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Voluntary medical male circumcision in resource-constrained settings

Nature Reviews Urology volume 12, pages 661–670 (2015)Cite this article

Subjects

Key Points

  • Voluntary medical male circumcision (VMMC) reduces heterosexual HIV acquisition; therefore, the WHO has issued recommendations to implement VMMC throughout East and Southern Africa

  • Most adult VMMCs have been performed using surgical methods such as the forceps-guided, dorsal slit and sleeve resection methods

  • Compared with surgical methods, devices should aim to make VMMC easier, safer, faster, sutureless, appropriate for administration by nurses, inexpensive, less painful, require less infrastructure and not require follow-up visits

  • Current devices involve use of clamps, elastic collar compression and ligature; surgical instruments that seal the wound with tissue adhesive and devices that cut and staple simultaneously have also been developed

  • Device-based techniques continue to be optimized but additional research is needed to further harness technological innovations for both conventional surgical and device-based methods to expand the reach of VMMC programmes

Abstract

Throughout East and Southern Africa, the WHO recommends voluntary medical male circumcision (VMMC) to reduce heterosexual HIV acquisition. Evidence has informed policy and the implementation of VMMC programmes in these countries. VMMC has been incorporated into the HIV prevention portfolio and more than 9 million VMMCs have been performed. Conventional surgical procedures consist of forceps-guided, dorsal slit or sleeve resection techniques. Devices are also becoming available that might help to accelerate the scale-up of adult VMMC. The ideal device should make VMMC easier, safer, faster, sutureless, inexpensive, less painful, require less infrastructure, be more acceptable to patients and should not require follow-up visits. Elastic collar compression devices cause vascular obstruction and necrosis of foreskin tissue and do not require sutures or injectable anaesthesia. Collar clamp devices compress the proximal part of the foreskin to reach haemostasis; the distal foreskin is removed, but the device remains and therefore no sutures are required. Newer techniques and designs, such as tissue adhesives and a circular cutter with stapled anastomosis, are improvements, but none of these methods have achieved all desirable characteristics. Further research, design and development are needed to address this gap to enable the expansion of the already successful VMMC programmes for HIV prevention.

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Figure 1: Surgical methods for voluntary medical male circumcision.
Figure 2: Voluntary medical male circumcision devices.

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Acknowledgements

The content of this manuscript is the sole responsibility of the authors. The information provided here is not official US Government information and does not necessarily represent the views or positions of United States Agency for International Development, the United States Department of State, nor the United States Government.

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Authors and Affiliations

  1. Department of Pathology, School of Medicine, Johns Hopkins University, Carnegie 437, 600 North Wolfe Street, Baltimore, 21287, MD, USA

    Aaron A. R. Tobian

  2. JHPIEGO, 1615 Thames Street, Baltimore, 21231, MD, USA

    Tigistu Adamu

  3. Office of the U.S. Global AIDS Coordinator, 1776 Massachusetts Avenue NW, Suite 300, 20036, Washington, DC, USA

    Jason B. Reed

  4. Office of HIV/AIDS at the US Agency for International Development, 2100 Crystal Drive, 9th Floor, Arlington, 22202, VA, USA

    Valerian Kiggundu & Emmanuel Njeuhmeli

  5. Johns Hopkins Center for Bioengineering Innovation & Design (CBID), Clark Hall Suite 208, 3400 North Charles Street, Baltimore, 21218, MD, USA

    Youseph Yazdi

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A.A.R.T., T.A. and E.N. researched data for article and wrote the article. All authors contributed to the discussion of content and to the review/editing of the manuscript before submission.

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Tobian, A., Adamu, T., Reed, J. et al. Voluntary medical male circumcision in resource-constrained settings. Nat Rev Urol 12, 661–670 (2015). https://doi.org/10.1038/nrurol.2015.253

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