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For more, see [[USAID]], [[Centers for Disease Control|CDC]], and the [[National Institutes of Health|NIH]].<!--
== PEFPAR promoting infant circumcision ==
"Typically, USAID’s policy is to circumcise males between the ages of 15 to 49, as one part of a comprehensive HIV/AIDS program. However, with encouragement from PEPFAR, the Raleigh Fitkin Memorial Hospital in Manzini, has led the way on infant circumcision, circumcising all male children born at the hospital since 2009 unless the parents opt out. This is a health facility delivering 8,000 babies a year where half of the women are HIV-positive). Prevention of mother to child transmission is now complemented with infant circumcision."<REF>{{REFweb
|last=
|first=
|date=2011-11-14
|title=The PEFPAR ripple effect
|url=http://www.one.org/us/2011/11/14/the-pepfar-ripple-effect/
|accessdate=2012-12-29
}}</ref>
|trans-title=
|language=
[[Category:Programs]]
PEPFAR
,removed blank line
[[Image:PEPFAR.png|right|thumb|PEPFAR]]
The '''President's Emergency Plan For AIDS Relief''' ('''PEPFAR''') is a United States governmental initiative to address the global [[HIV ]] epidemic and help save the lives of those suffering from the disease. Launched by U.S. President George W. Bush in 2003on the advice of [[Anthony Fauci]], PEPFAR has provided more than $80 85 billion in cumulative funding for [[HIV]]/[[AIDS ]] treatment, prevention, and research since its inception, making it the largest global health program focused on a single disease in history.
PEPFAR has begun providing money (United States tax dollars) for male circumcision programs.<ref>{{REFweb
|url=http://www.youtube.com/watch?v=60uUA0uGOkc#t=22m38s
|accessdate=2011-04-10
}}</ref> Focus countries have been invited to request program funding to increase access to the procedure. According to Kent Hill (assistant administrator for PEPFAR ignominiously ended the provision of non-therapeutic [[USAIDcircumcision]]of boys under age 15 in November 2019 due to significant, complications, injuries, and other abuses. ==Reimagining PEPFAR's Strategic Direction==This document, ''Reimagining PEPFAR's Strategic Direction'', published in September 2022, provides new directions for PEPFAR's fight against the ''HIV'' pandemic. The document is entirely silent on male and female circumcision, although male circumcision was the cornerstone of the previous effort to prevent HIV infection and PEPFAR formerly proudly trumpeted the 27,700,000+ circumcisions (AKA genital mutilations)in Africa that it had sponsored. It is unclear if PEPFAR will continue to promote circumcision, funding will increase which has been demonstrated to be "an important part" of PEPFAR programs in coming yearsineffective.<refname="reimagining2022">{{REFwebREFdocument |title=Reimagining PEPFAR's Strategic Directio |url=https://www.state.gov/wp-content/uploads/2022/09/PEPFAR-Strategic-Direction_FINAL.pdf |contribution= |last=Medical News TODAY
|first=
|datepublisher=2007-08-22U.S. Department of State |titleformat=PEPFAR To Begin Providing Funds For Male Circumcision Programs In Some African Countries, Officials SayPDF |urldate=http://www.medicalnewstoday.com/articles/80219.php2022-09 |accessdate=20112022-0311-3028
}}</ref>
== World AIDS Day (2010) Announcements ==
{{Citation
|Title=PEPFAR Press Conference
|Text=I'm pleased to note that USAID will play a signifigant significant role, with NIH, PEPFAR, and others [...] Swaziland, where we're all working in partnership to increase circumcision [...] to more than 80% in less than one year. It's the kind of example of a rapid scale-up [...] that can really make a difference [...] we can scale them up rapidly and do that in a successful and focussed way. [...] I want to share with you my deep respect for what you do, for your work and commitment. For proving to the world, that often didn't believe you could reach such high treatment numbers, or you could acheive achieve such rapid scale-up of circumcision [...] We take great inspiration from that [...]
|Author=
|Source=The White House
}}
==FACT SHEET: The Beginning of the End of AIDS 2011 ==
{{Citation
|Text=PEPFAR is leading the world in support for a rapid expansion of voluntary medical male circumcision. In the past few years, research has proven that this low-cost procedure reduces the risk of female-to-male transmission by more than 60 percent—and the benefit is life-long. Approximately one million male circumcisions for [[HIV ]] prevention have been done in recent years, with the United States providing the support for three-quarters of them. Building on this, over the next two years, PEPFAR will support more than 4.7 million voluntary medical male circumcisions in Eastern and Southern Africa.
|Author=
|Source=The White House
}}
Note that the 60% is a relative risk reduction (absolute risk reduction 1.31%) during 18 months - not life-long.<ref name="boyle2011">{{BoyleGJ HillG 2011}}</ref> ==President Obama announces bold new AIDS commitment 2011== President Obama commemorated World AIDS Day by stepping up America’s commitment to the fight against AIDS, both domestically and internationally. In addition to his broad rhetoric on the importance — and feasibility — of ending AIDS, he made a number of specific commitments. The US will (among other commitments) provide support for more than 4.7 million voluntary medical male circumcisions in Eastern and Southern Africa over the next two years.<REF>{{REFweb |last= |first= |date=2011-12-01 |title=President Obama announces bold new AIDS commitments |url=http://www.one.org/us/2011/12/01/president-obama-announces-bold-new-aids-commitments/ |accessdate=2012-12-29}}</ref>
== Swaziland ==
|date=2011-03-04
|publisher=Science Speaks: HIV & TB News
|quote=The Ministry of Health, supported principally by [[UNICEF ]] and [[PEPFAR]], is currently working to introduce and scale up neonatal circumcision.
|accessdate=2011-05-06
}}</ref>
Point of Interest: In recent studies, [[HIV ]] transmission was found to be more prevalent in circumcised males in Swaziland. The drive to circumcise the majority of Swazi men continues none the less.<ref>{{REFjournal
|last=
|first=
|pages=
|url=http://www.measuredhs.com/pubs/pdf/FR202/FR202.pdf
|quote=As Table 14.10 shows, the relationship between [[HIV ]] prevalence and circumcision status is not in the expected direction. Circumcised men have a slightly higher [[HIV ]] infection rate than men who are not circumcised (22 percent compared with 20 percent
|accessdate=2011-05-06
}}</ref>
From the PEPFAR Swaziland Operational Plan Report FY 2011 (emphasis added):<REF>{{REFweb
}}
From the PEPFAR Blueprint: Creating an [[AIDS]]-free Generation (emphasis added):<REF>{{REFweb
|last=
|first=
{{Citation
|Text=Action Step: Increase the number of males who are circumcised for the prevention of [[HIV]]....
10. Build the capacity of partner governments to begin planning for and financing an integrated, long-term '''early infant male circumcision (EIMC)''' program as the adult V[oluntary ]M[edical ]M[ale ]C[ircumcision] program is being scaled-up. PEPFAR’s financial support is prioritized to the adult VMMC program. However, '''once the adult program has progressed sufficiently, PEPFAR funds may be used to support EIMC activities'''.
== PEPFAR's African Safaris ==
From a blog.AIDS.gov entry by Jeffrey S. Crowley, M.P.H.{{MPH}}, Director, Office of National [[AIDS ]] Policy dated 26 May 2011:<ref>{{REFweb
|last=
|first=
{{Citation
|Text=Last week, I wrote about my attendance at the PEPFAR annual meeting in South Africa, the country that has more people living with [[HIV ]] (over 5 million) than any other country in the world. After this meeting, I visited the neighboring country of Swaziland, which has the unwelcome distinction of having the highest [[HIV ]] and TB prevalence rates in the world.
...
The United States Ambassador to Swaziland, the Honorable Earl Irving, was an incredible host. I attended a large reception at the Ambassador’s residence with the Honorable Minister of Health, Benedict Xaba and other Swazi leaders working on [[HIV]], as well as representatives from PEPFAR, Peace Corps, CDC, USAID, DoD, and private American institutions, including Columbia University’s International Center for [[AIDS ]] Care and Treatment Programs (ICAP) project. Another evening, the Ambassador hosted a dinner with leaders from the Swazi Cabinet, the Ministry of Health and the national [[AIDS ]] commission. I participated in a handover ceremony where the Ambassador ceremoniously transferred nine vehicles from PEPFAR to the government of Swaziland that will support their [[HIV ]] work in the field. Through this event I also had the opportunity to meet His Excellency the Right Honorable Prime Minister of Swaziland.
A major focus of PEPFAR’s work is to assist the Swazi government’s plan to scale up adult male circumcision. This lowers the risk that men will acquire [[HIV ]] infection and research models indicate that if the country can get up to 80% of its adult men circumcised, they could observe a substantial decline in [[HIV ]] transmission. I visited one of several mobile sites that enabled Swaziland and PEPFAR to quickly expand access to circumcision.
|Author=
|Source=
==RCTs shown to be erroneous==
Boyle & Hill (2011) established conclusively that the randomized controlled trials had disabling methodological and statistical flaws that invalidated their findings,<ref name="boyle2011" >{{BoyleGJ HillG 2011}}</ref> Therefore therefore the PEPFAR VMMC program is based on false information. [[Robert S. Van Howe|Van Howe ]] & Storms (2011) correctly forecast that institution of a circumcision program would increase the number of [[HIV ]] infections.<ref>{{REFjournal
|last=Van Howe
|first=Robert S.
|init=RS
|author-link=Robert S. Van Howe
|last2=Storms
|first2=Michelle
|init2=M
|author2-link=
|etal=no
|title=How the circumcision solution in Africa will increase HIV infections
|journal=Journal of Public Health in Africa
|location=
|DOI=10.4081/jphia.2011.e4
|accessdate=2021-02-16
}}</ref> [[Robert S. Van Howe|Van Howe]] & Boyle (2018) added further critical comment and suggested the possibility of fraud.<ref name="vanhowe2018">{{REFjournal |last=Van Howe |first= |init=RS |author-link=Robert S. Van Howe |last2=Boyle |first2= |init2=GJ |author2-link=Gregory J. Boyle |etal=no |title=Meta-analysis of HIV-acquisition studies incomplete and unstable |journal=BJU Int |date=2018-10-31 |url=https://www.bjuinternational.com/letters/meta-analysis-circumcision-incomplete-unstable/ |quote=Given the effectiveness of condoms, the lack of consistent findings on national levels, the methodologically flawed RCTs, the lack of translational research, and the impressive potential uptake and effectiveness of pre-exposure prophylaxis, circumcision as an intervention to prevent HIV infection should be treated with greater scepticism. |pubmedID= |pubmedCID= |DOI= |accessdate=2022-01-01}}</ref> PEPFAR, however, paid no attention to these warnings and continued to promote the harmful VMMC program.
== Investigations by the Office of Inspector General (OIG) ==
{{Citation
|Text=Our review found that CDC did not always monitor recipients’ use of President’s Emergency Plan for AIDS Relief (PEPFAR) funds in accordance with departmental and other Federal requirements. CDC implements PEPFAR, working with ministries of health and other public health partners to combat [[HIV]]/AIDS by strengthening health systems and building sustainable [[HIV]]/AIDS programs in more than 75 countries in Africa, Asia, Central and South America, and the Caribbean. HHS receives PEPFAR funds from the Department of State through a memorandum of agreement.
There was evidence that CDC performed some monitoring of recipients’ use of PEPFAR funds. However, most of the award files did not include all required documents or evidence to demonstrate that CDC performed required monitoring on all cooperative agreements. Of the 30 cooperative agreements in our sample, the award file for only 1 agreement contained all required documents. The remaining 29 award files were incomplete. In addition, 14 of 21 files were missing audit reports. (A report was not yet due for 9 of the 30 cooperative agreements.) The lack of required documentation demonstrates that CDC has not exercised proper stewardship over Federal PEPFAR funds because it did not consistently follow departmental and other Federal requirements in monitoring PEPFAR recipients.
{{Citation
|Title=
|Text=Through its Global [[HIV]]/[[AIDS ]] Program, CDC implemented the President's Emergency Plan for AIDS Relief (PEPFAR), working with ministries of health and other in-country partners to combat [[HIV]]/[[AIDS ]] by strengthening health systems and building sustainable [[HIV]]/[[AIDS ]] programs in more than 75 countries. Through a 5-year cooperative agreement, CDC awarded PEPFAR funds totaling $20.6 million to the Republic of Namibia, Ministry of Health and Social Services (the Ministry) for the budget period September 30, 2009, through September 29, 2010.
Our audit found that the Ministry did not always manage PEPFAR funds or meet program goals in accordance with award requirements. With respect to financial management, specifically financial transaction testing, we found that $3.7 million of the $4 million reviewed was allowable, but $243,000 was not. Additionally, the Ministry used PEPFAR funds to pay $565,000 of potentially unallowable value-added taxes (VAT) on purchases, did not accurately report PEPFAR expenditures for this cooperative agreement on its financial status report (FSR) submitted to CDC, and did not obtain an annual financial audit as required by Federal regulations.
{{Citation
|Title=President's Emergency Plan for AIDS Relief Funds
|Text=The President's Emergency Plan for AIDS Relief (PEPFAR) program authorized $78 billion from 2003 through 2014 in support of international programs for prevention, treatment, and care to combat [[HIV]]/[[AIDS]], tuberculosis, and malaria. OIG examined the funds spent through this program in a 2011 report focusing on whether the Centers for Disease Control and Prevention's (CDC) oversight met departmental and Federal regulations. OIG found that while CDC performed some oversight of recipients' fund use, most of the award files did not include all required documents or evidence to demonstrate that CDC performed required monitoring. Because of these concerns, OIG expanded its audits internationally to include CDC's monitoring of PEPFAR funds by offices in other countries as well as audits of recipient organizations abroad. OIG issued two audits on Namibia, one in 2012 and another in 2013, and has an additional eight audits conducted there and in South Africa and Vietnam that are near completion." OIG is also planning seven more audits of PEPFAR grantees in Ethiopia and Zambia for FY 2013.
|Author=
|Source=
==Recent developments==
[[Michel Garenne|Garenne]] & Matthews (2019) reported that there is little difference in the incidence of [[HIV]] infection between circumcised men and intact men in Zambia. The authors stated that the "effectiveness of VMMC could therefore be seriously questioned."<ref name="garrenne2019">{{REFjournal
|last=Garenne
|first=Michel
|init=M
|author-link=Michel Garenne
|last2=Matthews
|first2=Alan
|init2=A
|author2-link=
|etal=no
|title=Voluntary medical male circumcision and HIV in Zambia: expectations and observations
|trans-title=
|language=
|journal=J Biosoc Sci
|location=
|date=2019
|volume=52
|issue=4
|article=
|page=
|pages=560-72
|url=https://www.researchgate.net/profile/Michel-Garenne/publication/336532028_Voluntary_medical_male_circumcision_and_HIV_in_Zambia_expectations_and_observations/links/5ddbf732299bf10c5a333405/Voluntary-medical-male-circumcision-and-HIV-in-Zambia-expectations-and-observations.pdf
|archived=
|quote=
|pubmedID=31608845
|pubmedCID=
|DOI=10.1017/S0021932019000634
|accessdate=2021-03-07
}}</ref>
The [[VMMC Experience Project]] published a massive, illustrated 153-page report on VMMC in Africa for the United Nations on 4 May 2019.<ref name="fish2019">{{REFdocument
|title=Circumcision Campaigns: African experience and human rights: The U.N. Report
|trans-title=
|language=
|url=https://www.vmmcproject.org/wp-content/uploads/2020/09/VMMC-UN-Report.pdf
|archived=
|contribution=
|quote=
|trans-quote=
|quote-lang=
|last=Fish
|first=Max
|author-link=Max Fish
|publisher=VMMC Experience Project
|location=
|format=PDF
|date=2019-05-07
|accessdate=2021-05-15
}}</ref>
As reported above, PEPFAR announced in November 2019 that the program to circumcise children would be discontinued due to abuses and an extremely high incidence of botched circumcision resulting in permanent injuries and mutilations.<ref name="lipstick2019" />
</center>
<br>
[[George C. Denniston]], M. D.{{MD}}, M. P. H.{{MPH}}, the president of [[Doctors Opposing Circumcision (D.O.C.)| Doctors Opposing Circumcision]], in a letter to Ambassador Deborah L. Birx, M.D.{{MD}}, M. P. H.{{MPH}}, dated 29 June 2020, the head of the President’s Emergency Plan for AIDS Relief (PEPFAR) , has called on PEPFAR to suspend the provision of male [[circumcision]] because it is ineffective and may increase the reception of [[HIV ]] infection due to the loss of [[Immunological and protective function of the foreskin| immunological protections]] of the [[foreskin]], and to focus on the provision of anti-retroviral therapy and condoms.<ref name="denniston2020">{{REFdocument |title=Letter to Deborah L. Birx, M. D.
|url=https://pool.intactiwiki.org/images/2020-06-15b_LettertoPEPFAR.pdf
|contribution=
|last=Denniston
|first=George C.
|publisher=[[Doctors Opposing Circumcision(D.O.C.)]]
|format=
|date=2020-06-29
The [https://www.vmmcproject.org/ VMMC Experience Project] published an 18-page article on 9 September 2020, that is highly critical of PEPFAR's male circumcision program. In brief, it charges:
<blockquote>
Campaigns to circumcise millions of boys and men to reduce [[HIV ]] transmission are
being conducted throughout eastern and southern Africa, recommended by the
World Health Organization and implemented by the United States government and
contextual research, and the manner in which they have been carried out implies
troubling assumptions about culture, health, and sexuality in Africa, as well as a failure
to properly consider the economic determinants of [[HIV ]] prevalence. This critical
appraisal examines the history and politics of these circumcision campaigns while
highlighting the relevance of race and colonialism. It argues that the “circumcision
solution” to African [[HIV ]] epidemics has more to do with cultural imperialism than with
sound health policy, and concludes that African communities need a means of robust
representation within the regime.<ref name="fish2020">{{REFjournal
|author6-link=Brian D. Earp
|etal=no
|title=A new Tuskegee? Unethical human experimentation andWestern neocolonialism in the mass circumcision of Africanmen
|trans-title=
|language=English
|journal=Developing World Bioeth
|location=
|page=
|pages=1-16
|url=httpshttp://onlinelibrarywww.wileycircumcisionharm.comorg/doi/10images-circharm.1111org/dewbFish%20Earp%20New%20Tuskegee%20Dev%20World%20Bioeth%202020.12285pdf
|archived=
|quote=
|pubmedID=32909369
|pubmedCID=
|DOI=10.1111/dewb.12285 |accessdate=2021-0203-1307
}}</ref>
</blockquote>
[[David Gisselquist]] (2021) reported that "circumcising men to reduce their risk to get [[HIV]] from sex" was an error.<blockquote>In 2007, WHO and UNAIDS recommended “male circumcision should be recognized as an additional, important strategy for the prevention of heterosexually acquired [[HIV]] infection in men.” Subsequently, WHO and UNAIDS endorsed programs to circumcise 20 million men in 14 countries in sub-Saharan Africa during 2008-15.[34] After 11.7 million circumcisions were reported through 2015, UNAIDS set a new target to circumcise another 25 million men in 15 countries during 2016-20. Through 2017, the US government supported more than 80% of these circumcisions. WHO’s and UNAIDS’ recommendation was based on three studies in Africa that reported circumcised men were less likely to get [[HIV]] than intact men. But what happened in those studies? In two of the studies, men who reported no sexual risks (no partners or 100% condom use) got [[HIV]] at rates more than half as fast as the rates for men who reported any unprotected sex. The third study did not report men’s sexual risks. One study tested most wives, but has not said if the wives of men getting new infections during the study were known to be [[HIV]]-positive or [[HIV]]-negative. But criticizing these studies – how they were badly managed and reported<ref name="boyle2011" /> – does not get to the heart of the problem with circumcising millions of men to prevent [[HIV]]. Insofar as sex is a risk, men already have multiple options to protect themselves. And because there is overwhelming evidence bloodborne risks – most likely in medical settings – drive Africa’s epidemics (Chapter 6), it is irresponsible to put millions of men at risk for [[HIV]] and other bad outcomes from unnecessary operations.<ref>{{REFbook |last=Gisselquist |first=David |init=D |year=2021 |title= Stopping Bloodborne HIV: investigating unexplained infections |url=https://sites.google.com/site/davidgisselquist/chpt7sbh |pages= |isbn=978-1-913976-01-9 |accessdate=2021-02-16 }}</ref></blockquote> [[George Hill]], CFI, ATR, acting for [[Doctors Opposing Circumcision (D.O.C.)]], wrote to Deborah L. Birx on 28 January 2021 regarding her lack of action and to transmit a copy of the article by Fish ''et al''. (2020).<ref name="hill2021">{{REFdocument
|title=Letter to Deborah L. Birx
|url=https://pool.intactiwiki.org/w/images/2021-01-28A_LetterBirx_516.pdf
|last=Hill
|first=George
|publisher=[[Doctors Opposing Circumcision(D.O.C.)]]
|format=PDF
|date=2021-01-28
}}</ref>
The United States Department of State on 10 February 2021, announced a "temporary pause" in the development of Country Operational Plans and Regional Operational Plans, which it said was caused by the COVID-19 pandemic. The Department of State affirmed that "[[HIV ]] prevention and treatment services" would continue, but made no mention of male circumcisionor VMMC.<ref name="state2021">{{REFweb
|url=https://www.state.gov/temporary-pause-on-pepfar-cop-rop-2021-development-due-to-covid-19/
|title=Temporary Pause on PEPFAR COP/ROP 2021 Development Due to COVID-19
|accessdate=2021-02-13
}}</ref>
== Population-based studies ==
{{Population-based studies}}
==Two African surveys==
The previously reported studies were from developed Western nations. Now we have information from Sub_Saharan Africa.
French scientist [[Michel Garenne]], Ph.D. has published two reports in 2022 comparing the incidence of HIV infection in [[circumcised]] and [[intact]] men.
In his first report, Garenne presented the findings from a study in Lesotho, the enclave in South Africa. He reported:
<blockquote>
In couple studies, the effect of circumcision and VMMC on HIV was not significant, with similar transmission from female to male and male to female. The study questions the amount of effort and money spent on VMMC in Lesotho.<ref name="garenne2022A">{{REFjournal
|last=Garenne
|first=Michel
|init=M
|author-link=Michel Garenne
|title=Changing relationships between HIV prevalence and circumcision in Lesotho
|url=https://pubmed.ncbi.nlm.nih.gov/35373731/
|date=2022-04-04
|journal=J Biosoc Sci
|volume=online ahead of print
|pages=1-16
|DOI=10.1017/S0021932022000153
|pubmedID=35373731
|accessdate=2022-11-04
}}</ref>
</blockquote>
In his second report, Garenne (2022) presented information from six Sub-Saharan African nations (Eswatini, Lesotho, Malawi, Namibia, Zambia, Zimbabwe). He reported:
<blockquote>
"Results matched earlier observations made in South Africa that [[circumcised]] and [[intact]] men had similar levels of HIV infection."<ref name="garenne2022B">{{REFjournal
|last=Garenne
|first=Michael
|init=M
|author-link=
|etal=no
|title=Age-incidence and prevalence of HIV among intact and circumcised men: an analysis of PHIA surveys in Southern Africa
|trans-title=
|language=
|journal=J Biosoc Sci
|location=
|date=2022-10-26
|season=
|volume=
|issue=
|article=
|page=
|pages=1-13
|url=https://www.cambridge.org/core/journals/journal-of-biosocial-science/article/abs/ageincidence-and-prevalence-of-hiv-among-intact-and-circumcised-men-an-analysis-of-phia-surveys-in-southern-africa/CAA7E7BD5A9844F41C6B7CC3573B9E50
|archived=
|quote=
|pubmedID=36286328
|pubmedCID=
|DOI=10.1017/S0021932022000414
|accessdate=2022-11-04
}}</ref></blockquote>
{{SEEALSO}}
* [[Centers for Disease Control|CDC]]
* [[Circumcision and HIV]]
* [[National Institutes of Health|NIH]]
* [[Stop the Cut]]
* [[World Health Organization]]
* [[USAID]]
{{LINKS}}
* {{REFweb
|url=http://circwatch.org/tag/PEFPAR/
|accessdate=2021-02-15
}}
* {{REFweb
|url=https://foregen.webflow.io/commentarium-articles/international-contractors-are-profiteering-from-new-circumcision-devices
|title=International Contractors are Profiteering from New Circumcision Devices
|last=[[Foregen]] Staff
|first=
|author-link=
|publisher=[[Foregen]]
|date=2021-03-08
|accessdate=2021-03-08
}}
* {{URLwebsite|https://www.state.gov/pepfar/|2021-12-31}}
{{ABBR}}
{{REF}}
[[Category:Circumcision in Africa]]
[[Category:Fund]]
[[Category:Program]]
[[Category:From CircLeaks]]