Thinking Ahead: Voluntary Medical Male Circumcision Rollout With Devices
Male Circumcision V2 Sanac
-
Upload
nicholas-jacobs -
Category
Health & Medicine
-
view
1.710 -
download
1
description
Transcript of Male Circumcision V2 Sanac
![Page 1: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/1.jpg)
Bophelo Pele Male Circumcision Project: Orange FarmBophelo Pele Male Circumcision Project: Orange FarmDr. Dirk Taljaard, Project managerDr. Dirk Taljaard, Project managerProf. Bertran Auvert, Principal investigatorProf. Bertran Auvert, Principal investigatorDr. Dino Rech, Clinical managerDr. Dino Rech, Clinical manager
![Page 2: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/2.jpg)
Randomised controlled trials of male
circumcision to reduce HIV infection
Source: 2006 Report on the global AIDS epidemic
(UNAIDS, May 2006)
Rakai, UgandaGray et. al. (2007) Lancet; 369: 657 – 66
Kisumu, KenyaBailey et. al. (2007)Lancet; 369: 643 – 56
Orange Farm, South AfricaAuvert et. al. (2005) PLoS Med; 2 (11): e298
![Page 3: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/3.jpg)
B o ts w a n a
Z a m b ia
S w a z ila n d
Z im b a b w e
M a la w i
U g a n d a
S o u th A f r ic a
L e s o th o
M o z a m b iq u e
T a n z a n iaK e n y a
M a d a g s c a r
A n g o la
B e n in
C a m e ro o n
G h a n a
010
2030
40
HIV
pre
vale
nce
in a
dults
(%
), 2
005
2 0 4 0 6 0 8 0 1 0 0M a le c irc u m c is io n p re v a le n c e (% )
S u b -S a h a ra n A f r ic a
C o r re la t io n o f m a le c irc u m c is io n a n d H IV p re v a le n c e
B o ts w a n a
Z a m b ia
S w a z ila n d
Z im b a b w e
M a la w i
U g a n d a
S o u th A f r ic a
L e s o th o
M o z a m b iq u e
T a n z a n iaK e n y a
M a d a g s c a r
A n g o la
B e n in
C a m e ro o n
G h a n a
010
2030
40
HIV
pre
vale
nce
in a
dults
(%
), 2
005
2 0 4 0 6 0 8 0 1 0 0M a le c irc u m c is io n p re v a le n c e (% )
S u b -S a h a ra n A f r ic a
C o r re la t io n o f m a le c irc u m c is io n a n d H IV p re v a le n c e
HIV prevalence (%)
Male Circumcision (%)Source: Helen Weiss, LSHTM
Observational Studies of male
circumcision and HIV in Africa
![Page 4: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/4.jpg)
Where in sub-Saharan Africa?
0
20
40
60
80
100
MC
pre
vale
nce
05
1015202530354045
HIV
pre
vale
nce
(adu
lts)
42 countries in AfricaAdult population = 331 millionUncircumcised adult men= 54 million (33% of adult men)
To prioritize and calculate the economic and human resources required for this roll-out :
Countries with “high” HIV prevalence (CEA criterion): > 5%AndCountries with “low” MC prevalence < 80%
![Page 5: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/5.jpg)
Where in sub-Saharan Africa?
HIV(%)
MC(%)
Uncirc(million)
% totaluncirc
South Africa 25 35 8.0 32%
Zimbabwe 25 10 2.8 11%
Tanzania 9 70 2.7 11%
Malawi 14 17 2.3 9%
Zambia 17 12 2.2 9%
Mozambique 12 56 2.0 8%
Rwanda 5 10 1.8 7%
Burundi 6 2 1.7 7%
Lesotho 29 0 0.4 2%
Namibia 21 15 0.4 2%
Botswana 37 25 0.3 1%
CAR* 14 67 0.3 1%
Liberia 6 70 0.2 1%
Swaziland 39 50 0.1 1%
Total 25.2 100%
Countries: 42 countries � 14 countries (33%)Uncircumcised men: 54 million � 25 million (46%) HIV positive: 24 million � 14 million (58%)
* Central African Republic
14 countries
UgandaKenya (Nyanza province)
![Page 6: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/6.jpg)
Programmes established
• Swaziland: • Family Life Association of Swaziland (FLAS)• PSI Swaziland
• Botswana• Public Health Facilities offer MC• PSI providing counselling services
• Zimbabwe• PSI Providing MC services
• Zambia• PSI Providing services
• Kenya• Robert Bailey’s trial group providing services• 20,000 MC done between January and June ‘09
• Uganda• Ron Gray’s trial group providing services
• Rwanda• Scale up have started in the Military
• Other countries have committed to scale up but have not implemented yet
![Page 7: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/7.jpg)
Potential Impact of MC on HIV in sub-Saharan
Africa
� Modeling study: Over the next ten years in sub-Saharan Africa,
� MC could avert :
� 2.0 (1.1−3.8) million new HIV infections (men and women)
� 0.3 (0.2−0.5) million deaths (men and women)
� In the ten years after, a further :
� 3.7 (1.9−7.5) million new HIV infections (men and women)
� 2.7 (1.5−5.3) million deaths (men and women)
Williams et al. PLoS Med 2006 3(7): e262.
![Page 8: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/8.jpg)
Programming benefits of MC
• Entry point to reach men, including adolescents
• Opportunity to offer VCT
• Opportunity for behavioral change counseling: partner reduction and condom use
• Roll out must include community mobilisation and involve women in decision making
• Opportunity for STI treatment and advice …
![Page 9: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/9.jpg)
Evidence for other benefits of male
circumcision
Urinary tract infections in infants o 12X risk in uncircumcised boys than circumcised
Syphiliso 1.5-3.0 fold higher risk in uncircumcised men
Chancroido 2.5 fold higher risk in uncircumcised men
Human Papilloma Virus (HPV)o 63% reduction in circumcised men
Invasive penile cancer in meno 22 times more frequent in uncircumcised men
Cervical cancer in female partnerso 2.0 – 5.8 times more frequent in women with uncircumcised
partners (link with HPV)
![Page 10: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/10.jpg)
Net cost
* in million US$
Private Public
Cumulative net cost* at 10 years + 538 (296 – 846) - 111 (-282 – 90)
Cumulative net cost* at 20 years - 3 494 (-4 698 – -2 180) - 4 358 (-5 665 – -3 246)
After adjustment for averted HIV medical costs>0 � expenses<0 � saving
� saving!
![Page 11: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/11.jpg)
Number of circumcisions to avoid one HIV
infection
Number of MAMC to avert 1 HIV infection
(in 10 years)7.2 (6.5 - 7.9)
Number of MAMC to avert 1 HIV infection
(in 20 years)2.3 (2.0 - 2.5)
� 2 – 7 circumcisions to avoid 1 HIV infection in the first 10-20 years
![Page 12: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/12.jpg)
Risk factors for MC roll out
� Unsafe surgery leading to
complications/ adverse events
� Acceptability
� Cost
� Feasibility
� Possible unintended promotion of female genital mutilation or cutting FGM/C
� Behavioural risk compensation - MESSAGING
![Page 13: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/13.jpg)
![Page 14: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/14.jpg)
2006: review of 13 acceptability studies in 9 sub-Saharan countries:
Uncircumcised men for themselves: 65% (29-87%) Women (for their partners): 69% (47-79%) Men for their son: 71% (50-90%)Women for their son: 81% (70-90%)
Acceptable in sub-Saharan Africa ?
Westercamp et al. AIDS Behav. 2006 Oct 20.Not surprising: Zulus, Twanas …
![Page 15: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/15.jpg)
In South Africa?
� Policy and National Guidelines are in process –
� SANAC
� Technical Task Team, Mr. Dayanund Loykissoonlal, Acting Director, Prevention Strategies, NDOH
![Page 16: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/16.jpg)
Objectives:
� To fulfil an ethical obligation from the 1265 Male Circumcision Trial – by offering free and safe MC to the community (Orange Farm, South Africa) where the trial was done
� To establish a MC program in a community
� To evaluate the impact of such program on: � Knowledge, attitudes and practices towards MC
� Existing prevention strategies like sexual behaviour change, condom use, STI treatment seeking behaviour and VCT attendance
� The spread of HIV and HSV-2
![Page 17: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/17.jpg)
General information to the community
Community advisory boardCAB: Local NGO’s, Political structures, local leaders, scientists,
interested parties
Community meetings
![Page 18: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/18.jpg)
RecruitmentOutreach activities
• Schools, churches, community leaders • Local radio station: Thetha FM• Community outreach activities: all households
“What women should know about MC”“What men should know about MC”
• Community stakeholder workshops i.e.loveLife
• Local GPs• In the clinics (STI patients)
Door-to-door outreach
Local radio
![Page 19: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/19.jpg)
Outreach activities
In partnership with Society for Family Health
Door-to-door outreachLocal radio station:
Thetha FM
• Schools, churches, Shopping malls• Community
stakeholder workshops i.e.loveLife
• Train Station• Taxi ranks
![Page 20: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/20.jpg)
Outreach activities
In partnership with SFH
• We working together with local GPs• We have started communication in the
clinics, especially among STI patients
A Mobile speaker system is usedPamphlets are distributed
![Page 21: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/21.jpg)
Inclusion activities at Outreach centres
• Information session, anyone can attend, parents, spouses, partners� Safe sex messaging� Section on MC
Partial protection for men only6-week period of abstinence
� Individual counselling• VCT is recommended and offered• CD4 count test (on site) � ARVs• Paper work (minimum) for Inclusion,
including Informed consent
Wait 3 days before surgery!(7 days for smokers!)
![Page 22: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/22.jpg)
SurgeryWITS Urology Department Study Site
• Started with 2 surgery rooms• Need for High Volume high
quality models• Dr. Dino Rech and Dr. Sean
Doyle developed• 7 beds, in one room divided
by curtains• 1 doctor, 4 aux nurses, 1
suture nurse = 10 MC per hour• Maximum capacity with 3
doctors = 150+ per day
![Page 23: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/23.jpg)
SurgeryWITS Urology Department Study Site
• HIV+ participants are alsoCircumcised
• Cost: ZAR 300 approximately• Surgical kits developed and used• Monopolar electrocautery used• Assisted in the development of
MC MOVE • There is a follow-up visit 2-3
days after surgery• Emergency response
for participant after surgery• The rate of AE is 2.0% (187/9290). Ten participants (0.1%) were hospitalized.
![Page 24: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/24.jpg)
What can the research community do at this time?Basic research (biological receptors etc)Phase-4 studiesOperational researchMeetings, country consultations, toolkits…
With the aimTo improve our knowledge in MC, MC-HIV, MC-STIsTo contribute to guide implementation
Scientific evidence1986-2007
Implementation(regional, national, locallevel)
Recommendations2007
2009
Where are
we?
![Page 25: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/25.jpg)
Some research findings
![Page 26: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/26.jpg)
What are the characteristics of the men
being circumcised within the project?
Age (y) MC Pop
Mean 21.8 24.5
Median 20 22
0%
10%
20%
30%
40%
50%
60%
15-19 20-24 25-29 30-34 35-39 40-44
Population
Intervention
Age group OF Male pop MC cards
15-19 35.7 % 50.1 %
20-24 30.2 % 27.9 %
25-29 14.4 % 9.7 %
30-34 8.0 % 6.4 %
35-39 5.2 % 3.3 %
40-44 3.3 % 1.7 %
Age distribution
![Page 27: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/27.jpg)
Self reported MC status
� In a survey men were asked “Are you circumcised?”
� After the interview a physical examination was done to which they consented at the beginning of the interview
� Physical examination was done by a male nurse
� 45% of men who said they were circumcised had intact foreskin
� Possible reasons: � Confusion between MC and Initiation
� Confusion with words used, vernacular
� Lack of knowledge on what MC is
� How does HIV compare in these groups?
![Page 28: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/28.jpg)
HIV (%) and circumcision status
0
5
10
15
20
25
‘’Circumcised’’with foreskin
Uncircumcised
PRR=0.93p=0.73
18.8%20.2%
![Page 29: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/29.jpg)
HIV (%) and circumcision status
‘’Circumcised’’with foreskin
Uncircumcised
0
5
10
15
20
25
PRR=0.48 p=0.002
18.8%20.2%
9.5%
‘’Circumcised’’without foreskin
Thus, self reported MC status is a VERY unreliable indicator
![Page 30: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/30.jpg)
Findings
Not surprising: Zulus, Twanas …
Preferred circumcision status of partners, for sexually active women
![Page 31: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/31.jpg)
Findings
Not surprising: Zulus, Twanas …
89% of women who were included were sexually active. 35% of the 15 year olds were sexually active and of 17 year olds almost 70% were already sexually active. The mean age for sexual debut was 15.7 year of age.
The percentage of men and women who agreed with the following statements:
![Page 32: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/32.jpg)
Kim Dickson UNIADS Brian Pazvakavambwa WHOGeorge Schmidt, WHORichard Hayes, LSHTMCate Hankins, UNAIDSDaniel Halperin, HarvardDavid Wilson, WBHelen Weiss, LSHTMHelen Jackson, UNFPA CST, Harare
Acknowledgements
David LewisAdrian PurenScott BillyCynthia NhlapoGoliath GumedeVeerle Dermaux-MsimangVenessa MasekoFrans RadebeBongiwe Klaas Tsietsi MbusoGaph Phatedi Bongani MazibukuAgenda GumbuDr. ShilalukeDr. ZuluDr. GwalaDaniel ShabanguAudrey MakwanasiMale ChakelaPamela Maseko
![Page 33: Male Circumcision V2 Sanac](https://reader034.fdocuments.net/reader034/viewer/2022051013/548766905806b57b2f8b45c3/html5/thumbnails/33.jpg)
Thank you!