Background: Voluntary medical male circumcision (VMMC) has been scaled-up in fourteen Eastern and Southern African countries since 2009. The VMMC service package includes HIV testing, which offers a unique opportunity to reach men and realize the UNAIDS 90-90-90 goals. According to WHO, 10.5 million men were circumcised in these countries through December, 2015. However, little is known on HIV testing and linkage to care for clients who test HIV-positive in these programs.
Methods: This was a multi-country, retrospective study of VMMC services implemented in Botswana, Mozambique, Namibia, Tanzania, and Zambia, under respective ministries of health, with support from PEPFAR and Jhpiego. We reviewed client-level databases for the period September 2009 through December 2016, though countries initiated VMMC services at different times during this period (Table 1). Data were analyzed to determine HIV positivity rate, new HIV diagnoses, and successful linkage to HIV care and treatment.
Results: Cumulatively, 1,225,083 men received VMMC in the five countries, of which 1,157,240 (94.5%) were tested for HIV. Among the five countries, 13,534 (1.2%) males tested HIV-positive, ranging from 1.0 - 7.2% with Namibia having the highest positivity rate. For four countries, Botswana, Namibia, Mozambique, and Tanzania, 12,952 HIV positive clients were identified with 11,196 (86.4%) being newly-diagnosed, and 8,772 (78.4%) of those newly diagnosed linked to HIV care and treatment.

CountryTime Period# VMMC clients# tested (%)# Tested HIV-positive (%)# New HIV-positive (%)# Linked with HIV care/ treatment (%)
BotswanaJan 2014-Dec 201614,53814, 298 (98.4%)242 (1.7%) 242 (100%)76 (31.4%)
MozambiqueOct 2009 - Nov 2016589,415580,231 (98.4%)7,519 (1.3%)7,519 (100%)6,215 (82.7%)
NamibiaMay - Nov 20162,9172,576 (88.3%)186 (7.2%)27 (14.5%)17 (63.0%)
TanzaniaSept 2009-Sept 2016557,570504,545 (90.5%)5,005 (1.0%)3,408 (68.1%)2,464 (72.3%)
ZambiaApr 2015- Oct 201660,64355,590 (91.7%)582 (1.1%)not reportednot reported
Total 1,225,0831, 157, 240 (94.5%)13, 534 (1.2%)11,1968, 772 (78.4%)
[Table 1: HIV Testing and Linkage in VMMC]

(NB: Total tested HIV positive is underreported for Mozambique and Botswana since they only reported newly diagnosed HIV positive clients).
Conclusions: VMMC provides a unique opportunity to offer HIV testing for men who are hard-to-reach through other HIV testing approaches. Although overall yield may be relatively low (1.2%), VMMC is successful at identifying new HIV infections among clients who did not previously know their status and linking them to HIV care and treatment. Stronger data on linkage from VMMC to HIV treatment is needed, and additional efforts should be made to ensure better linkages across the prevention, care and treatment continuum.

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