This blog post, written by Zizo Zikali, first appeared on What’sUpHIV as part of a series covering the 8th South African AIDS Conference.

The department of health in partnership with USAID and The Centre for HIV and AIDS Prevention Studies (CHAPS) are working together to fight the HIV/AIDS epidemic by developing a safe and sustainable service delivery model for early infant male circumcision in South Africa.

Chief executive officer of CHAPS Dirk Taljaard said CHAPS conducted a study examining the feasibility of early infant male circumcision in Soweto and Orange farm in Johannesburg, Gauteng. Nearly 70 percent of 304 urban mothers and 142 fathers showed interest of circumcising their sons before they were six weeks old.

“The study concluded that early infant male circumcision would be acceptable in the country; despite the pull of traditional circumcision during adolescence among certain ethnic groups. However, there should still be discussions at national, provincial, district and local level as soon as possible.”

There was some dissent. Siyabonga Zulu, a 34-year-old man from Umlazi, south of Durban, believes that circumcising a minor would be violating their rights. He believed a child should be circumcised only when he has reached an age when he could decide for himself whether to opt for medical or traditional circumcision.

Angelo is a Program Manager at AVAC.

[Editor’s Note: It’s been a busy few months. We are happy to finally share this blog, which includes references to events from last quarter, but reviews progress on VMMC and details the still-new framework to operationalize VMMC. Look for a forthcoming blog on VMMC commitments at the recent PEPFAR COP reviews.]

A presentation by the World Health Organization (WHO) earlier in the year brought good news about voluntary medical male circumcision (VMMC), telling a story of lives saved—many, many lives. Facing a room full of VMMC experts, Dr. Buhle Ncube of WHO’s Africa Regional Office scrolled through a series of slides and highlighted a breathtaking number:

“More than 450,000 new HIV infections are projected to be averted by 2030 as a result of male circumcisions conducted in 14 priority countries even if programs stopped circumcising today.”

VMMC is a subject I care deeply about, and I spend many hours of work at AVAC on efforts to help accelerate its scale-up as part of combination prevention. These lives saved by VMMC represent a success and an opportunity. The opportunity had brought us to this meeting. Dr. Ncube’s presentation was part of the WHO’s February meeting to operationalize a new framework on VMMC.

Held in Durban, South Africa, the WHO brought together more than a hundred VMMC experts from fifteen priority countries (South Sudan was added recently) for the meeting. Attendees included Ministry of Health officials, WHO, UNAIDS, UNICEF and other UN staff, civil society, funders and implementers. The goals: to reflect on progress and impact to date; to discuss critical factors that explain the progress; and to explore new ways to address the challenges programs are facing. Funding for the VMMC programs in the priority countries was a big part of the conversation at the meeting, and unfortunately, I left the meeting with more questions than answers about aligning the new ambitious targets with real funds.

VMMC is one of the most powerful and cost-effective HIV prevention options currently available. Studies from 2006 showed that it reduces a man’s risk of acquiring HIV from a female partner by up to 60 percent, increasing to around 75 percent over time.

In 2007, WHO recommended that VMMC be scaled up in countries with high HIV prevalence and low levels of male circumcision. Although uptake was slow at the beginning, scale-up in most of the priority countries intensified as funders and implementers recognized that demand creation was as important as creating supply. UNAIDS and WHO set an ambitious goal of circumcising 80 percent of males in those countries by 2015, which would amount to about 20.3 million procedures, which would avert 3.4 million new HIV infections and save US$16.6 billion in future healthcare costs.

Participating in the deliberations at the Durban meeting gave me hope but also left me with chills. The successes show the power of this new tool, but scaling up this intervention depends on securing the political will to fund it. Those funds and the political will they require have not arrived.

Impressive progress
Although the original goal wasn’t realized, progress made is unprecedented in healthcare delivery—11.7 million males were circumcised by the end of 2015; increasing to more than 14 million by the end of 2016, about 69 percent of the original goal of 20.3 million procedures.

“The largest impact is from South Africa with an estimated 218,000 new HIV infections projected to be averted by 2030,” said Dr. Ncube. WHO further estimates that the goal of 80 percent coverage would avert another 470,000 new HIV infections by 2030 if VMMC rates can be sustained among 10- to 29-year-olds by 2020. This is worth taking a pause and celebrating!

Going forward with ambition
In 2016, UNAIDS released a new five-year strategy, and it contains an even more ambitious goal—27 million additional circumcisions by 2021. To align with this new strategy, WHO developed a new vision for scaling up VMMC called VMMC 2021. As civil society, we’ve often called for ambition, and we commend WHO for this boldness.

Wait a minute? Where is the funding to meet the ambitious goals?
This is what gives me chills! Achieving the new global target will require about five million procedures per year—double the current annual numbers. Moreover, the new VMMC 2021 framework calls for an alignment with the UN Sustainable Development Goals (SDGs), particularly Goal 3 (Good Health and Well-being); Goal 5 (Gender Equality); and Goal 17 (Partnerships).

“We must do things differently. We have to look at new institutional arrangements and widen global health architecture,” urged WHO’s Julia Samuelson.

This is a big shift that will definitely require a huge amount of resources. Yet the reality on the ground in countries is already dire. The truth is, ambitious targets that are not tied to funding are not very helpful. AVAC works with country-level coalitions to track both investment and progress towards national VMMC goals, and we see some consistent issues that impact progress toward targets. Each of these countries rely on PEPFAR as the major source of funding. In one place progress speeds along, in others it drags. Entire country programs like Malawi struggle widely. The task before us is not unachievable, but it’s huge.

So, where do we go from here?
As civil society, we welcome these new targets and approach. But, to meet them, more ambitious, more diverse and more predictable funding commitments are urgently needed from international donors and country governments. The new framework looks good on paper, but with no funding commitments to match those ambitions, we’re setting ourselves up to fail. And we can’t afford to fail.

So, I challenge PEPFAR to commit more resources for VMMC in the Country Operational Plans (not via PEPFAR Central Funds, which are highly unpredictibale, and subject to the discretion of bureacrats and politicians).

But we also need other donors to step up and join PEPFAR. So I also challenge country teams developing Global Fund concept notes to allocate more funds to VMMC. Sometimes civil society colleagues who are engaged in the Global Fund application process assume that VMMC has been fully funded by PEPFAR – but this is not the case.

Finally, I challenge country governments to take more ownership and commit more domestic finances to VMMC. Growing up, my teachers always told me that charity begins at home. Can we model this for the health of our people?

Slides and other key resources from the meeting available at this link.