This section outlines relevant VMMC programmatic and research gaps and recommends priority steps to address them (Table 1). Identifying and responding to these challenges is important considering some programs are reaching high VMMC coverage requiring an updated programmatic focus and technical support.

Circumcision coverage estimates play a critical role in VMMC program planning, target setting, and monitoring progress towards HIV epidemic control goals. The VMMC programs use a variety of survey and sampling methodologies, statistical tools, and data to estimate coverage. National household surveys, including the Population-based HIV Impact Assessment (PHIA) and the Demographic and Health Surveys (DHS), are commonly used to inform the estimation of VMMC coverage [21, 26, 27••]. However, evidence suggests male circumcision coverage estimates are unreliable with inconsistencies between data sources, coverage continuously exceeding 100% in some areas, and continued high demand in areas with high estimated coverage [28].

There are limitations to national household surveys when used to estimate coverage. Typically, the subnational circumcision estimates are less robust than national-level estimates when using national household surveys. Less robust estimates at the subnational level are partly because of inaccurate or dynamic denominator data with limited information on internal and external population migration, particularly in countries with older census data, high mobility, or areas with an unstable population with a high proportion of unregistered immigrants, migrant workers, and refugees. This denominator issue is particularly pronounced in countries where granular clinical data are missing at lower administrative levels and in countries with great variation in coverage across geographic regions. The lack of robust subnational-level estimates is partly because national household surveys are not designed statistically for estimating male circumcision coverage.

Additionally, there are limitations to how male circumcision is measured, usually through self-report, with challenges distinguishing medical and non-medical male circumcision. Previous research has found conflicting findings with self-reported circumcision status may be subject to reporting errors in some settings. At the same time, in other areas, there is high concurrence with physical exams [29, 30]. These inconsistencies can lead to over- and underestimating male circumcision coverage and an overall lack of robust and comparable estimates.

According to anecdotal reports, another challenge to estimating accurate coverage is VMMC may be “replacing” non-medical male circumcision in some settings. However, the models and tools used to estimate coverage sometimes assume the proportion of non-medical male circumcision in a national population remains constant. Therefore, additional research is needed to estimate non-medical male circumcision coverage more precisely in various settings.

Robust estimation of male circumcision coverage is important for all aspects of the program but is particularly critical for setting program targets. UNAIDS establishes VMMC targets roughly every 5 years, aligning with goals for ending the AIDS epidemic. Prioritized countries adopt these targets nationally, typically establishing 5-year plans to reach these goals. In addition, PEPFAR supports national governments in establishing program targets annually. However, the accuracy of these targets, particularly at the subnational level, is limited by the reliability of male circumcision coverage estimates discussed above. Overall, there has also been a lack of a standardized approach to establishing coverage estimates and set targets. In 2020, the UNAIDS Reference Group on Estimates, Modeling, and Projections, along with partners, worked with prioritized countries to integrate VMMC into the UNAIDS HIV estimates process to standardize the process [31, 32]. However, official global guidance for standardized estimation of circumcision coverage is needed to enable routine monitoring and more accurate and precise male circumcision coverage estimates.

Defining the types of data collected to supplement national household surveys could help countries determine when additional survey data is needed and which sources are best used in triangulating data. Guidance may be helpful to identify programmatic and service delivery gaps among specific eligible sub-populations with lower male circumcision coverage. Establishing standardized framework countries could easily adapt for estimating coverage at the district or lower administrative level or help identify pockets of low coverage could increase reliability in estimates. Additionally, improvements can be made to national household surveys to improve the accuracy of VMMC reporting. For example, a standardized male circumcision module could be included in national household surveys to more accurately document circumcision status among males through direct observation of circumcision status. As countries reach higher male circumcision coverage, estimating VMMC coverage will become increasingly challenging considering, as coverage rises, estimates become increasingly sensitive to errors in target population estimates.

Despite the success of the VMMC program, there is an ongoing effort to improve strategies to increase VMMC uptake to reduce HIV incidence to reach epidemic control. Programs currently use a variety of approaches and strategies to tailor the most successful interventions for enhancing uptake [17••, 33,34,35]. However, key gaps remain in understanding factors accounting for the choice to undergo the procedure, including motivators, barriers, and experiences [31, 36]. Programs have reported challenges reaching specific groups of men, some of whom are at higher risk of HIV infection and hard to reach for services. Hard-to-reach groups commonly include mobile workers, fishermen, truck drivers, miners, and seasonal workers [17••, 37•]. Populations at higher risk such as men diagnosed with STIs, male partners of female sex workers, and serodiscordant partnerships can also pose specific demand creation challenges [38, 39]. Another important programmatic challenge is the limited voluntary uptake of circumcision among males 30 years and older who are more likely to be married or cohabiting, finding it challenging to justify VMMC to their partners [40].

Programs are also facing a digital divide. There is varying capacity to implement technology in social media campaigns across prioritized countries. Only programs with the specialized knowledge, infrastructure, and financial resources to develop the mobile tools have the advantage of utilizing the algorithms social media affords reaching targeted groups with tailored messaging. Programs have experienced recent success in using innovative technology to target specific audiences through social media, particularly to engage older men [41].

A promising strategy for improving uptake of VMMC is psychographic-behavioral segmentation, using human-centered design (HCD). Through segmentation, potential VMMC clients are categorized according to certain characteristics, which allows for specific messaging based on a client’s profile [42]. Initial studies found differing client characteristics in Zimbabwe and Zambia, indicating the importance of tailored interventions [43, 44]. Another important factor for increasing uptake is understanding the stage of change in which the client is in when they are approached for VMMC [45]. Additional evidence is needed to understand how readiness for the procedure relates to the uptake of services. In addition to psychographic approaches, demographic and geographic segmentation are important for developing a strategic approach to demand generation. Demographic segmentation may be useful for increasing uptake among older age groups, because demand creation approaches are specifically tailored to address their needs. Another demographic segmentation factor for consideration is a client’s financial status. Wage loss from time off work for recovery after VMMC, including the perceived time needed, has differential effects on men depending on their financial status. More information is needed to understand situations in which compensation or incentives are most sensible for programs to offer and leverage proven approaches to reach different sub-demands. Geographic segmentation by clustering clients according to their location could benefit demand creation planning. Mapping and analytic technology such as geographic information systems can help programs plan for optimal use of resources and guide services with the greatest potential for VMMC conversion.

Device-based male circumcision may influence men’s perceptions of VMMC and may be a promising approach to increase uptake [17••, 46]. However, gaps still exist on whether device-based male circumcision increases demand among those previously hesitant or merely replaces surgical VMMC among those who eventually would have sought services. Research is also needed on the cost/benefit of targeting older men (≥ 30 years) for VMMC when fewer resources are believed to be required for demand generation targeting younger age groups (≤ 19 years) [47]. Once a program has reached high coverage and shifted towards sustainability, strategies to enhance uptake could focus on males aging into eligibility [48] with ongoing evaluations to ensure strategies continue to be effective on newly eligible clients.

Voluntary medical male circumcision is a preventive procedure typically performed on healthy males. Safety has been a critical priority for VMMC programs, and VMMC has demonstrated it is a safe procedure. Adverse events have been monitored since program inception, and overall, < 2% of VMMC clients have been identified through passive reporting as having moderate or severe AEs [49, 50]. In addition, national VMMC programs have made critical adjustments in response to safety signals, such as implementing mitigation measures in response to tetanus cases associated with VMMC, halting the use of forceps-guided circumcisions in clients 10–14 years old, enhancing pre-circumcision screening for bleeding disorders, and raising client age eligibility for conventional surgical VMMC to 15 years and older due to an increase in specific adverse events reported in 10–14-year-old clients [51,52,53].

Quality assurance and quality improvement activities commonly practiced by VMMC programs include AE surveillance, AE investigations and contributing root cause analyses, external quality assessments, and continuous quality improvement. However, each national program has its approach to quality and safety, which often changes over time and is frequently determined in reaction to an event. Therefore, the lack of a deliberate approach to program quality can lead to inadequate monitoring, missed epidemiologic signals, insufficient AE investigations and analyses, improper corrective actions, and ultimately, missed opportunities to improve safety for clients and staff.

With any surgical intervention, it is impossible to eliminate all complications. When AEs occur, timely diagnosis and optimal management can minimize long-term sequelae. Although tools and guidance have been developed to standardize and improve the management and prevention of commonly reported AEs, there is considerable variation in how national VMMC programs manage certain severe AEs [48, 54, 55]. Some programs have a well-planned AE management system, including designated specialty care providers or centers of excellence. Still, many lack a standardized approach or local capacity to manage these cases appropriately.

Informed consent/assent is a critical component of preoperative counseling. Counseling on risks and benefits can be transparent and delivered in easy-to-understand language with ample opportunities for clients to ask questions. Clients, especially younger adolescents, have a wide range of maturity and capacity to understand the procedure, potentially impacting their ability to give informed consent/assent. Although the general need for client understanding of risks and benefits prior to surgery is well-accepted, there is a potential need for greater assessment and support of adolescents’ capacity for autonomous decision-making in healthcare settings [56].

Improving VMMC safety is a constant priority for VMMC program planners and implementers. Recommended priority steps for improving the quality and safety of VMMC programs include a responsive, standardized, and comprehensive approach to AE surveillance. Through continuous quality improvement, surveillance data for action gives purpose to surveillance by translating safety events to improved outcomes for future clients and overall improved program safety. Continued monitoring of quality and safety activities can remain a critical component of VMMC programs. Standardized summaries of risks and benefits could be developed for VMMC programs to translate and use for eligible clients to improve informed consenting practices. In addition, global guidance is needed on how VMMC counselors can assess the ability of younger clients and their parents or guardians to comprehend and provide consent or assent for VMMC.

Robust networks and coordination across programs are needed to improve the safety and quality of VMMC programs. Establishing a network of shared safety experiences within and across national VMMC programs could amplify best practices and provide a mechanism to share AE management experiences. Additionally, improved coordination within and among countries to optimize the management of serious, complex AEs is needed. Additional research on the categorization of attributes of clients at higher risk for AEs or who missed follow-up appointments could help to identify higher risk clients to prevent adverse outcomes. Additionally, male circumcision devices warrant monitoring to inform programming decisions around safety and sustainability. Finally, another important gap is that the program has primarily concentrated on the quality of the procedure but has not focused as rigorously on the quality of other areas such as HIV testing services, medical record keeping, demand creation, and client education. Additional attention and resources may be needed to ensure all aspects of quality for the VMMC program are rigorously monitored.

Following the first 15 years of program expansion, the sustainability of national VMMC programs is becoming increasingly important. Although sustainability was initially conceived as a distinct phase of program transition, sustainability of VMMC will require a more gradual evolution including measured integration of VMMC services into national health systems. The sustainability of VMMC is particularly important with economic modeling predicting the program will continue to be a cost-effective prevention strategy and, in fact, cost-saving in most countries over a 50-year horizon [57]. In 2020, as part of the updated recommendations for VMMC, WHO published a framework for sustaining VMMC services [17••]. The framework builds upon the WHO’s health system “building blocks” and integrates VMMC-specific information [58]. The sustainability of VMMC is defined in the following ways: (1) the capacity of VMMC services to maintain high male circumcision coverage (≥ 90%); (2) the integration of VMMC services into a country’s health system; (3) strong country ownership and leadership; and (4) resource mobilization may include domestic and external funding. VMMC sustainability is a new area for national programs, and programmatic and research gaps remain, and each strategic planning component for sustainable VMMC services remains relatively unknown. One area which poses a challenge is long-term workforce needs. Although the capacity building of the health workforce, particularly nurses, to perform the surgical procedure has been a major success of VMMC implementers and donors, the long-term resource and policy could sustain this workforce capacity remain unknown.

Priority steps could be taken to progress successfully to fully sustainable VMMC programs. The VMMCs programs have relied largely on donor support, and the need for diversified financing streams is evident, as donor-funded programs alone are not sustainable. Engaging ministries of health and finance will be critical as national health priorities are financed. However, careful evolution of financial responsibility is essential, with most countries lacking the resources to fully support HIV prevention services. Priority components for VMMC sustainability for each of the building blocks are outlined in the WHO framework summarized in Table 2. Key steps for the first building block of finance include estimating country resource needs and inclusion into national health plans. Inclusion of VMMC programs into national health plans could include integration with other health services such as national sexual and reproduction health programs for adolescents and males. For health workforce planning, the establishment of systems to monitor staff retention and integration of the VMMC workforce into national workforce planning can be considered. Recommended initial steps towards workforce sustainability include the incorporation of VMMC into pre-service health care worker training programs [59]. Recommended steps for the strategic information building block include integrating data collection into routine monitoring and evaluation systems and modernizing data collection.

For the supplies and equipment building block, integration of procurement and distribution of supplies into national procurement systems are recommended. This area may be easier to transition, with several ministries of health already procuring supplies for other health services. Although the scale-up phase of the program primarily relied on single-use instruments, more recent guidance has prioritized reusable instruments, not only for the sustainability of services but also to reduce costs and environmental impact. Considerations for the leadership and governance building block focus on integration with local governance. Leadership and governance for VMMC have been country-led since the program’s inception and maintaining this momentum will be critical for the program’s sustainability. Lastly, key actions for the service delivery building block focus on strategic planning of health services and promotion of VMMC as part of a comprehensive package of care.

Measuring a country’s progress towards sustainability is critical for countries to understand and assess their transition. A 2022 landscape analysis conducted by WHO and UNAIDS applied the above-referenced framework and summarized the status of each country’s VMMC program in relation to the sustainability of services. The overwhelming majority of the WHO building block designations were either at an early or intermediate phase with minimal or only a few sustainable features present. A full report on the analysis is expected to be published in mid-2022.

Many countries have taken steps towards sustainability. Actions range from developing national plans for sustainability to piloting the transition of service delivery from donor-funded community organizations to government services [60, 61]. For example, several countries have tried to incorporate early infant male circumcision (EIMC) as part of their sustainability plan, but no national EIMC programs are currently active. In 2019, PEPFAR support for all EIMC activities was ceased after a careful review of impact and safety data. In 2020, WHO further cautioned countries to carefully consider the risks and benefits, human rights, and resources to safely deliver EIMC services for HIV prevention [17••].