Background:  An important landmark in the history of HIV prevention was the finding from 3 randomized controlled trials in Kenya, South Africa, and Uganda that adult male circumcision reduces the risk of heterosexual HIV transmission to men by approximately 60%. WHO and UNAIDS subsequently issued policy recommendations that safe male medical circumcision services should be scaled up as a priority intervention in settings with heterosexual epidemics characterized by high HIV prevalence and low levels of male circumcision. For priority technical and operational support, 13 southern and eastern African countries have been identified.

Methods:  Modeling suggests that scaling up of male circumcision programs to cover 80% of currently uncircumcised men could avert more than 4 million HIV infections between 2009 to 2025, result in savings of US$20 billion and require almost 12 million circumcisions to be performed in 2012. However, male circumcision scale-up continues to be questioned in many quarters. Critical issues identified as barriers to scale-up include:  human resource constraints, the possible negative consequences of male circumcision program scale-up for women, possible religious and cultural barriers to scale-up particularly in traditionally non-circumcising communities. There are also concerns that risk compensation may occur following the expansion of circumcision services if there is a false perception that male circumcision provides complete protection from HIV infection.

Results:  However, by the end of 2009, all 13 “priority” countries had begun scale-up of male circumcision programs. All countries had conducted situation analyses, were developing policies and strategies to guide scale-up, and training providers. Innovative measures to address human resource constraints were being explored, such as Kenya allowing complete task shifting to clinical officers and nurses, efficiency models being implemented in South Africa and Swaziland, and planning for the use of volunteer doctors. The most progress has been in countries where the Ministry of Health has taken leadership and championed the importance of circumcision to reverse the HIV epidemic.

Conclusions:  In spite of these gains critical challenges remain—the pace of service delivery is slow and unless current pace of scale up is not accelerated it will be long before the impact on the epidemic is realized.