BackgroundVoluntary medical male circumcision (VMMC) for HIV prevention has been a priority for Swaziland since 2009. Initially focusing on men ages 15–49, the Ministry of Health reduced the minimum age for VMMC from 15 to 10 years in 2012, given the existing demand among 10- to 15-year-olds. To understand the implications of focusing VMMC service delivery on specific age groups, the MOH undertook a modeling exercise to inform policy and implementation in 2013–2014.Methods and FindingsThe impact and cost of circumcising specific age groups were assessed using the Decision Makers’ Program Planning Tool, Version 2.0 (DMPPT 2.0), a simple compartmental model. We used age-specific HIV incidence from the Swaziland HIV Incidence Measurement Survey (SHIMS). Population, mortality, births, and HIV prevalence were imported from a national Spectrum/Goals model recently updated in consultation with country stakeholders. Baseline male circumcision prevalence was derived from the most recent Swaziland Demographic and Health Survey. The lowest numbers of VMMCs per HIV infection averted are achieved when males ages 15–19, 20–24, 25–29, and 30–34 are circumcised, although the uncertainty bounds for the estimates overlap. Circumcising males ages 25–29 and 20–24 provides the most immediate reduction in HIV incidence. Circumcising males ages 15–19, 20–24, and 25–29 provides the greatest magnitude incidence reduction within 15 years. The lowest cost per HIV infection averted is achieved by circumcising males ages 15–34: $870 U.S. dollars (USD).ConclusionsThe potential impact, cost, and cost-effectiveness of VMMC scale-up in Swaziland are not uniform. They vary by the age group of males circumcised. Based on the results of this modeling exercise, the Ministry of Health’s Swaziland Male Circumcision Strategic and Operational Plan 2014–2018 adopted an implementation strategy that calls for circumcision to be scaled up to 50% coverage for neonates, 80% among males ages 10–29, and 55% among males ages 30–34.

Swaziland is the first country to introduce national early infant male circumcision (EIMC) into voluntary medical male circumcision (VMMC) programming for HIV prevention. With more than 5,000 EIMCs performed between 2010 and 2014, Swaziland learned that EIMC requires inclusion of stakeholders within and outside of HIV prevention bodies; robust support at the facility, regional, and national levels; and informed demand. Expansion of EIMC and VMMC has the potential to avert more than 56,000 HIV infections in Swaziland over the next 20 years.

Beginning in March 2020, to reduce COVID-19 transmission, the US President’s Emergency Plan for AIDS Relief supporting voluntary medical male circumcision (VMMC) services was delayed in 15 sub-Saharan African countries. We reviewed performance indicators to compare the number of VMMCs performed in 2020 with those performed in previous years. In all countries, the annual number of VMMCs performed decreased 32.5% (from 3,898,960 in 2019 to 2,631,951 in 2020). That reduction is largely attributed to national and local COVID-19 mitigation measures instituted by ministries of health. Overall, 66.7% of the VMMC global annual target was met in 2020, compared with 102.0% in 2019. Countries were not uniformly affected; South Africa achieved only 30.7% of its annual target in 2020, but Rwanda achieved 123.0%. Continued disruption to the VMMC program may lead to reduced circumcision coverage and potentially increased HIV-susceptible populations. Strategies for modifying VMMC services provide lessons for adapting healthcare systems during a global pandemic.

TABLE. (Continued) CDC-supported voluntary medical male circumcisions -13 countries in eastern and southern Africa, 2017-2021 Country Fiscal year* No. of VMMCs performed Annual target achieved, % Client age group, yrs, no. (%) No. (%) <15 15-29 ≥30 VMMCs performed using a device † Clients who received HIV testing at a VMMC site Clients with a positive HIV test result § Clients with postoperative follow-up within 14 days of VMMC

There is an error in the Funding statement. The number for the Cooperative Agreement Project SOAR (Supporting Operational AIDS Research) is incorrect. The correct number is OAA-A-14-00060.