention in Eastern and Southern African countries with generalized HIV epidemics where male circumcision is uncommon. A target was set to reach 80% circumcision coverage among males aged 15-49 years in 14 these priority countries in the region, equivalent to 20.3 million VMMCs, by the end of 2016 (Joint United Nations Programme on HIV/AIDS, 2007). Mathematical modeling suggests that if 8 out of 10 adult men will become circumcised within 5 years, approximately 3.4 million new HIV infections may be prevented in 15 years, saving as much as $16.5 billion in HIV care and treatment costs (Njeuhmeli, 2011). In South Africa, one case of HIV may be prevented for every 5 men who become circumcised in this scenario. VMMC programs also offer unprecedented opportunities to engage men in health education and counseling, notably HIV testing and counseling services which is recommended and provided in all PEPFAR VMMC programs. Furthermore, men who are identified as HIV positive by VMMC programs are referred for HIV care and treatment, broadening the potential community-level HIV prevention benefits of the program, as HIV-infected persons on treatment are much less likely to transmit HIV to their sexual partners (Cohen MS et al, 2011). VMMC also has a large, even though indirect, effect on women’s risk of HIV infection. As HIV prevalence decreases in men as a result of becoming circumcised, women’s probabilities of encountering HIV-infected partners are also reduced. In fact, almost half of the new HIV infections that may be prevented are among women, if scale-up is rapid, as described in the above modeling scenario. Women with circumcised male sex partners also have reduced risk of sexually transmitted infections, including carcinogenic strains of HPV, and associated cervical cancer (Pintye, 2014) (Wawer M. e., 2011) (Casteluega, 2002). The purpose of this funding opportunity announcement is to provide additional funds to existing CDC-South Africa partners for the purpose of scale-up of voluntary medical male circumcision (VMMC) in 27 high-burden districts, as well as sub-districts with low male circumcision (MC) prevalence.

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