Progress in male circumcision scale-up: country implementation and

Progress in male circumcision scale-up:

country implementation and research update

June 2010

List of Abbreviations ACHAP AfricaComprehensiveHIV/AIDSProgramme

AIDS AcquiredImmunodeficiencySyndrome

BLM BanjaLaMtsogolo

BOTUSA Botswana-USApartnership

CDC CentresforDiseaseControl

CHAM ChristianHealthAssociationofMalawi

CIDRZ CentreforInfectiousDiseasesResearchZambia

DHS DemographicandHealthSurvey

DMPPT DecisionMakersProgrammePlanningTool

FHI FamilyHealthInternational

FLAS FamilyLifeAssociationofSwaziland

GFATM GlobalFundforAIDS,TBandMalaria

HCP HealthCommunicationPartnership

HIV HumanImmunodeficiencyVirus

HMIS HealthManagementInformationSystem

IEC InformationEducationandCommunication

IMC InternationalMedicalCorps

Jhpiego JohnHopkinsProgramforInternationalEducationinGynaecologyandObstetrics

KAP Knowledge,AttitudesandPractice

M&E MonitoringandEvaluation

MC MaleCircumcision

MCC MaleCircumcisionConsortium

MOH MinistryofHealth

MOH&CW MinistryofHealthandChildWelfare

MOH&SW MinistryofHealthandSocialWelfare

MOVE ModelsforOptimisingtheVolumeandEfficiencyofMCservices

MSI MarieStopesInternational

NAC NationalAIDSCouncil/Commission

NGO NonGovernmentalOrganization

OR OperationsResearch

PEPFAR TheUSPresident’sEmergencyPlanforAIDSRelief

PSI PopulationServicesInternational

VCT VoluntaryCounsellingandTesting

QA Qualityassurance

QI QualityImprovement

RCT RandomizedControlTrial

RHRU ReproductiveHealthandHIVResearchUnit

SANAC SouthernAfricanNationalAIDSCouncil

SRH SexualandReproductiveHealth

TOT TrainingofTrainers

TRACPlus TreatmentResearchAIDS,TBandMalariaandotherepidemics

UNAIDS JointUnitedProgrammeonHIV/AIDS

UNFPA UnitedNationsPopulationFund

UNICEF UnitedNationsChildren’sFund

USAID UnitedStatesAgencyforInternationalDevelopment

USG UnitedStatesGovernment

UTH UniversityTeachingHospital

WHO WorldHealthOrganization

ZNFPC ZimbabweNationalFamilyPlanningCouncil

IntroductionIn2007,WHO/UNAIDSrecommendedthatmale

circumcisionbeincludedintheHIVpreventionpackage.

ThirteenSouthernandEasternAfricancountrieswith

highHIVprevalence,lowlevelsofmalecircumcisionand

generalizedheterosexualepidemicshavebeenidentified

asprioritycountriesformalecircumcisionscale-up,these

are:Botswana,Kenya,Lesotho,Malawi,Mozambique,

Namibia,Rwanda,SouthAfrica,Swaziland,Tanzania,

Uganda,ZambiaandZimbabwe.Thesecountrieshavebeen

engagedindevelopingprogrammesformalecircumcision

implementationandareatvariousstagesofprogramme

scale-up.

Tenkeyelementshavebeenidentifiedascriticaltomale

circumcisionprogrammescale-up,theseinclude:leadership

andpartnerships;situationanalysis;advocacy;enabling

policyandregulatoryenvironment;strategyandoperational

planfornationalimplementation;qualityassuranceand

improvement;humanresourcedevelopment;commodity

security;socialchangecommunicationandmonitoringand

evaluation.TheseareoutlinedinfullintheOperational

guidanceforscalingupmalecircumcisionservicesfor

HIVprevention,WHOandUNAIDS,2008whichcanbe

accessedathttp://www.who.int/hiv/pub/malecircumcision/

op_guidance/en/index.html.

Thisreportprovidesanoverviewofprogressinmale

circumcisionprogrammescale-upinallthethirteenpriority

countriesaccordingtothekeyelements.Informationfor

eachcountryhasbeencontributedbyfocalpersonsfrom

MinistryofHealth,UNAgencieswithincountries,PEPFAR

programmesincludingU.S.CentersforDiseaseControl,

USAID,andotherimplementingagenciesthroughregular

progressreports,collaborativeconsultations,meetingsand

discussions.Servicedeliverystatisticshavebeenprovidedas

muchaspossiblefromMinistryofHealthreports,however,

somestatisticswereprovidedbysupportingagencies.Most

oftheinformationhasbeencollectedduringthemonthof

May2010.

Thisreportalsocontainsasectiononplannedandongoing

researchinthefieldofmalecircumcisionforHIVprevention.

Wewouldliketoacknowledgethecontributionsofallthe

studysponsors,investigators,fundersandreviewers.

Anyfurtherupdates,revisionsorcorrectionscanbesent

tothemalecircumcisionforHIVpreventionClearinghouse

[email protected]

Botswana

Kenya

Lesotho

Malawi

Mozambique

Namibia

Rwanda

South Africa

Swaziland

Tanzania

Uganda

Zambia

Zimbabwe

http://www.who.int/hiv/pub/malecircumcision/op_guidance/en/index.html

http://www.who.int/hiv/pub/malecircumcision/op_guidance/en/index.html

mailto:[email protected]

SECTION ONECountry

implementation update

1

Botswana Statistics:• Population:1.8m

• HIVPrevalence:17.6%

• MCPrevalence:11.2%

Leadership, partnerships & advocacy1. Leadership:MOHleadingtheprogramme.Dedicated

MCcoordinatorappointedanddistrictandfacilitylevel

focalpersonsassigned.SafeMCreferencegroupisin

placeforadvisory,policyissues;chairedbyDirectorof

DepartmentofHIV/AIDSPreventionandCare.Technical

workinggroupinplacewithallpartnersrepresented,

STIunitisthesecretariat.NACsupportsresource

mobilization.

2. Partnerships:WHO,UNAIDS,ACHAP,CDC/BOTUSA,

I-Tech,Jhpiego,PSI.Partnersprovidefinancial,human

andtechnicalsupportresources.

3. Advocacy:FormerPresidentFestusMogaeis

chairpersonofNACandaleadingfigureinthe‘African

championsforHIVpreventioninitiative’.Heled

adoptionofMCasadditionalHIVpreventionstrategy

inBotswana.Sensitizationofpolitical(Cabinet,MPs)

andsocialleaders,media,civilsocietyorganizations,

privatepractitioners,healthcareproviders,medicalaid

schemesandpublicdonein2009.

Situation analysisRapidsituationanalysisofhealthfacilitiesconducted

bygovernmentandpartnersin2007.Resultsinformed

thedevelopmentofthenationalsafemalecircumcision

additionalstrategyforpreventionofHIV/AIDS.

In-depthneedsassessmentof51publicandprivate

facilitiesabilitytoexpandandstrengthensafeMCservices

conductedin2008/9whichinformedthedevelopment

ofthenationaloperationalplanforscalingupsafemale

circumcisioninBotswana:2011–2015.Situationanalysis

oftraditionalhealersalsoconducted.

Policy and regulatory frameworkMChasbeenincorporatedintoexistingHIVprevention

policy,approvedbycabinet.

Strategy and operational planStrategyapprovedbygovernment.Phasedscale-up

plantoreachMCprevalencerateof80%amongHIV-ve

males0-49yearsoldby2016.Sixfacilitiesselectedto

bestrengthenedascentersofexcellence.DMPPTused

toderivecostingandimpactdata.MCincludedinGFATM

application.

TrainingSafeMCtrainingcurriculumhasbeendevelopedwhich

includesavideo.

ByApril2010,90healthworkerstrained(medicalofficers

andnurses/socialworkers).Teamofmastertrainersfrom

I-TECHtrainedbyMOH.Currentlydecentralizedtraining

beingconductedinthecentersofexcellence.

TraditionalhealersHIVtrainingcurriculumhasbeen

developedwithsafeMC.

Quality AssuranceQAframeworkhasbeendeveloped,strategybeing

developed.WHOMCQAguideandtoolkithavebeen

adaptedandthestandardsadopted.TeamofQAfacilitators

weretrainedataWHOworkshopinSeptember2009.

Twentyeightfocalpersonsincentersofexcellencetrained

onQA.Externalqualityassessmentsconductedatfour

centersofexcellenceinFebruary2010.InternalQA

assessmentsongoing.

Service deliveryScalingupofservicedeliverystartedinApril2009withMC

servicesintegratedintoexistingHIVpreventionservices.

ThirtyfivepublichealthfacilitiesareperformingMC

includingthesixcentersofexcellence,sevenpublicclinics

andafewprivates.

CDC/ACHAP/WHOsupportedtheMOHtoprovidemassMC

servicesinJuly2009forinitiatesintheKgatlengdistrict.

1321initiateswerecounseledandofferedHIVtesting;

88.5%weretested,96.2%circumcised,3.8%excluded

with2%mildtomoderateadverseevents.Allinitiateswere

reviewed24-48hrspost-MC.

Servicedeliverystatistics:

MCsdonefromJanuary2009-March2010=6,180.

CommunicationAshort-termcommunicationstrategyhasbeendeveloped

toguideimplementationandaddressimmediatepublic

informationneeds.FirstphaseofstrategylaunchedinApril

2009asasix-monthmultimediacampaign;30billboards

erectedcountry-wideand32minibusesbranded.TV

messages,radiospots,newspapermessageswereaired.

BO

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KenyaStatistics: • Population:37.5m

• HIVPrevalence:7%forthecountry.

15.3%forNyanzaprovince.

• MCPrevalence:85%forthecountry.

40%forNyanzaprovince

Leadership, partnerships & advocacy1. Leadership:Leadership:MOHcontinuestoprovide

overalltechnicalleadership.Programmenow

mainstreamedintoMOHannualplanningprocess.A

nationalandprovincialtaskforceareoperational.Focal

MCpersonsatnationalanddistrictlevels.JointMC

inter-ministerialtaskforceworkingwell.

2. Partnerships:TheMCC(FHI,UniversityofIllinoisat

ChicagoandEngenderHealth),NyanzaReproductive

HealthSociety,ImpactResearchandDevelopment,

MSI,IMC,APHIA(EngenderHealth,PATH,PSI),UNICEF.

PEPFAR,WHO/UNAIDS,Gatescontinuetobekey

partners.WorldBankisnewpartnersinceJanuary

2010.

3. Advocacy:MinistryofMedicalServicescalledfor

continuedscaleupatrecentstakeholdermeeting.He

joinsvoicesfromPrimeMinisterMr.RailaOdingawho

hasendorsedthescaleupofMCandin2009metwith

thecouncilofLuoelderstopromoteMC.

Situation analysis SituationanalysiscompletedforNyanza,Teso,Turkanaand

Nairobiprovinces.

Policy & regulatory framework MCpolicyisinplace,called‘NationalguidanceforMC’to

enhanceacceptanceassomegroupsfeltthataformal

policywouldsuggestamandateofMCforallmen.

DMPPTtrainingdone,datacollectionbeingfinalizedand

reportavailablesoon.

Strategy and operational plan ThevoluntarymaleMCstrategicplanfornext5yearswas

publishedinApril2010;tobepostedonMCClearinghouse.

Keytarget:allprovincestohaveMCprevalenceof80%by

2013.Thetargetgroupsare15-49yearoldsandnewborns.

Aphasedapproachtoservicedeliveryunderway,with

initialprogammeinNyanza;NairobiProvincenowadding

activities;preparatoryactivitiesinWesternProvince.

Training

Nearly800providersofvariouscadreshavebeentrained.

Quality assurance Aqualityimprovementteamhasbeenestablished.Atthe

nationalleveltheM&EteamisinchargeofQI/QAinthe

healthsectorandMCisintegratedinthis.

WHOMCQAtoolkitisbeingused.Localadaptation

underway.

QAstrategyisinthestrategicplan.WHOsupportedQI

national/provincialtrainingApril2010.

Service delivery ServicedeliveryscaledupinNyanzaandstartedinNairobi.

MCservicesbeingofferedinprisons.


MCsSept2008-April2010=110,000.

WorldBankfundingforpilotof5000MCinTesoarea.

Communication Communicationstrategypublished.Nationalharmonized

IECmaterialsdevelopedandbeingusedinfield.

Monitoring & evaluationM&Eframeworkinplace.M&Esystemandformstomonitor

MCuptakeandadverseeventsdevelopedandformsbeing

distributed.

M&EindicatorsdevelopedinlinewithWHO/PEPFAR

recommendations.

MCincorporatedintoroutineKenyaAIDSInformation

system.

KE

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Botswana

3

LesothoStatistics: • Population:2m


• MCPrevalence:48%

Leadership, partnerships & advocacy1. Leadership:MOHisleadingtheprogramme.MCTask

Forcewithtwosub-committeeshavebeencreated:the

ClinicalandtheAdvocacyandCommunicationsSub-

committee.MCFocalpersonhasbeenidentifiedinthe

MOH.

2. Partnerships:PSI,PEPFAR,WHO,UNAIDS,UNICEF,

UNFPA.

3. Advocacy:Extensiveadvocacyhasbeendonewith

traditionalleaders.TraditionaltaskteamonMCformed.

Situation analysis Situationanalysisinformalhealthsectorhasbeen

completed.Finalreportprintedandreadytodisseminate.

Policy & regulatory frameworkMCPolicyhasbeenapprovedbyMoH&SocialWelfare

minister.Policysummarizedintoabrief,translatedin

Sesothoandreadytobedisseminated.MCscaleupwillbe

implementedaspartofacomprehensiveHIVHealthSector

Preventionstrategywithinthehealthsector;thispolicyis

alsoreadyfordissemination.

Regulationsdonotallowcertaintaskshiftingtonurses.

Areviewisplannedofregulationsandprocessesoftask

shiftinginLesothoandothercountries.

Strategy and operational planStrategyandoperationalplanapproved;awaitingaformal

launch.

GuidelinesoncomprehensiveHIVpreventionservicewith

MCasonecomponenthavebeenelaboratedandare

nowunderreview.Exploringwaysofhowtoworkwith

traditionalproviders.

Training Currentlytrainingplansnotyetdeveloped.

Quality assuranceQAactivitieshavenotbeenstarted.Supervisionguidelines

arebeingadapted.

Service deliveryFormalscale-uphasnotstarted.Districtassessmenton

comprehensiveHIVpreventionserviceistobeconducted;

findingstoinformplanningfortheseservices.Public-private

partnershipsbeingreinforcedasNGOsareinvolvedand

workinginlinewiththenationalguidelines.

CommunicationDevelopmentofIECmaterialsforHIVpreventionservices

includingMCisongoingwithinthehealthsector.

Monitoring and evaluation M&Eframeworkhasnotyetbeendeveloped.Planstobe

developedforoperationsresearch.

LE

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Botswana

4

Malawi Statistics: • Population:13.2m

• HIVPrevalence:12%


Leadership, partnerships & advocacy1. Leadership:TheMOHisheadingtheMC

subgroupconsistingofnational,multilateral&NGO

representatives.AfocalpersonforMChasnotyetbeen

appointed.Highlevelleadershipisstillneeded.

2. Partnerships:WHO,UNAIDS,UNICEF,UNFPA,CHAM,

CDC,PSI,BLM.

3. Advocacy:Planningtoidentifyalocalchampionfor

MC.Advocacyisstillneededatvariouspoliticaland

healthproviderlevels.Advocacymeetingsheldin

2007;stakeholdersmeetingheldinAugust2009.

Situation analysis Datacollectionforsituationanalysiscompleted.Findings

anddraftreportpresentedtostakeholders;finalversion

withrecommendationsawaitingapprovalbythePermanent

Secretary.Mainfindings:conduciveenvironmentexistsfor

establishmentoffocusedMCprogramme.

Policy & regulatory framework Nopolicyorregulatoryframeworkexistsyet.

Strategy and operational plan Nostrategyoroperationalplanexistsyet.

TrainingTrainingactivitiesnotyetdeveloped;awaitinggovernment

policyandstrategy.

Quality assurance QAactivitieshavenotbeenstarted.

Service delivery Formalscale-uphasnotstarted.

AlocalNGO,BLMisprovidingMCservicesintheirclinics.


MCsdoneDecember2009-May2010=1,200

Communication Acommunicationplanhasnotbeendeveloped.

Monitoring & evaluationM&Eframeworknotyetdeveloped.Operationsresearch

planstobedeveloped.

MA

LA

WI

5

MozambiqueStatistics: • Population:21m



Leadership, partnerships & advocacy1. Leadership:MOHleadingtheprogramme.Anational

taskforceisinplace.MCfocalpersonidentifiedinMOH

(asurgeonworkinginthenationalreferralhospital).

2. Partnerships:PEPFAR,PSI,USG,WHO,UNAIDS,

UNICEF,JHPIEGO.

3. Advocacy:Formerpresidentsinvolvedin‘African

championsforHIVpreventioninitiative’visited

MozambiqueinJune2009.Afollowupplanofaction

includingcontinuousadvocacyforscalingupaccessto

MCserviceshasbeendiscussedwiththegovernmentof

Mozambique.

Situation analysis Ahealthfacilityreadinessassessment(facilityrapid

assessment)hasbeencompletedbyJhpiego.AKAPsurvey

isplannedfor2010.

Policy & regulatory framework NoformalMCPolicydeveloped.Anationalstrategyfor

intensifyingHIVpreventionactivitieswasadoptedand

launchedbythePresidentofMozambiqueinDecember

2008.

Strategy and operational plan AnoperationalplanforHIVpreventionhasbeendeveloped

whichincludesMC.Fivepilotsiteshavebeenselected.

Scale-uptobeinitiatedin2010.

TrainingAfewseniorstaffoftheMOHhavebeentrainedonMC.

Trainingplansandmaterialsarebeingdevelopedwiththe

supportofWHO,UNAIDSandJhpiego.

A‘trainingoftrainers’workshopisplannedfor2010which

willbefollowedbyacascadetrainingofstaffinall11

provincesin2010-2011.

Trainingmaterialsfortraditionalcircumcisersarebeing

developedbytheNationalTaskForce,tobefinalizedand

testedin2010.

Quality assurance QAtrainingmaterialsandmethodologyarebeing

developedbytheMCnationaltaskforce.Thematerialwill

betranslatedintoPortugueseandadaptedtothenational

contextin2010.FieldtestingandimplementationoftheQA

programisplannedforlate2010.

Service delivery Noformalscaleuphasstarted.MCservicesareprovided

ondemandandaspartofroutineminorsurgeryservices.

MCservicesaredeliveredmainlyingovernmenthospitals.

ThereisnoknownprivateproviderofMCservicesin

Mozambique.


MCsdoneNovember2009toMay2010:853

Communication Acommunicationstrategyisbeingdevelopedwiththe

supportoftheNationaltaskforceandPSI.

Monitoring & evaluationM&EframeworkforMChasbeendeveloped.NinecoreMC

indicatorshavebeenselectedandvalidated.

Anoperationsresearchagendaisbeingdevelopedbythe

nationaltaskforce.

MO

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NamibiaStatistics: • Population:2m



Leadership, partnerships & advocacy1. Leadership:MOHleadingtheprogramme.ANational

TaskForceisinplace.MCfocalpersonidentifiedin

MOHandMCCoordinatorhired.

2. Partnerships:WHO,UNAIDS,PEPFAR(IntraHealth,

I-Tech,PSI),CDC.

3. Advocacy:The‘AfricanChampionsforHIVPrevention

Initiative’visitedinJune2009.Advocacydonefor

healthworkers;advocacywithtraditionalleadersis

required.

Situation analysis Situationanalysisreportnowavailable.

Situationanalysisneededintermsofunderstanding

traditionalcircumcisers’practices.Workshopwithtraditional

healersisbeingplanned.

Policy & regulatory framework ReviseddraftpolicysubmittedtoMOHManagement;

includestaskshiftingofsurgicaltaskstonurses.

Thisdraftpolicyavailableandguidingpilotingprogramme.

Strategy and operational plan Strategyhasbeendevelopedandbeingrolledoutina

limitednumberofpilotsites;plansunderdevelopment.

Costingandimpactdataforthenationalstrategywas

derivedbyusingtheDMPPT,butDMPPTtoberedonegiven

newinformation.

TrainingTaskForcedevelopedMCtrainingcurriculum&addingto

VCTcurriculum.TwoMCtrainingshavebeenconductedin

2009;1in2010.Pilotinginselectedhealthfacilities.Also

MCprojectmanagementcoursewithhospitalmanagement

staffatpilotsites.

Quality assurance QAtrainingwillbeincludedinthepilotprogrammethatis

underway;trainersfollowuptrainees.

Service delivery Formalscale-upnotyetstartedbutatpilotsitesservice

deliveryunderway.

Fivepilotsiteshavebeenidentified.Threesitesarein

operation.ThreededicatedMCteams(MD,Nurse)hired

tomitigateHRconstraints.Assessmentoffivefacilities

todeterminefeasibilityofintroductionofvolunteer

programmedone.


MCsdoneAugust2009toMay2010=340.

Communication Communicationstrategyatfinalstageofapproval.

MCcommunicationmaterialsarebeingproduced.Concerns

aboutmatchingriseindemandwithsupply

Monitoring & evaluationM&Esystem,databaseandtoolsdeveloped,appliedand

revisedbasedonpilotsiteexperience.

Noplansinplaceyetforoperationsresearch.

NA

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RwandaStatistics: • Population:9.3m



Leadership, partnerships & advocacy1. Leadership:NAC(CNLS)coordinatesandleadsmulti-

sectoralapproach;MOHresponsibleforMCasasurgical

interventioninhealthfacilities&ensurenormsand

standards.TRACplusresponsibleforMCwithinHIV.

TechnicalWorkingGroup(TWG)since2008aspartof

NationalHIVpreventionTWG;withsubgroupsoncost

andimpact.MCfocalpersonappointedandislocatedin

TRACplus&CNLS.

2. Partnerships:WHO,UNAIDS,UNICEF.USG,Jhpiego,

civilsocietyorganizationsespeciallyyouth.

3. Advocacy:Symposiumoncosteffectivenessof

paediatricMCin2007.Nationaladvocacycampaign

conductedinSeptember/October2008.

Situation analysis Facilityreadinessassessmentcompleted.Dataisbeing

analysed,reportexpectedDecember2009.

KAPsurveyongoing-toinformstrategyplandevelopment.

Onechallengeisthemobilityofhumanresources

Policy & regulatory framework MCintegratedinNationalHIVpreventionpolicy;MC

specificpolicyunderdiscussion.DMPPTmeetingplanned

Strategy and operational plan MCdraftnationalstrategyawaitingfinalapproval;MC

includedinNationalStrategicPlan.Formalimplementation

strategynotyetavailable.Nationalguidelines(normsand

standards)forimplementationdeveloped;awaitingfinal

approval.

DMPPT:Guidelinesintheprocessofdevelopmentfrom

decisionmakersbasedonpolicyscenariosthatconsider

resourcescurrentlyavailableforMCortheprevention

keyresultintheNationalStrategicPlan;onescenarioto

beselectedandnextstepsforoperationalplanstobe

developed.

Onechallengeisthedevelopmentofascaleupplan.

TrainingTwoprogrammemanagerstrained;sixNationaltrainers;

sitestafftrained:69nurse/counsellors,17providers.

Trainingandcapacitybuildingofhealthworkersfromarmy

healthservicesinKanombeandKaduhaconductedin

September2009.

Quality assurance QAframeworkandstructurenotyetdeveloped.

Service delivery FoursitessupportedbyJhpiego.Ongoingimplementation

ofservicedeliveryinmilitaryfacilities.

JointMCimplementationplannedin2districtswithUNICEF,

WHOUNAIDS.


MCsdoneOctoberthroughtoMay2010=542.

Communication CommunicationthroughRwandaHealthCommunication

Centre.TRACPlushastargetedall30districtmayorsto

includeMCintheirHIV/AIDScontrolplans.

OnechallengeisthemisconceptionsaboutMCinthe

generalpopulation.

Monitoring & evaluationNationalM&EplanforHIV/AIDS(2009-2012)ongoing.

RW

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South AfricaStatistics: • Population:48.5m



Leadership, partnerships & advocacy1. Leadership:MOHisleadingwithSANACand

ProgrammeImplementingCommittee;Deputy

PresidentisChairofSANACandthereisaMCfocal

personinMOH.Anationalmulti-sectoraltaskforceon

MMC,chairedbytheChiefDirectorofHIVandAIDS,

willbeconstitutedandserveasthetechnicaland

advisorybody.ProvincialanddistrictMMCTaskforces,

undertheleadershipoftheProvincialheadsofhealth,

willbeformedtospearheadandcoordinatethesafe

malecircumcisionroll-outinprovinces.

2. Partnerships:RHRU,Jhpiego,UNAIDS,UNICEF,WHO,

FuturesGroup,CDC/PEPFAR,SFH.

Thepolicywillbeimplementedinpartnershipwith

traditionalleaders;faithbasedorganizations,thepublic

andprivatehealthsectorsandothercivilsocietysectors

thatshouldpromoteMCaspartoftheircomprehensive

HIVpreventionresponse.

3. Advocacy:AdvocacywithdifferentSANACgroups

(men,women).Researchtaskteaminvolvedin

advocacy.

Situation analysis Anationwidesituationalanalysisandareviewofthe

existingMMCresearch&servicesinSouthAfricaarein

progress.Operationallessonscontinuetobelearntfrom

theMMCProjectunderwayinOrangeFarm,asafollow-up

totheOrangeFarmRCT.

Policy & regulatory framework The“MalecircumcisionpolicyforHIVpreventioninSouth

Africa”providestheframeworkforpolicymakersand

implementersofsafemalecircumcisionactivities;inthe

processoffinalization.Prioritizesmale15-49yearsold.

Priorityprovinces:Kwa-ZuluNatal,Mpumlanga,Northern

Cape.MMCtobeprovidedpredominantlyatPHCfacility

inlinewithpolicyofdecentralizationofallpublichealth

services.PolicyalsorespectstraditionalMCandwillprovide

forstrengtheningofqualityoftraditionalMCaspartofpublic

healthinterventiontoreduceadverseevents.

Strategy and operational plan Draftstrategyinplaceandimplementationguidelines

developed.DMPPTdone.Planisthatallprovincesshould

havesufficientcapacityandresourcestoroll-outMMC

accordingtonationalguidelines.Forcepsguidedmethodis

primarymethodforMMC.

TrainingTwotrainingcentresforMMCwhichusetheOrangeFarm

modelhavebeenestablishedinPietermaritzburg(Kwa-

ZuluNatal):EastBoomCommunityHealthCentreandthe

Districthospital.

Quality assurance Routineprogramevaluationshallbeacomponentofmale

circumcisionservicesforqualitycontrolandtoguidethe

planningofservices.

Service delivery National/ProvincialworkshoponMMC,March2010,

includingdevelopmentandimplementingpartners.MMC

guideline&othersupportingdocumentshavebeen

finalized.Kwa-ZuluNatalprovinceistorolloutMMCin11

districts.MpumalangaandNorthernCapeprovincesare

beingassistedtodevelopplans.

Thelinkbetweenthepublicandprivatesectorwillbe

improvedtoprovidequalityservicescollaborativelyand

efficiently.


MCsthroughApril2010=18,100.

Communication TheSANACcommunicationstechnicaltaskteamhas

developedacommunicationframeworkforMMCthatforms

thebasisforthedevelopmentofanationalcommunication

strategyformalecircumcision.Keymessageshavebeen

developedandpostershavebeenprinted.

Monitoring & evaluationOperationsresearchwillbeconductedtostrengthen

malecircumcisionservicesandtoimplementeffective,

comprehensiveHIVpreventionprogrammesinthecontext

ofsexualandreproductivehealth.

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SwazilandStatistics: • Population:1m


• MCPrevalence:8%

Leadership, partnerships & advocacy1. Leadership:MOHleadingtheprogramme.National

taskforceincludesallpartnerswhoareworkingon

MC.DeputydirectorclinicalservicesistheMCfocal

personandchairoftheMCtaskforce.AdedicatedMC

coordinatornowinplaceinMOH.

2. Partnerships:Supportingpartners:WHO,UNICEF,

UNAIDS,PEPFAR,FLAS,MCpartnership(PSI,Jhpiego,

MSI,PopulationCouncil).

3. Advocacy:CurrentPrimeMinisterisstrongsupporter

ofMC.

Situation analysis Partsofsituationanalysisdonetoinformpolicy

development.

Policy & regulatory framework FinalizedpolicyonsafemalecircumcisionforHIV

preventionadoptedbycabinet,officiallaunchpending;

postedonmalecircumcisionClearinghousewebsite.

Strategy and operational plan StrategyandImplementationPlanforScalingupSafeMale

CircumcisionforHIVPreventioninSwazilandfinalizedand

printed.PostedonthemalecircumcisionClearinghouse

website.

TrainingTrainingisongoing.Jhpiego/PSIhavedonefivetrainingsin

2010.Atotalof79providers,20doctorsand59nurses

havebeentrained.

Quality assurance In2010WHOandJhpiegoQA/QItoolsmergedandareto

beimplementedinallhealthfacilities.

Service delivery Additionalgovernmentsites(nowtotalsix)identified

toprovideintegratedMCservices.TheMCTaskForce

CoordinatorensurestheworkplansofNGOimplementers

aresharedwiththeMOH.CabinetapprovedMOH

AcceleratedSaturationInitiative.MCservicedeliverymodel

pilotedusingvolunteerphysiciansfromAmericanUrological

Association,April-May2010.Fourvolunteerphysicianswere

placedathealthfacilities.


MCsdone2006-March2010=9,309.

Communication TheMCProgrammeCoordinatorisincreasingawareness

inothersectorsandhasbegungivingpresentationsto

theMinistryofEducation,faith-basedorganizations,and

privatesectors.FromFebruary2010,amediacampaign

aboutMCoccurredthatincludedweeklynewspaperarticles

andnationalradiospots.HPIfacilitateddialoguewith

parliamentariansonMC.MOHworkedwithbothHouses

ofParliamentwhoadoptedaResolutiontocommitto“the

objective,missionandvisionofMaleCircumcisionforHIV

Prevention”inSwaziland.

Monitoring & evaluationM&Eframeworkisindraftform.

MCtaskforceSub-ResearchCommitteewhichconsists

ofprogrammeplanners,seniorgovernmentofficialsand

higherinstitutionsoflearningwillbeoverseeingongoing

research.

SW

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TanzaniaStatistics: • Population:40m



Leadership, partnerships & advocacy1. Leadership:MOHleadingtheprogramme.MCTask

ForcewasformedinOctober2007with25members.

MCresponsibilityaddedtoIECHeadwithinNational

AIDSControlProgrammeintheMOH&SW

2. Partnerships:NIMR,WHO,CDC,UNICEF,USAID,

Jhpiego,AssociationofPrivateHospitals.

3. Advocacy:MChasbeenwidelypracticedinregionsfor

traditionalandreligiouspurposes.Thereisnoevidence

ofoppositiontoMC.

Situation analysis Situationanalysishasbeencompleted.Finalreport

available.

Traditionalprovidersstudycompleted.Reportavailable.

Policy & regulatory framework DevelopmentofspecificMCpolicystillbeingdiscussed.

Strategy and operational plan Draftnationalstrategyawaitingfinalapprovalofthe

government.MCincludedinthe5yearnationalmulti-

sectoralHIV/AIDSstrategicframework2008-2012andthe

healthsectorHIV/AIDSstrategy2008-2012.

TrainingAdaptationoftheWHOManualforMaleCircumcisionfor

HIVPreventionunderLocalAnesthesiaandtheTraining

Manual:CounselingforMaleCircumcision;itisbeing

utilizedindemonstrationsites.

Total49MCproviderstrained(additional45tobetrainedin

May2010).

Quality assurance Standardsforservicesprovidingmalecircumcision

underlocalanesthesia,asitestart-upguide,a3-day

facilityorientationandoperationsguidedevelopedfor

demonstrationsites;tobeadaptedforcountryuse.

Service delivery AnadditionaldemonstrationsiteprovidingMCservicesset

up(totalfour).

MOVEgraduallybeingintroducedatthesefoursites.


MCsdoneOctober2009throughMarch2010=3,148.

Communication Clienteducationmaterials(flipchart,brochure,poster,

flyer)developed;demandcreationmaterialsstillindraft

butwilltargetmen,adolescentsandtheirguardians,

femalepartners.

Monitoring & evaluationM&Etoolsformalecircumcisionhavebeendevelopedfor

demonstrationsites;tobeadaptedforcountryuse.

TA

NZ

AN

IA

11

UgandaStatistics: • Population:32m



Leadership, partnerships & advocacy1. Leadership:NationalTaskForceforMCisinplace.

2. Partnerships:Supportingpartners:WHO,UNAIDS,

UNICEF,UNFPA,PEPFAR(USAIDandCDC),FHIand

MakerereUniversitySchoolofPublicHealth.Multiple

developmentpartnersavailablebutawaitingfirmplans

tobecomeactive.

3. Advocacy:Nolocalchampionsidentified.Thereis

increasingacceptanceforMCforHIVpreventionbut

advocacystillneededwithparliamentmembers.

Situation analysis Situationalanalysistodeterminetheacceptabilityand

feasibilityofmedicalMCpromotioninUgandahasbeen

completedanddisseminated.Mappingsurveyofmedical

MCservicescompleted.

Policy & regulatory framework PolicyapprovedinMarch2010.

Strategy and operational plan Planningforstrategydevelopment.Consultationsongoing

onwhichMCsurgicaltechniquetoadoptandwhichcadres

todosurgery.ResultsofDMPPTunderdiscussiontoinform

targetgroupinstrategy.

TrainingNationwidetrainingnotyetinitiated.Healthworkersfroma

selectednumberoffacilitiesarebeingtrainedattheRakai

HealthSciencesResearchProject.

Quality assurance QAactivitieshavenotyetinitiated.

Service delivery Formalscale-upnotyetstarted.Scaleupexpectedafter

thelaunchofthePolicyin2010.

Militarywillingtoofferservices.

Communication Communicationsstrategyapproved,May2010.MC

awarenesscampaignsongoing.IECmaterialsdeveloped.

Monitoring & evaluationMonitoringandevaluationframeworkhasnotyetbeen

developed.Operationsresearchisongoinginspecificsites.

UG

AN

DA

12

ZambiaStatistics: • Population:12m


• MCPrevalence:13.1%

Leadership, partnerships & advocacy1. Leadership:MOHleadingtheprogramme.National

TaskForceinplace.AdedicatedNationalMC

Coordinatorhasbeenappointed.

2. Partnerships:Supportingpartners:UTH,MC

Partnership(PSI,Jhpiego,MSI,PopulationCouncil)and

CIDRZ.

3. Advocacy:Ongoingadvocacy.HighlevelmeetingJuly

2009.

Situation analysis Situationalanalysisincludingacceptabilityandhealth

facilityreadinessassessmenthasbeencompleted;dueto

beprinted.

Policy & regulatory framework CabinetmemoincorporatingMCinHIVpreventionhasbeen

approved.Theagreementisnottohaveastandalonepolicy

butratherpartofcomprehensiveHIVpolicy.

Lookingattaskshiftingandworkingwithtraditional

providers.

Strategy and operational plan DisseminationofthenationalMCstrategyand

implementationplan2010-2020toalldistrictsinNorth

Western,CopperBeltandEasternProvinces.

DMPPTdatacollectioncompletedanddueforanalysis.

TrainingPartnershipwithJhpiegoandUTHfortraining.

Approximately350providerstrained.

Trainingofprovidersongoing.MCtrainingmanuals

adapted;nationalMOHMCtrainingmanualsfinalised.

Quality assurance QAstrategyinplace.QIteampresentatnationallevel.

WHOQAguideandtoolkittobeimplemented.

MChealthworkercertificationframeworkdevelopedwith

MedicalCouncilofZambia.

Service delivery ServicedeliverysitesadoptingMOVEprinciples


MCstoJanuary2010=20,779:

Public-10,476

NGO-9,566

Private-737.

Communication Communicationactivitiesbeingimplemented.Media

programmesincorporatingMC;men’shealthkit.

Monitoring & evaluationReportingtoolsandsystemputinplacetoallowMC

implementerstoreporttoMOH.

Provincialanddistrictdisaggregatedannualtargetsmade

andprovidedtoprovincialmedicalofficers

OngoingORthroughuniversityteachinghospital.

ZA

MB

IA

13

ZimbabweStatistics: • Population:12m



Leadership, partnerships & advocacy1. Leadership:MinistryofHealthandChildWelfareis

providingleadershipwithanappointedFocalPerson

leadingtheMCprogramme.MCTaskForcewith

subcommitteesformed.SteeringCommitteeandthree

TechnicalWorkingGroupsareinplace.TheMinistry

continueshavingMCSteeringCommitteemeetings

comprisingofdifferentpartners.FocalpersonforMC

andcondomprogrammingidentifiedintheMOH&CW.

2. Partnerships:Supportingpartners:ZNFPC,WHO,

UNFPA,PSI,churchorganizations.

3. Advocacy:Ongoingsensitizationandinvolvement

oftraditionalcircumcisers,medicalpractitioners,

provincialhealthteamsandcommunitystakeholders.

AonedayworkshopwasconductedinFebruary2010

withProvincialMedicalDirectorstoadvocateforthe

servicedeliverymodelsfortherolloutphaseofmale

circumcision.

Twostakeholdersmeetingswereheldtosensitizethe

keystakeholdersintwoprovinces.

Situation analysis MCsituationanalysisconductedandresultsdisseminated

tostakeholders.

Policy & regulatory framework MCpolicyfinalizedinOctober2009.LaunchedinNovember

2009.

Strategy and operational plan Thecountryisintheprocessofdevelopingamale

circumcision5-yearStrategyandImplementationPlan.The

StrategyisexpectedtobecompletebyJune2010.

TheDMPPTisinprogressandexpectedtobecompletedby

endMay2010.

TrainingNotrainingsundertakeninthisquarter.Establishedcentral

leveltrainingsiteatZNFPCHarare&2othertrainingsites

havebeensetup.NationalTOTwasconductedpreviously

for18nationaltrainersconsistingofsurgeons,nursesand

counselors.Onehundredandfournursesanddoctors

trained.TrainingmaterialshavebeenadaptedfromWHO

trainingguidelines.

Quality assurance DevelopedaqualityassuranceMCcounsellingtoolto

improvethequalityofMCservices.

Service delivery Servicedeliverystatistics:

MCsdonetoMarch2010=4,361.

Communication Developed10billboardstoincreaseawarenessandvisibility

ofMCservices.Developedflyerstargetingyouth,parents

andguardianinanefforttoincreaseawarenessofthe

servicestoyouthandparents.

Monitoring & evaluationEvaluationofthepilotphaseofMCwasconductedandthis

willinformthestrategy.

ZI

MB

AB

WE

14

SECT

ION

TW

OPl

anne

d an

d on

goin

g re

sear

ch o

n m

ale

circ

umci

sion

for H

IV p

reve

ntio

n

16

Intr

oduc

tion:

Sincethethreerandomizedcontrolledtrialsdemonstratedreduced

riskoffemale-to-maletransmissionofHIV,avarietyofresearchhas

beenundertakenorisplanned,tocontinuetoinformthescale-up

ofmalecircumcisionservices.Thissectionprovidesasummary

ofresearchrelatedtomalecircumcisionasofJune2010.The

contributionsofallthestudysponsors,investigators,fundersand

reviewersofthisoverviewaregratefullyacknowledged.

17

Titl

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Type

of s

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ecti

ves

Stud

y po

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tion

Sta

tus

Beha

viou

r, kn

owle

dge/

attit

udes

/bel

iefs

Aprospectivestudy

ofbehavioralrisk

compensationrelated

tomalecircumcision

(MC)asanHIV

preventionmethod

KisumuEast,

KisumuWest

andNyando

Districts,

Kenya

UniversityofIllinois

atChicago&Nyanza

ReproductiveHealth

Society(TheBill

andMelindaGates

Foundationthrough

themalecircumcision

Consortium)

Observational

prospectivestudy.

Followupat6,

12,18,and24

monthsafter

circumcision/

enrolment.

Evaluatesexualriskbehaviour1a)changes

insexualriskbehaviourb)sexualfunction

andsatisfactionc)perceptionofHIVrisk;

2)evaluateperceptionsofcircumcisionin

long-termfemalepartnersofcircumcised

participants.

1600Circumcisedand1600

matcheduncircumcisedmales

aged>18years;long-term

femalepartnersofcircumcised

males

Recruitment

completed.Follow-

upongoing

Impactofmale

circumcisiononsexual

riskbehaviours

Kisumu

Municipality,

Kenya


atChicago&Nyanza

ReproductiveHealth

Society(TheBill

andMelindaGates

Foundationthrough

themalecircumcision

Consortium)

Seriesof3cross-

sectionalrandom-

householdstudies

conductedevery2

years

Changesinperceptions,knowledgeand

beliefsaboutmalecircumcisionandHIV

overtime.HIVandmalecircumcision

prevalencefollowingintroductionofmale

circumcisionservicesingeneralpopulation

overtime.

Menandwomenaged15-49

yrs,1,000maleand1,000female

participantsineachstudycycle

(totaln=6,000)

Baselinesurvey

completed

Prospectivestudy

ofbehavioralrisk

compensationpost

malecircumcision

Zambia

Thepopulationcouncil

(Bill&MelindaGates

foundationthrough

malecircumcision

partnership)

Observational

prospectivestudy

atbaseline,6,12

and24months

postenrollment.

Evaluate:a)changesinsexualriskbehavior

overtimeamongmenandwomenb)

changesinageanduseofcondomsat

firstsexc)changesinwomen'sabiltyto

negotiatesafesex.

Randomsampleof1750males

and1650females15-29years;

oversampleofmales15-24years

andfemales15-19yearswillbe

obtainedtoassesschangesin

riskbehavioramongyoungadults

specifically.Qualitativesamples

of30maleandfemalestudy

participants.

RecruitmentJuly/

Aug2010

Evaluationofthetiming

oftheresumptionof

sexualactivitypost-

malecircumcision

Zambia


(Bill&MelindaGates

foundationthrough

malecircumcision

partnership)

Observational:

Baselineand6

weekspost-male

circumcision

Measuretheprevalenceofunprotected

sexualbehaviorduringthehealingperiod

post-malecircumcision.

225meninterviewedimmediately

priortomalecircumcisionand6

weekspostmalecircumcision;

validationofreportingofsexual

activitywithmaritalpartnersof

maleparticipants

RecruitmentJune/

July2010

Evaluatingmethodsfor

improvingoutcomes

forwomenofmale

circumcisionclients

whoareHIV+or

clientswhorefuseHIV

VCT

Zambia


(Bill&MelindaGates

foundationthrough

malecircumcision

partnership)

Observational

formative

assessment

Toreducewomen’sHIVriskfromHIV+

menwhohaverecentlyhaveundergone

malecircumcisionby1)assessingand

improvingknowledgeofHIVrisk2)

improvingadherencetosexualabstinence

amongpartnersofmalecircumcisionclients

duringpost-operativehealingperiodand3)

evaluatemethodsforimprovingHIVVCT

amongmalecircumcisionclients.

Malecircumcisionclientsandtheir

sexualpartners

Protocolunder

development

18

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ecti

ves

Stud

y po

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tion

Sta

tus

Information,

CircumcisionandHIV

Prevention

70Villagesin

Kuntamanji,

Malawi

UniversityofMichigan

withtheUniversityof

MalawiChancellors

College.

Randomized

controlledtrial

Estimatebehaviouralresponsesto

informationaboutmalecircumcision

protectiveeffectandHIV.

1,200circumcisedand

uncircumcisedmen

Ongoing

Com

mun

icat

ions

Textmessagingto

improveadherence

topostoperative

clinicappointments

andreduceearly

resumptionofsexual

intercourse

KisumuEast,

KisumuWest

andSiaya,

Kenya

Universityof

Washington,Fogarty

throughUniversity

ofIllinoisChicago&

NyanzaReproductive

HealthSociety

Randomized

controlledtrial

Assesstheefficacyoftextmessages

forincreasingadherenceto7daypost

surgicalfollowupvisitandforreducingthe

proportionofmenwhoresumesexbefore

42dayspost-operatively.

Menaged18years+whoget

circumcisedatanyoffourstudy

clinics

Submittedto

Institutional

ReviewBoards

(IRBs)

SMSmessagingto

Improveadherence

topostoperative

clinicappointments

andtoreduceearly

resumptionofsexual

intercourseaftermale

circumcision

Zambia


(Bill&MelindaGates

foundationthrough

malecircumcision

partnership)

Randomizationto

differentdosesof

SMSmessaging,

includingtosexual

partners

Assesstheefficacyoftextmessagesfor

increasingadherencetothe7daypost-

surgicalfollow-upvisitandforreducingthe

proportionofmenwhoresumesexbefore

42dayspost-op.

Malecircumcisionclientsandtheir

sexualpartners

Protocolunder

development

Communicatingpartial

protectionofmale

circumcision

Kisumu

Eastand

KisumuWest

districts

inNyanza

Province,

Kenya

FamilyHealth

International(TheBill

andMelindaGates

Foundationthrough

themalecircumcision

Consortium)

Phase1:formative

qualitativein-

depthinterviews

Phase2:

qualitative

interviews/focus

groupstotest

andrefineinitial

messages

Phase3:

quantitative

messagetesting

usingpost-test

onlyrandomized

design

1)Insightintomen'sandwomen's

understandingofpartialprotectionof

voluntarymedicalmalecircumcision

2)Messagesthateffectivelycommunicate

partialprotectivenessofvoluntarymedical

malecircumcisionthatcanbeincorporated

intomalecircumcisioncommunication

strategiesinNyanzaProvince,Kenya.

-circumcisedanduncircumcised

menaged18-39years

-womenofreproductiveage

18-39years

Underway,

completion

December2010

19

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ecti

ves

Stud

y po

pula

tion

Sta

tus

Com

mun

ity im

pact

Effectofmale

circumcisiononHIV

atpopulationlevel:

demonstratethat

theroll-outofmale

circumcision(MC)

hasanimpactonthe

spreadofHIVata

communitylevel.

OrangeFarm

township,

SouthAfrica

Agencenationalede

recherchessurlasida

etleshépatitesvirale

(ANRS)

Phase4study,

with3cross

sectionalsurveys

amongthe

generalpopulation

Assesstheimpactoftherolloutofamale

circumcisioninterventioninthecommunity

on:

a.knowledge,attitudesandpractice

regardingmalecircumcision

b.sexualbehaviourandcondomuse

c.thespreadofHIV,HSV-2andHuman

papillomavirus.

Males15yearsandolderin

OrangeFarmtownship

Underway:

Completionin2013

Effectsofrapidly

achievinghighlevel

malecircumcision

coverageonHIV

incidence

Swaziland

nationally

CDC/PEPFARand

MinistryofHealth

Longitudinal

cohort(s)

1)Acceptability/feasibility/uptakeof

acceleratedsaturationapproach;2)risk

compensation;3)reducedHIVincidence.

Groupsforincidencemonitoring

beingdetermined

Protocolunder

development;

baselineexpected

tobeinitiated

beforeyear-end

2010

Communityeffectsof

malecircumcisionon

HIVEpidemic

Uganda

TheBillandMelinda

GatesFoundationand

NationalInstitutes

ofHealththrough

RakaiHealthSciences

Institute

Phase4

longitudinalstudy,

5yearsfollow-up

Assessacceptability,sexualriskbehaviours

andattitudestowardsandcomprehension

ofmalecircumcision.Assessthelongterm

effectivenessofmalecircumcisionforHIV

(incidence)andSTIpreventionatthe

populationlevel.

1)15,000communitycohort

participantsage15-49years

Ongoing

Cost

ing

Costingandimpact

ofmalecircumcision

inUgandaandSouth

Africa

Health

facilities

throughout

Uganda,

SouthAfrica

USAIDthroughthe

HealthPolicyInitiative

Costinganalysis

andmodelling

withprimarydata

collection

Calculatetheunitcostofdeliveringmale

circumcisionandestimatetheimpactof

variouspolicyapproachestoscalingup

malecircumcision.

27healthfacilitiesinUgandaand

20healthfacilitiesinSouthAfrica

Datacollection

completed,initial

analysisofdata

underway

Estimatingthecosts,

cashflowanalysis

andimpactofmale

circumcisioninKenya

andZimbabwe

Health

facilities

throughout

Nyanza

province,

Kenyaand

Zimbabwe

USAIDviaHealthPolicy

InitiativeandUNAIDS

throughtheTechnical

SupportFacility,South

Africa

Costinganalysis

andmodelling

withprimarydata

collection

Calculatetheunitcostofdeliveringmale

circumcisionandestimatetheimpactof

variouspolicyapproachestoscalingup

malecircumcision.

30healthfacilitiesinNyanza

provinceand5facilitiesin

Zimbabwe

Datacollection

completed,initial

analysisofdata

underway

Scalingupmale

circumcisionprograms:

demandresponsesto

prices

Kawale

(Lilongwe)

Malawi

UniversityofMichigan

andMarieStopes

Internationalwiththe

UniversityofMalawi

CollegeofMedicine

Randomized

controlledtrial

Estimatetheelasticityofdemandtoprices

ofadultmalecircumcision.

1800uncircumicsedadultmen

Ongoing

20

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of s

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/obj

ecti

ves

Stud

y po

pula

tion

Sta

tus

Dev

ices

TheShangRing:A

novelmalecircumcision

deviceforHIV

prevention

HomaBay

District

Hospital,

Kenya

EngenderHealthand

WeillCornellMedical

College;Kenya

NationalAIDSControl

Programmeand

MinistryofHealth.

Non-comparative

pilotstudy

1)Assesssafety&efficacyoftheShang

RingforadultmalecircumcisioninKenyan

mentodetermineifsafeforuseinlarger

studiesinAfrica;2)assessacceptability

amongprovidersandsatisfactionamong

menbeingcircumcised.

40HIV-negativemenaged

18to54yearsseekingmale

circumcision

Completed.

Dataanalysis&

manuscriptwriting

areunderway

TheShangRing:

Evaluationofhealing

atthreetimeintervals

andpotential

forspontaneous

detachment

HomaBay

District

Hospital,

Kenya

Bill&Melinda

GatesFoundation

throughFHIwith

EngenderHealthand

WeillCornellMedical

College,University

TeachingHospital,

Lusaka,Kenya

NationalAIDSControl

Programmeand

MinistryofHealth.

Non-comparative

safetyand

acceptabilitystudy

1)Assesshealingafterremovalofthe

ShangRingatthreedifferenttimepoints,7,

14and21days;2)determinewhetherthe

devicewillspontaneouslydetachifremoval

isdelayedforlongerthanthecurrently

recommendedtimeof7-10days,uptoa

maximumof21days.



circumcision

SubmittedforIRB

review.

Comparisonofthe

ShangRingwith

conventionalsurgical

methods

1)Zambia:

Lusaka,

University

Teaching

Hospital

/Society

forFamily

Health,

2)Kenya:

HomaBay

District

Hospital,

Kenya

Bill&MelindaGates

Foundationthrough

FamilyHealth

Internationalwith

EngenderHealthand

WeillCornellMedical

College;University

TeachingHospital,

Lusaka,Kenya

NationalAIDSControl

Programmeand

MinistryofHealth.

Randomized

controlledtrial

1)Comparethepainandacceptabilityof

theShangRingprocedurewiththeforceps

guidedsurgicalcircumcisiontechnique

(Kenya)andthedorsalslittechnique

(Zambia);

2)comparethesafetyandthecourse

ofwoundhealing,includingthetimeto

completehealing,betweentheShangRing

adultmalecircumcisionprocedureandthe

standardsurgicalcircumcisionprocedures;

3)comparetheeaseoftheShangRing

methodversusstandardcircumcision

surgicalprocedures.



circumcision:200ShangRingand

200standardsurgicalprocedures

SubmittedforIRB

review.

Shangring

Uganda

NationalInstitutesof

Health

Safetyand

acceptability

ToassessShangRingsafetyand

acceptabilitycomparedwithdorsalslit.

250HIV-negativemen,15-49

yearsold

Planned

21

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ecti

ves

Stud

y po

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tion

Sta

tus

Form

ativ

e re

sear

chAssessingmethods

toimprovetheself-

reportingofmale

circumcisionstatus

amongmenandtheir

partners

Zambia

(Lusaka

andrural

sample)and

Swaziland

(Mbabane,

Manzini)


(Bill&MelindaGates

foundationthrough

malecircumcision

partnership)

Randomizedto

3studyarms:

(1)verbal

description(2)

verbaldescription

+illustration,(3)

computerized

self-administration

withverbal

descriptionand

illustration

Toevaluatemethodsforimprovingthe

reportingofcircumcisionstatus:a)assess

thevalidityofself-reportsandpartner-

reportsofMCstatus;b)investigate

whetherillustrationsofacircumcised&

uncircumcisedpenisimprovesaccuracyof

MCreporting.

Menaged18–34yearsandtheir

femalepartners,&adolescent

boysaged13–17years.

CompletedMay

2010

Assessmentof

informedconsent

processandparticipant

understanding

Zambia,

Swaziland


(Bill&MelindaGates

foundationthrough

malecircumcision

partnership)

Qualitativeand

quantitative

assessment

ofclient

comprehension

(1)Makerecommendationsfor

standardizingandstreamliningtheinformed

consentprocesswhileadheringtoWHO,

UNAIDS,andotheracceptedinformed

consentguidelines;(2)toassessmale

client’scomprehensionofkeyconceptsin

theinformedconsentprocess.

Keyinformants;parents/

guardians;adultandadolescent

males;adultandadolescent

malesundergoingmale

circumcision

Zambiacompleted

April2010.

Swaziland

underway

Hea

ling

Astudyofpost-surgical

woundhealling

Universities

ofNairobi,

Il linois,and

Manitoba

Research

andTraining

Center,

Kisumu


atChicago&Nyanza

ReproductiveHealth

Society(TheBill

andMelindaGates

Foundationthrough

themalecircumcision

Consortium)

Longitudinal

follow-upof

clientspost-

surgeryto6

months

Toassessprogressionofwoundhealingand

keratinization;differencesinwoundhealing

byHIVstatus,CD4count,age,resumption

ofsex,condomuseandotherfactors.

Men>15yearscircumcisedat

theUNIMResearchandTraining

Center,Kisumu

Protocolunder

development

Healingand

keratinization

RakaiDistrict

Uganda

TheBillandMelinda

GatesFoundation

throughtheRakai

HealthSciencesProject

(RHSP)

Prospective

research.W

eekly

visualand

dermascopic

examinationofthe

surgicalwound

Todeterminethetimerequiredfor

completehealingandkeratinizationof

scartissuebyHIVstatus.InHIV-infected

men,determineifviralloadisincreased

bystress/inflammationofsurgeryand

measureHIVsheddingfromsurgical

wound.

100HIV-positiveand100HIV-

negativemen

Underway

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ecti

ves

Stud

y po

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tion

Sta

tus

Hum

an re

sour

ces

Respondingtothe

humanresource

capacitydevelopment

andtrainingneeds

HomaBay,

Rachuonyo,

Rongoand

Nyando

distirctsin

Nyanza,

Kenya

EngenderHealth(The

BillandMelindaGates

Foundationthrough

themalecircumcision

Consortium)

Deskreview;

facility

assessments;in-

depthinterviews

withkey

informants;focus

groupdiscussions

withsexualand

reproductive

healthand

HIVprogram

managers&

healthworkers

1)Determinegapsinhumancapacity

andtrainingneedsrelatedtomale

circumcision;2)identifyhumanresource

andtrainingbarriers/facilitatingfactorsto

introducingmalecircumcisionservices;

3)recommendationsregardingstrategies

toaddresscurrenthumanresourceand

traininggapstosupportmalecircumcision

roll-out.

NotApplicable

Finalizingstudy

report.

Privatesectorhealth

providersassessment

Nyanza

Province,

Kenya

FamilyHealth

International(TheBill

andMelindaGates

Foundationthrough

themalecircumcision

Consortium)

Cross-sectional

study

1)Descriptionandclearunderstanding

ofcostsassociatedwithbringingfacilities

andemployeestominimumstandardsfor

malecircumcisionprovision;2)actualcosts

associatedwithprovidingmalecircumcision

servicesaccordingtoWHOminimum

package;3)recommendationsforstrategies

tointegrateprivatemalecircumcision

serviceprovisionwithMOHservices.

Surveyandobservations

ofprivate-for-profit,non-

governmentalandfaith-based

organizationhealthfacilities

Completed

Assessmentofnon-

physicianclinicians

performingmale

circumcision

HomaBay,

Rachuonyo,

Rongoand

Nyando

distirctsi n

Nyanza,

Kenya

EngenderHealth(The

BillandMelindaGates

Foundationthrough

themalecircumcision

Consortium)

Prospectivestudy

1)Malecircumcisionsurgicalandpost-

operativeproceduresperformedbytrained

non-physiciancliniciansatregularfacilities

workplace;2)malecircumcisionsurgical

outcomesat7-daysand60-dayspost-

surgery;3)patientsatisfactionwithmale

circumcisionservicesprovidedbynon-

physiciancliniciansat7-daysand60-days

post-surgery;

4)costsassociatedwithprovidingmale

circumcisionbynon-clinicianphysicians.

2,530malecircumcision

procedures-malesaged13-54

years

Underway,

completion

September2010

Assessmentoftraining

Uganda

PEPFAR

Observational

study

Processassessmentwithpreandpost

trainingevaluationsandmonitored

surgeries.

Trainees

Ongoing(280

completed)

Assessmentof

physiciansandclinical

officers

Uganda

Centerfor

Communication

Programs/USAID

Observational

study

Safetyandtimerequiredforsurgery.

Men15-49yearsold

Ongoing

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nt m

ale

circ

umci

sion

Infantmale

circumcisionin

Gaborone,Botswana,

andsurroundingareas:

Feasibility,safetyand

acceptability

Gaborone,

Mochudiand

Molepolole,

Botswana

PEPFAR/Centers

forDisease

ControlBotswana-USA

Partnership(BOTUSA)

Prospective

randomizedtrial

oftwomethods

forinfantmale

circumcision.

Ascertain:1)actualuptake/acceptance

ofinfantmalecircumcisionanddetermine

parentalfactorsassociatedwithuptake;

2)feasibility(includingcost)andsafetyof

infantmalecircumcisionusingMogenclamp

versusPlastibell;3)parentalsatisfaction

withtheresultsofcircumcision.

300maleinfants(150ineach

arm)inBotswana

Enrollingwith

approximately190

ofthe300infants

enrolled.

Evaluationofsafe

voluntaryinfant

medicalmale

circumcisioninselected

facilitiesinNyanza

Province,Kenya(The

MtotoMsafiProject)

KisumuEast,

KisumuWest

andSiaya

districts

inNyanza

Province,

Kenya


atChicago&Nyanza

ReproductiveHealth

Society(TheBill

andMelindaGates

Foundationthrough

themalecircumcision

Consortium)

Casecontrolstudy1)Comparebeliefsandattitudesabout

circumcisionbetweenparentschoosing

infantmalecircumcisionandthose

decliningtheprocedure;2)identify

facilitatorsandbarrierstouptakeofinfant

malecircumcision;3)measureadverse

eventratesassociatedwithinfantmale

circumcision.

Consentingparentsinselected

healthfacilities.Recruiting300

parentsacceptinginfantmale

circumcisionand300parents

declininginfantmalecircumcision

Underway

Evaluationofsafety

andacceptabilityof

neonatalcircumcision

usingGomco,Plastibell,

andMogenmethods

Lusaka,

Zambia

CentersforDisease

Control,Centrefor

InfectiousDisease

ResearchinZambia

andtheUniversity

TeachingHospital

DepartmentofUrology

Prospective

randomizedtrial

TotestthehypothesisthattheGomcoand

Mogenclampsmethodswillbesaferthan

thePlastibellmethodinZambia.

600neonates(450fromthe

UniversityTeachingHospital,

Lusakaand150fromaMatero

referenceclinic)

Underway

Mol

ecul

ar m

icro

biol

ogy,

imm

unol

ogy

Genitalanaerobes,

inflammationandHIV

risk

RakaiDistrict

Uganda

USANationalInstitutes

ofHealth/National

InstitutesofAllergy

andInfectiousDiseases

Molecular

microbiology,

immunologyand

epidemiologic

observational

study

AIM1.Toassessthecorrelationbetween

theburdenofgenitalanaerobesand

inflammatorymarkersinHIV-uninfected

menandtheirfemalepartners.

100HIV-negativemarriedmenin

theinterventionarmwhoreceived

circumcisionatenrollmentand

100meninthecontrolarmwho

receivedcircumcisiondelayed

for24months,andtheirlinked

femalepartners(n=200)

Specimenanalysis

tostartinJuly,

2010

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tion

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tus

Genitalanaerobes,

inflammationandHIV

risk

RakaiDistrict

Uganda


ofHealth/National

InstitutesofAllergy


Case-control

design

AIM2.Toassesstheassociationsbetween

genitalanaerobes,inflammatorymarkers

andrisksofHIVacquisitioninmenand

women.AIM3.InHIV-discordantcouples

assesstheassociationsbetweengenital

anaerobicburden/inflammatorymarkers

andtheriskofHIVtransmission/acquisition.

AIM4.Estimatethemediatingroleof

genitalanaerobes/inflammationinthe

efficacyofcircumcisionforHIVprevention

inmen(ifMCisshowntodecreasegenital

anaerobesandinflammationandtheyare

associatedwithacquisition/transmission.

AIM2.Amongthe194HIV-

seroconverters(cases)anda

randomlyselectedgroupof

persistentHIV-seronegative

controls.AIM3.310HIV-

discordantcouples.AIM4.N/A

Specimenanalysis

tostartinJuly,

2010

Circumcision:HIV,

STIsandBehaviours

inaRCTandPost-

RCTsurveillance:In

situanalysisofHIV

transmissioninforeskin

Johns

Hopkins

University

Laboratory,

Baltimore,

MD,USA


ofHealth/National

InstitutesofAllergy


Basicscience

1)Toenvisagetheearliesteventsand

virus-hostcellinteractionsintransmission

byanalyzingforeskinsfromapparently

HIV-uninfectedmenenrolledinRakai

circumcisiontrials;2)todeterminethe

basesforobservedlowratesoffemale-

to-maletransmissionbyinsitustudiesof

foreskinsfrommenwhoareindiscordant

relationshipswithHIVpositivewomenand

arehighlyexposedbutremainserologically

andPCRnegativetoHIV.

Foreskinsfrom14menwitha

newHIV+serologyatthefirst

visitpost-circumcision,6men

whoarePCR+butserologically

negativeatmalecircumcision,

and50menwhoarehighly

exposedbutserologically

uninfected.

Underway

Communityeffectsof

malecircumcisionon

HIVepidemic:Foreskin

inflammationand

mucosalimmunology

studies

RakaiDistrict

Uganda

TheBillandMelinda

GatesFoundation

throughtheRakai

HealthSciencesProject

(RHSP)

Basicscience

Foreskinsremovedduringmalecircumcision

providemucosaltissueandanewmodel

fortheinvestigationofmucosalbarriers

andsusceptibilitytoHIVinfectionand

transmission.

ConsentingHIVnegative

adultmales,age15-49years,

undergoingelectivemale

circumcisionattheRHSP

Underway

Mon

itorin

g Amonitoringand

evaluationstudy

toassessthe

implementationofmale

circumcisionasanHIV

preventionstrategy

KisumuEast,

KisumuWest

andNyando

Districts,

Kenya


atChicago(TheBill

andMelindaGates

Foundationthrough

themalecircumcision

Consortium)

Prospectivestudy

1)Evaluatemonitoringandevaluation

system;2)adverseeventrates(byseverity,

type,cliniciancadre,etc.);3)identify

factorsthatfacilitateandactasbarriers

totheuptakeofmalecircumcision;4)

evaluatetimetoonsetofsexualactivity;

5)assesssatisfaction(appearance,sexual,

healthfacility,etc).

Circumcisedmalesaged>12

yearsrecruitedatselectedhealth

facilities;usingthepassive

system(n≈4,000)andasub-

sampleofclientsthrough30-40

dayspost-surgeryusingtheactive

system(n≈2,000).

Datacollection

completed

Home-basedstudyof

post-operativeadverse

events

Nyanza

Province,

Kenya

PEPFAR/Westat

Prospectivestudy

1)Adverseeventsrates;2)losstofollow-

uprates;3)barrierstoadherenceto

routinefollow-up;4)othersourcesofpost-

opclinicalcare.

Sub-sampleofcircumcisedmales

aged>12yearsrecruitedat

selectedhealthfacilitiestoreceive

home-basedassessmentat20

days.

Protocolbeing

finalized

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tion

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tus

Serv

ice

deliv

ery

Assessmentofthe

'ModelsforOptimising

theVolumeand

EfficiencyofMC

Services(MOVE)

methods

Kenya,

Zimbabwe,

and

potentially

SouthAfrica

andZambia

USAIDProjectSEARCH

throughJohnsHopkins

BloomsbergSchool

ofPublicHealth-

Research2Prevention

ProjectwithPSI,

Jhpiego&MOH.

Facility-based,

multi-country

operations

researchstudy

TrackadoptionofMOVEelementsand

determinebenefitsintermsofimproved

productivityandcostefficiency,with

equivalentsafety.

Asampleofselectedfixedsite

healthcarefacilities,andpossibly

arandomsampleofoutreach/

mobilesitesineachparticipating

country

Protocolsubmitted

Assessmentofmale

circumcisionservices

atoutreachhealthcare

facilities

HomaBay,

Rachuonyo

&Rongo

distirctsin

Nyanza,

Kenya

EngenderHealth(The

BillandMelindaGates

Foundationthrough

themalecircumcision

Consortium)

Prospective

studyofmale

circumcision

performedby

trainedmedical

officersworking

atoutreachhealth

facilities.

1)Malecircumcisionsurgicalandpost-

operativeproceduresatoutreachservice

sites;2)malecircumcisionsurgical

outcomesat7-daysand60-dayspost-

surgery;3)patientsatisfactionwithmale

circumcisionservicesreceivedatoutreach

sitesat7-daysand60-dayspost-surgery;

4)costsassociatedwithprovidingmale

circumcisionthroughoutreachservices.

800malecircumcisionprocedures

onmalesaged18-54years

Underway,

completionSept

2010

ComparingOutcomes:

Physicians,Nursesand

ClinicalOfficers

Zambia


(Bill&MelindaGates

foundationthrough

malecircumcision

partnership)

ProspectiveatMC

and6weekspost-

MC;randomize

clientstodifferent

providertypes

Evaluateclinical,post-operativeandclient

satisfactionmalecircumcisionoutcomesfor

differentprovidertypes.Assessphysician,

nurseandclinicalofficerattitudesandjob

satisfactionaswellasproviderprogramme

drop-out;assessimpactonotherservices

provided.

Malecircumcisionclientsand

providers

Protocolunder

development

Assessingdifferent

suturetypesonmale

circumcisionclient

outcomes

Swaziland


(Bill&MelindaGates

foundationthrough

malecircumcision

partnership)

Randomization

tostandardand

quickabsorbing

sutures

Assessingdifferentsuturetypesonmale

circumcisionclientoutcomes:1)clinical

andpost-operativeadverseeventsrates;2)

clientsatisfaction;3)timingofresumption

ofsexualactivitypost-malecircumcision.

Malecircumcisionclients

Protocolunder

development

Assessmentofpost-

operativeadverse

eventsratesamong

compliantandnon-

compliantclientswho

donotreturnfor

follow-upvisits

Swaziland


(Bill&MelindaGates

foundationthrough

malecircumcision

partnership)

Observationaland

experimental

Measurepost-operativeadverseevents

ratesamongafullsampleofmale

circumcisionclients,includingthosewho

arecompliantandnon-compliantwith

follow-upvisits;evaluatepredictorsof

adverseeventsandnon-compliancewith

follow-upvisits;evaluatemethodsfor

improvingf ollow-upvisitrates

Malecircumcisionclients

Protocolunder

development

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tus

Sexu

ally

tran

smitt

ed in

fect

ions

and

repr

oduc

tive

trac

t inf

ectio

nsHIVandSTIIncidence

Kisumu,

Kenya

UniversityofIllinois-

ChicagoandNyanza

ReproductiveHealth

Society(TheBill

andMelindaGates

Foundationthrough

themalecircumcision

Consortium)

Cohortstudy,

post-RCT

EstimatethedifferencesinHIVandother

STIincidencebetweencircumcisedand

uncircumcisedmen.

Menages18-34years

Continuingfollow-

up

Malecircumcision:HIV,

STIsandbehaviorsin

aRCTandpost-RCT

Surveillance;Human

papillomavirus(HPV)

testing

RakaiDistrict

Uganda

andJohns

Hopkins

University

Laboratory,

Baltimore,

MD,USA


ofHealth/National

InstitutesofAllergy


Randomized

clinicaltrialwith6,

12and24month

followupvisits.

1)Assesstheefficacyofmalecircumcision

forhighriskHPVpreventionandto

determinetheprevalence,incidenceand

clearanceofHPV;2)assesstheefficacy

ofcircumcisionforreductionofgenital

highrisk-HPVinfectionsinfemalepartners

ofHIV-infectedanduninfectedmaletrial

participantsbycomparingHPVprevalence

andincidenceinfemalepartnersof

circumcisedanduncircumcisedmarried

men.

Samplesfrom609HIV-negative

and530HIV-positivemen,and

femalepartners

Underway

Circumcision:HIV,

STIsandbehaviorsin

aRCTandpost-RCT

Surveillance

RakaiDistrict

Uganda


ofHealth/National

InstitutesofAllergy


PhaseI V,post-

trialsurveillance

studyofmale

circumcision

effectiveness

1)ConductSTIassaysonstoredsamples

todeterminetheefficacyofcircumcision

inpreventingselectedSTIs;2)assessthe

long-termeffectivenessofcircumcisionfor

HIV/STIprevention,andeffectsonsexual

riskbehaviors,byconductinganadditional

5yearsofannualfollowupamongmen

whohadenrolledintheNIHtrial.

5,000menaged15-49years

originallyenrolledinthemale

circumcisiontrial.

Underway

Progress in male circumcision scale-up: country implementation and

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Transcript of Progress in male circumcision scale-up: country implementation and