EngenderHealth’s Work on Male Circumcision

Paul Perchal, MA, Director, HIV/STI ProgramMark Barone, DVM, MS, Senior Medical Associate

PEPFAR Male Circumcision Partner’s Meeting19-20 May 2009

Overview of Presentation

• Brief background on EngenderHealth.

• Service delivery:– APHIA II Nyanza MC

activities, Kenya – Men As Partners (MAP) MC

activities in Tanzania and South Africa

• Research:– Male Circumcision

Consortium Project – Shang Ring Pilot Study

EngenderHealth…

• U.S.-based international non-profit.

• Partners with governments, institutions, communities, and health care professionals to improve the quality of health care in the world’s poorest communities.

• Long history of introducing new clinical contraceptives and other reproductive health technologies in impoverished communities with limited resources.

• Currently has programs in more than 25 countries (MC work in Kenya, Tanzania, and South Africa).

MC Funding

0200,000400,000600,000800,000

1,000,0001,200,0001,400,000

$US

FY 07-08 FY 08-09

Fiscal Year

MC Funding

Private

USAID

APHIA II Nyanza MC Activities

• USAID-funded project in western Kenya.

• Supports MOH, private, & faith-based facilities in introducing MC for HIV prevention at 30 sites in 4 districts.

• Working at all levels of the health system.

• Integrated approach to service delivery.

Supply-Demand-Advocacy Model

Quality client-provider

interaction

Quality client-provider

interactionDemandSupply

Advocacy

• Supportive service policies promoted• Human and financial resource allocation fostered• Gender equity advanced

• Supportive service policies promoted• Human and financial resource allocation fostered• Gender equity advanced

• Service sites readied

• Staff performance improved

• Training, supervision and logistics systems strengthened

• Service sites readied

• Staff performance improved

• Training, supervision and logistics systems strengthened

• Accurate informationshared

• Image of services enhanced

• Communities engaged

• Accurate informationshared

• Image of services enhanced

• Communities engaged

Fundamentalsof Care

StakeholderParticipation

““More More More More MoreMoreServices People PlacesServices People Places””

to into in

Data for Decision-Making

Increased knowledge Increased knowledge + acceptability+ acceptability

Increased availabilityIncreased availability

Improved policy + program environmentImproved policy + program environment

Increased Access, Quality and UseIncreased Access, Quality and Use

Findings from Site Assessments – Equipment/Supplies

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Type

Equipment and Supplies (n=38 sites)

APHIA II Nyanza MC Service StatisticsOctober 2008-April 2009

0

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600

800

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1200

# o

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<15 15-24 25-34 35-44 45+

Age

n=1,774

Tanzania and South Africa

• Developed and field tested a needs assessment tool in Mwanza, Tanzania, in 2007.

• Our CHAMPION Project in Tanzania is currently conducting a national survey to help assess men’s attitudes, beliefs, and practices regarding HIV prevention and gender, including MC.

• Incorporates MC messages in Men as Partners (MAP) activities for PEPFAR supported HIV prevention services.

Challenges in MC Service Delivery

• Limitations of task shifting vs. full time dedicated MC staff.

• A number of health providers lack motivation.

• Initially low uptake of HIV testing at time of MC.

• Unreliable supply of consumables.

• Lack of specific instruments needed, instruments of poor quality or insufficient numbers for high volume.

• Lack of support from some traditional leaders in non-circumcising communities.

Male Circumcision Consortium Project

• EngenderHealth is responsible for leading the following 3 research studies:

– Assessing the human resource capacity and training needs to support MC roll-out.

– Assessing the safety, efficacy, and cost of non-physician clinicians providing MC services.

– Assessing the safety, efficacy, and cost of MC outreach services.

The Shang Ring for MC

• Developed & commercially available in China.

• A published study and other data suggest good safety profile.

• Benefits of the Shang Ring:– Simple design; easy to use, learn & teach– Short procedure time ( 3-10 minutes)– Minimal bleeding– Tight seal along wound– Sutureless closure; excellent cosmetic results– Design decreases risk of serious surgical errors

The Shang Ring MC Device

Shang Ring Pilot Study

• We will examine clinical outcomes and patient satisfaction in a small sample of Kenyan men in order to assess:– Safety– Efficacy (in terms of successful circumcision)– Acceptability/satisfaction

• The pilot will also lay the groundwork for a larger RCT.

• Prospective, non-comparative study at one health facility.

• 40-50 men seeking MC will be enrolled, undergo MC with the Shang Ring and be followed for 6 weeks.