The state of medical male circumcision

50 %
50 %
Information about The state of medical male circumcision
Health & Medicine

Published on February 19, 2014

Author: HEARD_SA

Source: slideshare.net

Description

The state of medical male circumcision- The study revealed that male circumcision prevalence is high in Angola (80%), Madagascar (80%) and the United Republic of Tanzania (70%) however, it is necessary to scale up MMC in countries such as South Africa, Swaziland and Zimbabwe which all have high HIV prevalence but low MMC uptake. The study investigated MMC policies and programmes already in place in SADC countries in order to identify where policy development and programmatic activities should be concentrated to increase uptake of MMC.

Executive Summary This study examined the state of medical male circumcision (MMC) in the 15 SADC countries. Its aim was to answer the following five questions: What are the current prevalence rates of HIV and male circumcision (MC)? How have HIV and AIDS policy responses, especially National Strategic Plans (NSPs), incorporated MMC? What are the current MMC policies? What are the existing MMC programme initiatives? How effective have these MMC programmes been? MC prevalence is high in Angola (80%), Madagascar (80%) and the United Republic of Tanzania (70%). It is necessary to scale up MMC in the countries with high HIV prevalence and low MMC prevalence (WHO, 2008). Botswana, Malawi, Namibia, South Africa, Swaziland, Zambia and Zimbabwe have low MMC prevalence and relatively high HIV prevalence. NSPs on HIV and AIDS are important documents that guide programmatic outcomes and procedures, and need to include detail on MMC programme demand creation, pre-procedure, procedure and post-procedure. Most countries have made improvements in their NSPs to include MMC. Only five countries; Angola, Democratic Republic of Congo, Madagascar, Mauritius and the Seychelles do not include MMC in their current NSPs. SADC MMC programmes have a high level of acceptance. There are effective methods for social mobilisation for MMC, promoting patient comfort at MMC sites, providing pre- and post-procedure counselling, using safe and hygienic methods and completing the procedure at a minimal cost to the patient. However, SADC MMC programmes are constrained in providing clarity on the procedure to patients, using time efficient procedures, providing better infrastructure and trained staff, greater use of hospitals as MMC sites and providing reminders/ advice to patients away from the MMC site post-procedure.

Table Of Contents 1. Introduction............................................................................................................................................................................................... 01 2. Aims of the Study.................................................................................................................................................................................... 02 3. Background................................................................................................................................................................................................ 03 3.1. HIV and AIDS Epidemic............................................................................................................................................... 03 3.2. HIV and Male Circumcision (MC) Prevalence................................................................................................ 03 3.3. Medical Male Circumcision (MMC) for HIV Prevention........................................................................... 04 4. Policy Responses to HIV and AIDS, and MMC........................................................................................................................ 06 4.1. Past Policy Responses which Explicitly Mentioned MMC....................................................................... 06 4.2. National Strategic Plans (NSPs) for HIV and AIDS and the Incorporation of MMC......................................................................................................................................... 07 4.3. Current Policy Responses on MMC...................................................................................................................... 10 4.3.1 MMC policies in NSPs “needing improvement”..................................................................... 11 4.3.2 MMC policies in “comprehensive” NSPs.................................................................................... 12 5. Characteristics of Effective MMC Programmes.................................................................................................................... 14 5.1. Demand Creation........................................................................................................................................................... 14 5.2. Programme Implementation................................................................................................................................... 15 5.2.1. Pre-procedure......................................................................................................................................... 15 5.2.2. Procedure.................................................................................................................................................. 16 5.2.3. Post-procedure....................................................................................................................................... 18 6. Assessment of MMC Programmes................................................................................................................................................. 19 6.1. Country MMC Programmes....................................................................................................................................... 19 6.1.1. Demand creation.................................................................................................................................. 19 6.1.2. Programme implementation......................................................................................................... 21 6.2 MMC programmes and achievement of NSP goals..................................................................................... 26 7. Recommendations................................................................................................................................................................................. 28 8. Conclusions ........................................................................................................................................................................................... 32 9. References.................................................................................................................................................................................................. 33

List of Acronyms AIDS Acquired Immunodeficiency Syndrome AMMC Adult Medical Male Circumcision CDC Centre for Disease Control HCT HIV Counselling and Testing HIV Human Immunodeficiency Virus MC Male Circumcision MMC Medical Male Circumcision MoH MOVE Ministry of Health Models for Optimising the Volume and Efficiency NACA National Agency for the Control of AIDS NSP National Strategic Plan NGO Non-Governmental Organisation PEPFAR President’s Emergency Fund for AIDS Relief RCT Randomised Control Trial SADC Southern African Development Community SMS Short Message Service STI Sexually Transmitted Infection UN United Nations UNAIDS Joint United Nations Programme on HIV/AIDS UNGASS United Nations General Assembly Special Session UNICEF United Nations Children’s Fund USAID United States Agency for International Development VMMC Voluntary Medical Male Circumcision WHO World Health Organization

1 Introduction Given the high rates of HIV especially in sub-Saharan African countries, various national governments have directed and invested in campaigns and programmes, often advised by the World Health Organization (WHO), to promote HIV prevention and reduce transmission rates. One such programme, medical male circumcision (MMC), has been scientifically demonstrated to be a biological protective factor for HIV transmission. Three randomised control trials (RCTs) were conducted in Africa to determine whether medically performed circumcision of adult males would reduce their risk of HIV acquisition, and to ensure that any significant results were in fact due to MMC rather than confounding factors. The first study, conducted in South Africa, was stopped in 2005 and subsequent studies in Kenya and Uganda were stopped in 2006 after interim analyses from each found that MMC significantly reduced male participants’ risk of acquiring HIV infection (Auvert et al., 2005; Bailey et al., 2007; Gray et al., 2007; Lissouba, Taljaard, Rech et al., 2010). Men who had been representatively assigned to the circumcision group had a 60% (South Africa), 53% (Kenya), and 51% (Uganda) lower incidence of HIV infection compared to men assigned to the control group who were to be circumcised at the end of the trials. As a result of these three trials MMC has been promoted as an important initiative for HIV prevention. MMC acts as a direct biological protective factor for men; the removal of the foreskin decreases men’s risk of contracting HIV. In traditional male circumcision, however, the foreskin may not be removed correctly and therefore would not counteract the risk for HIV contraction. The implications for women are more indirect and long term since increasing MMC rates for men induces increased protection from HIV infection for women; hence the emphasis on MMC saturation for men. Despite recent large-scale resources allocated to MMC programmes in selected Southern African Development Community (SADC) countries, the uptake of MMC has been disappointing. It is therefore necessary to investigate MMC policies and programmes already in place in the countries with the highest HIV prevalence rates. Once the extent of MMC policies and programmes are clear it will then be possible to identify where policy development and programmatic activities should be concentrated to increase uptake of MMC and reduce HIV transmission rates. INTRODUCTION 01

2 Aims of the Study Given the high rates of HIV prevalence in SADC countries and the resultant discovery that MMC is an extremely effective preventative factor for HIV transmission, governments have recognised the need for investment in scaling up and improving current MMC programmes. In its issue brief, UNAIDS (2011) included voluntary MMC in countries with high HIV prevalence and low rates of circumcision as one of the basic programme activities for the global HIV response. This study report will provide baseline data which will be used as a tool to assist in identifying opportunities to scale up resources and build capacity for those countries with low MMC and high HIV prevalence. The research questions addressed in this review document are: 1 | What are the current prevalence rates of HIV and MC? 2 | How have HIV/AIDS policy responses, especially National Strategic Plans (NSPs), incorporated MMC? 3 | What are the current MMC policies? 4 | What are the existing MMC programme initiatives? 5 | How effective have these MMC programmes been? Four methods were used to formulate this review document: 1 | Review of the literature 2 | Draft research report writing 3 | Consultations with various stakeholders 4 | Final research report produced This study has the support of the SADC HIV unit based in Botswana. The second phase of the study will use this review document along with consultations with the SADC HIV Unit, regional UN agencies and external funding bodies to identify potential target countries where MMC interventions would materially increase the number of circumcisions and therefore reduce HIV prevalence and incidence rates into the future. 02 AIMS OF THE STUDY

3 Background 3.1. HIV and AIDS Epidemic In 2011, the number of people living with AIDS worldwide was 34 million with 2.5 million new infections, 20% lower than in 2001 (UNAIDS, 2012). In the same year, the number of people dying of AIDS-related causes fell to 1.7million (UNAIDS, 2012). Young adults (aged 15-24) have the highest HIV incidence and account for 45% of all new HIV infections. Sub-Saharan Africa continues to be the most heavily affected region, accounting for 69% of people living with HIV globally (UNAIDS, 2012). Despite HIV prevention efforts, incidence rates in the region remain high with an estimated 1.8million adults and children acquiring HIV in 2011 (UNAIDS, 2012). These high incidence rates, combined with increased survival rates due to expanded HIV care and treatment programmes, contribute to the high HIV prevalence rates observed in the region. HIV prevalence in each of the 15 SADC countries in 2011 can be found in Table 1. No evidence, besides modeling evidence, shows that HIV prevention programmes have a direct impact on HIV incidence (UNAIDS/WHO/SACEMA, 2009). Modeling, however, associates HIV prevalence with behaviour change for large-scale MMC uptake (UNAIDS/WHO/SACEMA, 2009). MMC has also been shown in RCTs to provide around a 60% reduction in risk of HIV acquisition in men (Auvert et al. 2005; Bailey et al. 2007; Gray et al. 2007). 3.2. HIV and Male Circumcision Prevalence Table 1 outlines the population, HIV prevalence, HIV prevalence of men and MC prevalence in the 15 SADC countries. MC prevalence is only above 70% in four countries (Angola, Democratic Republic of Congo, Madagascar and the United Republic of Tanzania). In many of the countries most adversely affected by HIV, high HIV prevalence rates are combined with low MC prevalence rates. Whilst this is a source of concern it is also an indication of the potential gains that can be achieved in reducing HIV prevalence in the future by rapidly increasing MMC in these same countries. Table 1: Prevalence of HIV and MC in SADC Countries 2 BACKGROUND 03

TABLE 1: CONTINUED 1. The Henry J. Kaiser Family Foundation (2012). 2. The Henry J. Kaiser Family Foundation (2011a). 3. The Henry J. Kaiser Family Foundation (2011b). 4. Halperin and Timberg (2012). Data retrieved from District Health Surveys and reflects most current data as of 2012, but the most recent year of data available varies by country. 5. Government of the Democratic Republic of Congo (2010). 6. Data not disaggregated by the Government of the Democratic Republic of Congo. 7. Data not available as Mauritius and Seychelles are not considered part of the Sub-Saharan African region. 8. Government of Seychelles (2012). HIV prevalence percentages were calculated manually based on population data and data on numbers of adults and men living with HIV. 3.3. MMC for HIV Prevention For at least a decade, multiple cross-sectional, prospective and population-level studies have identified low levels of MC as a risk factor for increased levels of HIV transmission (Siegfried et al., 2005; Weiss et al., 2000). In 2000, a systematic review and meta-analysis of HIV in Africa, which included 19 cross-sectional studies, five case control studies, and one partner study, noted a substantial protective effect of MMC on the risk of HIV acquisition in men (Weiss et al., 2000). In population-based studies that adjusted for confounding factors, the relative risk for HIV infection was reduced by 58% in circumcised men (AVAC Global Advocacy for HIV Prevention, 2012). For men at high risk of HIV, such as those seeking treatment for sexually transmitted infections (STIs), the association between reduced HIV risk and MMC was strong. A 2003 Cochrane Review of 35 observational studies, including many of the same studies used in the 2000 meta-analysis, found inconsistent results in 14 cross-sectional and one prospective study in the general population (Siegfried et al., 2003). However, the single cohort study included in the meta-analysis showed a significant difference in HIV acquisition rates (odds ratio 0.58, 95% CI 0.36 - 0.96) for circumcised men. As with earlier meta-analysis, results from the subset of 19 studies among high-risk populations found a consistent, substantial protective effect of MMC. In the mid 2000s three RCTs were conducted in Africa to examine the possibility that the observational findings described above were due to confounding factors, and to determine whether medically performed circumcision of adult males would reduce their risk of HIV acquisition and transmission. The first study, conducted in South Africa, was stopped in 2005, and subsequent studies in Kenya and Uganda were stopped in 2006 after interim analyses from each found that MMC significantly reduced male participants’ risk of acquiring HIV infection (Auvert et al., 2005; Bailey et al., 2007; Gray et al., 2007; Lissouba et al., 2010). That is, the impact of MMC was established so significantly in each of these trials that it was considered unethical to continue the trial and prevent the control group from receiving MMC. Men who had been representatively assigned to the circumcision group had a 60% (South Africa), 53% (Kenya), and 51% (Uganda) lower incidence of HIV infection compared to men assigned to the control group to be circumcised at the end of the trials. 04 AIMS OF THE STUDY

More recent data collected through follow up from the Kenyan trial demonstrated even greater protective efficacy. HIV seroincidence was 0.77/100 person years among circumcised males compared to 2.37/100 person years among control group males who did not seek MMC after the trial ended, equating to a 68% reduction in risk of HIV acquisition (Bailey et al., 2008). In a costing study of MMC programme implementation in Botswana, results suggest that scaling up adult and neonatal MMC to reach 80% coverage by 2012 would result in averting almost 70,000 new HIV infections through 2025, at a total net benefit of US$47 million across that same period. This results in an average cost per HIV infection averted of US$689 (Bollinger et al., 2009). Scaling up MMC to reach 80% of adult and newborn males in South Africa by 2015 would avert more than 1.2 million adult HIV infections between 2009 and 2025, yield total net savings of US$6.5 billion between 2009 and 2025, and require 2.3 million MCs in the peak scale up year (2012) (USAID, 2011). In March 2007, WHO and UNAIDS published normative guidelines on policy and programme implications resulting from the weight of the evidence for MMC and HIV prevention (WHO/UNAIDS, 2007). Key conclusions and recommendations included: • MMC should now be recognised as an additional important intervention to reduce the risk of heterosexually acquired HIV infection in men; • MMC should always be considered as part of a combination HIV prevention package, which includes the provision of HIV testing and counselling services; treatment for STIs; the promotion of safer sex practices, such as abstinence from penetrative sex, reduction in the number of sexual partners, and delay in the onset of sexual relations; the provision of male and female condoms and promotion of their correct use; • Countries with high prevalence, generalised heterosexual HIV epidemics and low rates of MC such as is present in many SADC countries should consider urgently scaling up access to MMC services and mobilising resources to support this. AIMS OF THE STUDY 05

4 Policy Responses to HIV and AIDS, and MMC 4.1. Past Policy Responses which Explicitly Mentioned MMC Past policy responses to MMC in each of the SADC countries are detailed in Table 2. As the UNAIDS and WHO normative guidelines were only published in 2007, NSPs prior to that time in countries with low MC prevalence and high HIV prevalence are unlikely to include MMC as a policy response. 06 POLICY RESPONSES TO HIV AND AIDS, AND MMC

In 1986 the first case of AIDS was diagnosed and in 1987 a national programme to fight AIDS was started in Angola. In 1999 the first NSP was outlined for the period from 2000-2002 by representatives of 17 Ministries, 17 provinces, the National Assembly, national and international non-governmental organisations (NGOs), churches, universities, Red Cross and United Nations agencies. Financial support was provided by the World Bank and technical support by UNAIDS. The government created a reference unit in Luanda in 2002 for the treatment of people infected by HIV. Despite the thorough and well supported development of NSPs in this country, there was no mention of MMC in Angola’s second NSP, The National HIV/AIDS Strategic Plan for 2003–2008. Likewise, Botswana’s first and previous National Strategic Framework to HIV and AIDS 2003-2009 advocated for and had significant success in the areas of anti-retroviral therapy and mother-to-child transmission programmes. However, this NSP did not mention MMC. Malawi, Mozambique and Swaziland all discuss MC or MMC in their previous NSPs. In Malawi, however, only traditional MC was mentioned and it was presented as a threat to health, rather than an effective HIV prevention strategy. Swaziland’s previous NSP recognised MC as an emerging evidence-based prevention strategy, but made no distinction between MMC and MC, nor explicitly referenced MMC. This distinction is important as traditional or non-medical MC, if performed incorrectly, may not counteract the risk of HIV contraction. Only Mozambique made substantial policy recommendations regarding MMC. The NSP for the Combat of HIV/AIDS for 2005 – 2009 advocated for MMC as providing significant protection from HIV infection among circumcised individuals which it stated was in the region of 70%. It indicated that although this protection primarily benefits men, as circumcision coverage approaches 100% it would also benefit women and, gradually, uncircumcised men. The policy document also makes recommendations on the necessary conditions for the adoption of MC as an instrument for the control of the dissemination of HIV in the country. No other country mentions MMC in a previous version of its NSP. 4.2. NSPs for HIV and AIDS and the Incorporation of MMC Table 3 details the common characteristics in the current NSP on HIV and AIDS for each SADC country. List of common characteristics mentioned in the NSPs: 1. Advocates for MMC by using past research: policy document describes MMC as a protective factor for HIV and AIDS. 2. Supports the promotion of safe MMC as part of a strategy: policy document lists MMC as a core activity for HIV prevention or indicates intentions to rollout MMC for HIV prevention. 3. Intends to further develop policy on MMC: policy document describes intentions to improve on current policy on MMC and intentions to rollout MMC programmes. 4. Intends to commission research on MMC: policy document suggests government will pilot safe MMC services and assess demand and outcome so as to examine what strategies for rollout, type of procedure and process, infrastructural necessities and which facilities work best for the country. 5. Initiates contact with countries undertaking successful MMC rollout: policy document states that the country would like to, is going to, currently is or has already made contact with countries with successful MMC rollout so as to learn effective strategies and practices and possibly apply similar strategies in own country’s MMC policy. 6. Details access: policy document provides information on how men would be encouraged to undergo MMC, POLICY RESPONSES TO HIV AND AIDS, AND MMC 07

how MMC would be advertised and how the procedure would be made accessible and attainable to them at the local level. 7. Details pre-procedure: policy document includes stipulations around required activities before the patient undergoes MMC. This should include some or all of the following: safe sex education messaging, individual counselling, testing and referral, consent processes, and physical examinations. 8. Details procedure: policy document provides information on how the procedure would be carried out. For example, it would specify the process of medically removing the foreskin and staffing requirements. 9. Details post-procedure: policy document includes post-procedure programme aspects such as provision of post-counselling and facilities where this may be obtained. Information provided could also include the staff required to provide this service and other post-procedural assistance that could occur away from the MMC provision facilities themselves. 10. Mentions rollout: policy document mentions intentions for widespread rollout of MMC. 11. Detailed plans for rollout: policy document provides specific plans for rollout such as dates when MMC rollout will occur, the manner in which rollouts will occur, which facilities will be used and which staff will be recruited. 12. Set targets for MMC upscale: policy document provides specific target dates for MMC scale up and the MMC prevalence they would like to accomplish with timelines attached. 13. Inclusion of neonatal MMC: policy document includes neonatal MMC as part of its plans for MMC upscale. 14. Plans for monitoring and evaluation/reviewing: policy document indicates the need and importance of monitoring and evaluation of MMC rollout and programmes. It may also provide specifications on how monitoring and evaluation will be carried out, for example, by including time schedules and the methods planned to be used. 15. Includes a resource needs estimate: policy document estimates amounts of resources that the country would require for scale up of MMC programmes. Estimates may be provided for staffing, equipment, facilities and infrastructure and advertising for the promotion of MMC as a preventative factor for HIV. 16. Provision of data on MMC prevalence: policy document includes information on MMC prevalence in the country. 17. Avoidance of traditional MC: policy document states that traditional MC is not as safe as MMC and that this should be avoided by the country. 08 POLICY RESPONSES TO HIV AND AIDS, AND MMC

Analysed policies by reviewing NSPs and allocated an effectiveness rating for each country according to them being either: Comprehensive (having 5 or more characteristics) OR Needing Improvement (having 2-4 characteristics) OR Weak (having 0 characteristics). POLICY RESPONSES TO HIV AND AIDS, AND MMC 09

4.3. Current Policy Responses on MMC Table 4 presents a description of the information on MMC included in the current NSP for each country. 10 POLICY RESPONSES TO HIV AND AIDS, AND MMC

TABLE 4: CONTINUED Only four SADC countries have comprehensive policy responses while five SADC countries do not mention MMC in their policies at all. All ten countries that did mention MMC in their policies portrayed it as a necessary action for HIV prevention and supported the promotion of safe MMC in their countries. 4.3.1. MMC policies in NSPs “needing improvement” Botswana, Lesotho, Zambia and Zimbabwe all have NSPs that mention MMC, but need improvement. In Botswana MMC is promoted as an additive strategy for HIV prevention. The NSP advocates for creative mechanisms to ensure the national response can capitalise on and sustain the prevention brought about by safe MMC. Zambia and Zimbabwe both present MMC as a potentially important prevention intervention. Zambia notes current low levels of MMC as well as unsafe traditional MC practices which may contribute to HIV prevalence, but does not provide details around how or where MMC should be rolled out, nor does it outline target groups or numbers. The Zimbabwe NSP, on the other hand, calls for further research on feasibility and acceptability of MMC implementation, which can then be used to inform pilot MMC initiatives in certain regions. Likewise, Lesotho aims only to commission and complete annual research studies on various health issues including circumcision. In Malawi, the NSP acknowledges the need for an open debate about sensitive but evidence-based interventions like condoms and MMC. It aims to increase the use and quality of MMC services. The Ministry of Health (MoH) and partners should develop MMC policy, intervention and communication guidelines based on international and local evidence, pilot safe circumcision services and assess demand and outcome. A resource needs estimate per broad POLICY RESPONSES TO HIV AND AIDS, AND MMC 11

activity of the response called a Resource Needs Model is also provided, where the estimated cost is $10.7 million - 3% of the total HIV prevention budget. MMC is mentioned as part of the strategic prevention programme intervention for Swaziland. The NSP specifically focuses on MMC in a section entitled Concentrating on MMC of HIV negative men, with priority age group from 1524 years, with programmes also encouraging neonatal MMC. To reduce the probability of infection, the NSP aims to scale up HIV prevention of infection to unborn babies through MMC. It acknowledges that MMC in Swaziland remains low despite scaling up in other African countries like Kenya and South Africa. It is reported that MMC was banned by King Mswati II who ruled the country in the 19th century, based on the understanding that men recovering from the procedure would be less able to defend the country. It also indicates that MMC is increasingly becoming accepted and encouraged by the current government. 4.3.2. MMC policies in “comprehensive” NSPs Mozambique’s comprehensive policy response to MMC in the NSP advocates for MMC by providing evidence for MMC’s significant protection against HIV infection among circumcised individuals, with benefits extending to women and uncircumcised men as circumcision coverage approaches 100%. It also states the necessity to begin creating the conditions for the adoption of MMC as an instrument to contain the propagation of HIV in the country, including the exchange of experiences with Swaziland, which is at a more advanced stage of this process. Mozambique’s MoH plans a gradual introduction of circumcision for neonates and, at a later stage, for adults. In Namibia MMC is listed as a programmatic area, a priority biomedical intervention and as a gap in and a challenge for Namibia’s NSP. The document acknowledges the discrepancy between traditional MC and MMC, as well as men’s preference for traditional MC. The NSP provides data on existing low rates of MMC, but shows the rates and method of circumcision vary dramatically across the country. Educated men are more likely to be circumcised (35% of men with more than secondary education, compared to 15% of men with incomplete primary education), as well as men living in the regions of Kunene (52%), Omaheke (57%) and Otjozondjupa (42%) as opposed to other regions. The NSP notes that demand can only be met through an organised strategy of recruitment, training and retention of qualified counselors and testers, and provides details of how MMC rollout will occur using the WHO and UNAIDS guidelines to support the procedures (WHO and UNAIDS 2007). Namibia has an active MMC task force that has developed an MMC communication strategy, as well as educational and awareness materials. However, the draft MC policy and action plan are not yet finalised. In addition, it states that Namibia has begun MMC activities at five pilot sites and will be rolling out MMC activities countrywide. Further efforts to scale up MMC throughout Namibia will involve a number of strategies. Firstly, the capacity of health facilities will be strengthened by providing the necessary equipment and supplies for MMC. Secondly, human resource capacity will be strengthened and expanded. Once MMC is rolled out to health facilities, additional qualified doctors will be required and the government will consider task-shifting to allow qualified and experienced nurses to perform MMC procedures. Traditional birth attendants will also be trained in appropriate skills to support neonatal MMC. A dedicated team of doctors who will perform MMCs will be mobilised and deployed to relevant health facilities in partnership with development partners. Training, supervision and mentorship for MMC service providers will be carried out as an on-going activity. Community mobilisation will be intensified through the involvement of community based organisations to generate demand for MMC. The NSP concludes by stating that the Ministry of Health and Social Services will initiate consultations with traditional health circumcisers to establish the specific roles they will play to contribute to their MMC outcomes. The South Africa NSP provides a history and rationale for MMC in the country. MMC is included in Strategic Objective 2, to “Prevent new HIV, STI and TB infections,” and is part of a combination prevention for HIV which is currently being initiated. “As a result of new evidence showing that the risk of HIV transmission in circumcised men is significantly reduced, in 2010, South Africa instituted an aggressive rollout of a national medical male circumcision (MMC) programme. The goal was to reach 80% of men aged 15-49 (approximately 4.3 million men) by 2015. 12 POLICY RESPONSES TO HIV AND AIDS, AND MMC

As of June 2011, 237 812 medical male circumcisions had been conducted. In the past five years, South Africa has been host to a number of prevention trials. These include a RCT assessing the effectiveness of MC in preventing HIV infection. The result showed an effectiveness of about 60%. Recommendations are included and are that key populations should be targeted for prevention, care and treatment interventions should be included specifically in provincial strategic implementation plans. These key populations include: men between the ages of 12-49 (the inclusion of young men is to offer MMC before sexual debut to offer optimal protection), MMC, condoms, prevention messaging, HIV Counseling and Testing (HCT) and TB screening. Evidence for MMC success in preventing HIV is provided as having 54% efficiency in terms of interventions that prevent HIV as based on studies in SA that provide clear evidence of prevention interventions.” (SA NSP: p 12). The rollout of voluntary MMC (VMMC) must be respectful to human rights consistent with the South African Constitution. MMC must be voluntary and only carried out with informed consent. The government should prohibit the use of any devices that have not been approved by the WHO including the Tara Klamp and the AlisKlamp. The quality of informed consent at mass MMC camps is also an area of concern. VMMC must be carried out methodically and properly to increase numbers, and systems for reviewing VMMC sites should be established. These reviews must be carried out by an independent team and all sites providing VMMC should receive visits twice annually. Targets for expanding VMMC access and uptake will be set in South Africa’s National HIV Treatment and Prevention Policy for HIV. As of June 2011, the South African government aims to circumcise 4.3 million men, or 80% of men aged 15-49, over the next five years. Data from a population-based HIV survey in Tanzania showed that circumcised males were almost three times more likely to be HIV positive than uncircumcised males and that contaminated circumcision equipment is a likely explanation for these findings. The NSP thus highlights the need for continued efforts to ensure that traditional practices are reduced or carried out in hygienic conditions. On the other hand, the lack of MMC is also presented as a factor increasing HIV risk and prevalence. The NSP states that Tanzania supports the trials in Kenya and the WHO policies on MMC. MC prevalence rates in Tanzania are about 70%, with considerable variation between regions. The high HIV prevalence regions of Mbeya and Iringa have relatively low male circumcision rates (34.4% and 37.7% respectively), which might imply a causal relationship. The Tanzanian NSP acknowledges the need for stakeholder consultations that will carefully need to consider policy, cultural, human rights, ethical and operational aspects in promoting MMC. Furthermore, it states that possible adverse effects such as undermining of existing protective behaviour and performing of circumcision under unhygienic conditions by untrained practitioners must be anticipated and avoided. The NSP therefore promotes the scale up of safe MMC as a preventive measure in appropriately selected regions in Tanzania and that the rollout will occur after careful study of all aspects, while safeguarding against adverse effects. POLICY RESPONSES TO HIV AND AIDS, AND MMC 13

5 Characteristics of Effective MMC Programmes Various studies have indicated that quality and feasible MMC rollout can be achieved and adapted to African low-income settings and can be implemented promptly and safely according to international guidelines. These programmes can act as models for the scale-up of comprehensive MMC services and be tailored to rural and urban communities with high HIV prevalence and low MMC rates. Kenya has been successful in scaling-up MMC programmes as indicated by an 85% MMC prevalence rate with a 7% male HIV prevalence rate (WHO & UNAIDS, 2010). Another programme that has been successful is the ANRS 12126 ‘‘Bophelo Pele’’ project which commenced in 2008 in the township of Orange Farm, South Africa, through which 14,000 men have been circumcised, with a rate of approximately 740 circumcisions per month (Lissouba et al., 2010). 5.1. Demand Creation It is important to promote awareness of MMC as a protective factor for HIV in order to encourage men to be circumcised and increase MMC rates (Brito et al., 2009). In a study in the Dominican Republic, increasing awareness through campaigns resulted in a 74% increase in MMC uptake (Brito et al., 2009). Media advertising on the radio and newspapers in Kenya have increased MMC uptake by 7% (McConnell, 2009). Involving community mobilisation and outreach, as well as communication approaches aimed at both men and women incorporating broader HIV prevention strategies and promoting sexual health, are essential to an effective MMC programme (Lissouba et al., 2010). According to a study of factors affecting knowledge and awareness of MMC for HIV prevention, less educated people, women and youth as opposed to adult men should be increasingly targeted by information campaigns about the positive health effects of MMC as they are less likely to be aware of MMC as a protective factor for HIV than those who are educated (Wilcken et al., 2010). Socio-economic status and/or employment status, traditional MC rates and even circumcision status were not found to be determinants of awareness of MMC’s HIV prevention properties (Wilcken et al., 2010). In addition, sexually active men may be more willing to be circumcised if educational resources detailing the benefits of the procedure are made available. Programmes were also effective in areas where MMC was not traditionally performed due to cultural reasons. This was accomplished by reinforcing the health benefits in spite of the cultural taboos around MMC (McConnell, 2009). These educational activities constitute a great opportunity to educate people on sexual health and reinforce safe-sex practices generally as well as increase MMC specifically. Furthermore, information is necessary to reduce concerns about the possible decrease in sexual pleasure as a result of MMC (Brito et al., 2009; WHO and UNAIDS, 2008). Effective programmes were differentiated in the manner in which they gained access to the three distinct ages (birth [pediatric], adolescence and adulthood) at which circumcision could possibly occur. In programmes concentrating on pediatric MMC, hospitals publicised information mostly to women and mothers of male children at birth or on visits for vaccinations, whereas for adolescent MMC, schools were targeted (Mwandi et al., 2009). Cultural factors which affect the age at which circumcision mostly occurs were also taken into account. For example in Zulu youth, circumcision commonly occurs at birth while in the Xhosa tradition, circumcision occurs mostly in initiation camps at age 12 or 13 years (Mwandi et al., 2009). The manner in which MMC is framed is also important to increase uptake (Gilliam et al., 2010) and differs across 14 CHARACTERISTICS OF EFFECTIVE MMC PROGRAMMES

countries (WHO & UNAIDS, 2008). Therefore the delivery of resonant and effective messages that take into account prior perceptions and use the most appropriate means of communicating the benefits and the value of MMC to different audiences should be used (Gilliam et al., 2010). Effective methods used to access men include: 1. Acceptance levels of MMC are gauged first to ensure that acceptance levels for MMC are high (WHO & UNAIDS, 2011b; Republic of Botswana, 2008). 2. Community door-to-door or “snow-ball sampling” access to people. According to reviews and reports of various MMC programmes (Lissouba et al., 2009; Republic of Botswana, 2008) this form of physical social mobilisation works well as this is direct and personal. Physical social mobilisation includes any face-to-face or personal effort to encourage MMC. 3. Setting up “camp” at a well-visited community site, for example a shopping centre, with pamphlets and nurses to address both men and women in order to encourage men to go for MMC (WHO & UNAIDS, 2011b). 4. Use of social media mobilisation, including advertising such as in taxis that have televisions which play advertisements encouraging men to go for MMC and provide the relevant locations, or on television programmes such as Soul City’s “Siyayinqoba - Beat It” which encourages men to go for MMC. Social media mobilisation includes any form of social media such as television, internet or radio. 5. Use of advertisements in the local newspapers (WHO & UNAIDS, 2011b). 6. Speaking with learners at neighborhood schools (WHO & UNAIDS, 2011b). 7. Use of short message service (SMS) or social network service. For example an organisation called “Brothers for Life” in South Africa has set up an SMS service which responds to SMS queries by providing three sites in the correspondent’s area that are currently running MMC programmes (WHO & UNAIDS, 2011b). 8. MMC is promoted as a health or cultural issue since health concerns are listed as the major reason participants favour circumcision of a male child or themselves (Kebaabetswe et al, 2003; WHO & UNAIDS, 2011a; Republic of Botswana, 2008). The ANRS 12126 Bophelo Pele Project provides an excellent example of effective demand creation. In this project, combined communication programmes were targeted at the individual, family, peer, and community using such tools as weekly radio broadcasts, a mobile speaker system once a week, a singing group at special events, and community block parties. Every household in the area was visited at least once to provide personal communication, and school talks and clinic visits were organised. Information was disseminated through pamphlets written in the local languages providing gender specific information on adult MMC (AMMC). This included the effect of AMMC on HIV transmission, including warnings against risk compensation (Lissouba et al., 2010). 5.2. Programme Implementation 5.2.1. Pre-procedure Following a demand-creating programme involving NGOs and community health organisations that should include door-to-door communication, posters, radio shows, and/or any of the other techniques described in the previous section, patients should be made aware of the process of MMC they will undergo. Pamphlets should be handed out and posters informing patients of the process should be displayed on the walls of the clinic/health facility where MMC takes place. Pre-counselling should be provided by medical staff prior to the MMC procedure CHARACTERISTICS OF EFFECTIVE MMC PROGRAMMES 15

on the procedure itself, as well as post-procedure effects. Pre-counselling should also ensure that patients are satisfied with their decision to have MMC performed at their chosen health facility (Republic of Botswana, 2008). Programmes identified as effective in the past have also provided information to prospective MMC patients regarding risk compensation and the patients’ reasons for wanting to be circumcised (WHO & UNAIDS, 2007; WHO & UNAIDS, 2008). The pre-procedure process should follow this course of action: 1. The procedure is made clear to participants prior to and during the process. Documents informing patients of the process are displayed on the walls of clinic/health facility where MMC takes place or pamphlets are handed out at the health facility, and/or the procedure and aftercare of the wounds are explained in a compulsory counselling/education session before the MMC procedure. (UNAIDS, 2008; Treatment Action Campaign, 2011; Republic of Botswana, 2008). 2. Pre-counselling is provided on the MMC procedure specifically on the procedure itself, the post-procedure and to ensure that patients are satisfied with their decision to have the MMC performed as well as with the procedure used at their chosen health facility. Pre-counselling should also include risk reduction counselling, including MMC as part of a comprehensive risk reduction strategy. (UNAIDS, 2007; UNAIDS, 2008; Treatment Action Campaign, 2011; Republic of Botswana, 2008). Information is provided regarding risk compensation (Treatment Action Campaign, 2011; Republic of Botswana, 2008). A Kenyan study on acceptability of MMC highlighted the importance of this since 7% of uncircumcised men in their sample reported that circumcised men do not need to wear condoms (Mattson et al., 2005). 3. Clinicians and counsellors provide circumcision counselling to most patients (Treatment Action Campaign, 2011). 4. The patient’s reason for wanting to be circumcised is obtained (Treatment Action Campaign, 2011). 5. The patient is offered and strongly recommended to take an HIV test prior to the procedure, and those testing positive are referred to local NGOs or healthcare facilities for ongoing support and treatment (Lissouba et al., 2010). 6. Patients, or parents if the patient is a minor, are required to sign a consent form prior to the procedure, and must undergo a physical examination or present a doctor’s note to ensure that the patient will benefit from MMC for health reasons (Lissouba et al., 2010). 5.2.2. Procedure Effective programmes establish an innovative surgical organisation and protocol prior to implementation of MMC. These programmes have a number of staff allocated to perform different stages of the circumcision called task sharing teams. Specifically, in the Orange Farm Project up to 150 AMMCs under local anesthesia could be performed by a team of providers per day. Equipment included sterilised circumcision disposable kits and electrocautery. The procedures were performed daily by three task-sharing teams consisting of one medical circumciser and five nurses (Lissouba et al., 2009). For adults and adolescents, three methods are recommended: the Guided Forceps, the Dorsal Slit and the Sleeve Resection methods (WHO, 2008). Specifically for paediatric and neonatal circumcision, four methods are recommended: the Dorsal Slit; the Plastibell; the Mogen clamp; and the Gomco clamp (WHO, 2008). The Tara Klamp has been used but was found to be problematic (WHO, 2008). The most successful and preferred method amongst adult men is the Guided Forceps (Plus News, 2009; WHO, 2008). However in the case of a high risk for bleeding, the Sleeve Resection method is recommended (Plus News, 2009). The Guided Forceps is the simplest technique. In this procedure, the foreskin is pulled forward over the glans with a pair of forceps, and the foreskin is then snipped, using the edge of the forceps as a guide. The dorsal slit is a 16 CHARACTERISTICS OF EFFECTIVE MMC PROGRAMMES

procedure where the slit is made from the opening of the foreskin to a point a few centimetres in, and then a circle is cut around the glans. Sleeve Resection is more complicated, but often preferred when there is a risk of excessive bleeding. In this procedure, two parallel cuts are made along the shaft of the penis, resulting in a thin band or sleeve of detached foreskin. When this is removed, the top and bottom portions of the foreskin are attached with dissolving sutures. Following circumcision, an antibiotic ointment may be applied and the area is wrapped in loose gauze. This is usually excluded, however, as processes are generally clean and render antibiotics unnecessary. Two new non-surgical devices are being piloted and these are known as the Shang Ring and the PrePex. Data on the use of these procedures will be available later this year (AVAC, 2012). As with all surgical procedures, there is a risk to the patient and provider during the surgical procedure. Adverse effects/complications following adult circumcision include the following: • Bleeding related: -Excessive bleeding -Swelling/haematoma • Infection related: -Infection of wound -Wound dehiscence -Abscess formation -Scarring/disfigurement (caused by Infection) Together bleeding- and infection-related adverse effects account for over 95% of adverse effects reported. • Less frequent adverse effects include: -Excessive pain -Scarring/disfigurement (non-infection related) -Wound dehiscence (non-infection related) -Damage to the penis -Insufficient skin removed -Excessive skin removed -Torsion of the penis -Problems with voiding -Anaesthesia-related event -Occupational exposure (like needle stick injuries) (WHO and PSI, 2011) Countries or regions which have spent effort and resources to train available medical doctors and nursing staff in sufficient numbers have been successful in achieving a high number of MMCs. This was the case in Kenya where 180 personnel including 40 medical doctors were trained (Patrick et al., 2009). This training takes one to two CHARACTERISTICS OF EFFECTIVE MMC PROGRAMMES 17

weeks. Training for effective programmes includes learning the new and improved MMC techniques which were described above (Patrick et al., 2009). In successful programmes the MMC procedure is carried out in the following ways: 1. In most circumstances, time efficient procedures are used. 2. The Guided Forceps method or Sleeve Resection if the patient is prone to heavy bleeding are preferred as efficient methods in terms of time and resources. (WHO, 2008; Plus News, 2009; South African Department of Health, 2010; WHO & UNAIDS, 2011b). 3. Adults age 18-49 comprise the majority of patients (WHO & UNAIDS, 2011b; Republic of Botswana, 2008). 4. MMC procedures are also carried out for neonates and pre-pubescent age groups (WHO & UNAIDS, 2011a). 5. Attempt to use hygienic methods to promote safety (UNAIDS, 2008; WHO & UNAIDS, 2011a). 6. The use of the MOVE model for mass MMC since it is effective and efficient (South African Department of Health, 2010; WHO & UNAIDS, 2011b; Njeumeli et al., 2011) The MOVE model describes a best practice setup and procedure for mass circumcisions. It is now a recommended best practice for countries where PEPFAR supports programmes. 7. Good infrastructure and staffing to increase comfort for participants. 8. Most MMC occurs in hospitals since most men prefer to be circumcised in a hospital setting (Kebaabetswe et al., 2003; Republic of Botswana, 2008). 9. Procedure is completed at a minimum cost to the patients with the possibility of free MMC (UNAIDS, 2008; WHO & UNAIDS, 2011b; Republic of Botswana, 2008). 5.2.3. Post-procedure “Risk compensation” or “disinhibition”, where men who have recently been circumcised undertake riskier sexual activities given their belief that the MC procedure has reduced their probability of contracting HIV, is cause for concern. Therefore education and short and long term follow up is required to reinforce condom use, limit of partner exchange and encourage safe post-operative behaviour (Patrick et al., 2009; McConnell, 2009). Counsellors/nurses/medical doctors all need to provide information to patients on the above-mentioned aspects (Andersson et al., 2010). A general overview of how effective programmes provide post-operation support has been provided below: 1. Patients are kept in recovery for a set amount of time to ensure no adverse effects occur. The recovery period may or may not include monitoring a patient’s vital signs. 2. After the procedure, most facilities also offer counselling on post-operative care, risky sexual behaviour reduction, resumption of sexual activity and other male reproductive health topics. This is provided by doctors/ nurses/counselors at the MMC site (WHO & UNAIDS, 2011a; Republic of Botswana, 2008). 3. Pamphlets are provided for participants to take home to guide them through the stages of care, including removal of bandage after two days and abstinence for six weeks (UNAIDS, 2008; WHO & UNAIDS, 2011a). 4. Social networks or media services are used as reminders to provide further information and support. For example in South Africa Brothers for Life established an SMS service to remind participants of what to do on each day post-circumcision. Men reported this to be helpful as they received personalised care without having to physically go to the clinic/hospital for guidance after the operation (WHO & UNAIDS, 2011a). 18 CHARACTERISTICS OF EFFECTIVE MMC PROGRAMMES

6 Assessment of MMC Programmes 6.1. Country MMC Programmes Table 5 indicates effective programme characteristics categorised by demand creation, preparation before the procedure, the procedure itself and post-procedure assistance. This has been compiled from the effective programme characteristics described in the literature and outlined in the previous section. Thereafter country specific information is provided. 6.1.1. Demand creation Limited neonatal MMC is occurring in most SADC countries. Benefits of neonatal programmes will only be seen in approximately 15 years, and a focus on neonatal programmes could potentially draw resources away from AMMC programmes which service those currently at risk. Further, neonatal MMC cannot be considered voluntary as the child is not old enough to make the decision for himself. However, neonatal programmes may also provide significant benefits in scaling up national MMC programmes. Beginning neonatal MMC programmes may help address concerns around the potential for increased risky sexual behavior (currently being addressed through clinical trials). Such a programme is similar to routine medical services offered in the developed world, has little potential to influence sexual behaviours, is the safest way to introduce circumcision services to the country (as MMC in children is easier to carry out with fewer complications) and can eventually be expanded to include services for older children and adults (WHO & UNAIDS, 2007; WHO & UNAIDS, 2008; Kebaabetswe et al., 2003). Government support and initiative for MMC programmes is critical. An evaluation study found that despite high acceptability of MMC in SADC countries for both infants and men, the scale up of MMC was relatively low. This ASSESSMENT OF MMC PROGRAMMES 19

may be the result of a lack of governmental initiative to conduct these programmes (Kebaabetswe et al, 2003). Promoting MMC as a health or cultural issue may be effective, as health concerns were listed as the major reason participants favoured circumcision of a male child or themselves (WHO & UNAIDS, 2007; WHO & UNAIDS, 2008; Kebaabetswe et al., 2003). Many countries did present MMC in this manner. Individual country activities on demand creation are reviewed in Table 6. 20 ASSESSMENT OF MMC PROGRAMMES

No programmes creating demand for MMC are in place in the Democratic Republic of Congo, Madagascar, Mauritius or Seychelles. Although support for MC is high in Angola as most people belong to traditional religious groups which have initiation camps (Plus News, 2007), access and support for MMC is not as high. Conversely, in Tanzania, MMC prevalence and support is high for religious reasons as there are high numbers of Muslims, Christians and traditional religions, all of which have high rates of circumcision (Wambura et al., 2009). MMC is therefore encouraged from a religious perspective, and men take the initiative to seek health facilities for MMC on their own. (Wambura et al., 2009). An SMS service is used to identify local MMC centres. If a person texts ‘‘TOHARA’’ (‘‘circumcision’’ in Swahili), they receive two messages on the benefits of VMMC. Texting ‘‘WAPI’’ (‘‘where’’ in Swahili) sends a message on where and at what times VMMC services will be available (Bertrand et al., 2011). Acceptance rates in Lesotho are not high and media advertising is not being used to build demand, although there are technical working groups endorsed by the national government in place to increase uptake of MMC programmes (Plus News, 2009). In Mozambique, Zambia, and Zimbabwe, MMC programmes have full government support, and media social mobilisation is used more often physical social mobilisation (SADC HIV & AIDS Unit, 2011). Swaziland also has full government and PEPFAR support with the launch of VMMC in 2008, though school-based social mobilisation is not a priority (WHO & UNAIDS, 2010). MMC programmes in Namibia are motivated by government urgency to scale up MMC programmes. Media social mobilisation is again prioritised over physical social mobilisation (Republic of Namibia Ministry of Health and Social Services, 2007). Programmes have full government support as well as PEPFAR support to funded partners in South Africa, with a South African National Aids Council (SANAC) document on policy and nationwide rollout completed. Much publicity has been generated to promote social mobilisation for MMC, especially with the Bophelo Pele Project. MMC is treated as a health issue to prevent HIV transmission (South African Department of Health, 2010). Botswana uses media social mobilisation via television and radio advertisements to encourage men to visit clinics to undergo safe MMC surgery (UNAIDS & NACA, 2010). This initiative was launched by the MoH in 2009. The project, launched following a series of studies showing that MMC can reduce a man’s risk of HIV infection, aims to circumcise nearly 500 000 men over five years in an effort to prevent the spread of HIV (UNAIDS & NACA, 2010). The MoH is training sectors on safe MMC and workplace programmes are educating men on MMC (UNAIDS & NACA, 2010). Hospitals countrywide are scheduling and performing the procedure, and, as of mid-May 2009, 50 healthcare providers, including 27 physicians, had been trained to perform MMC (UNAIDS & NACA, 2010). Malawi also has full government support for countrywide scale up of MMC. Hygiene is questionable in traditional facilities but safe in healthcare facilities (Bengo, Chalulu, Chinkhumba, Kazembe, Maleta et al., 2010). Programmes encouraging parents to talk to youth on MMC, sensitising traditional healers to MMC, and raising awareness in youth and traditional healers by NGOs have been ongoing (Bengo et al., 2010). MMC has been presented mostly as a cultural issue which may be the cause of higher numbers of traditional MC as opposed to MMC (Bengo et al., 2010). 6.1.2. Programme implementation Most countries have programmes which include the lowering of patients’ anxiety over the circumcision and creating a conducive environment for safe and comfortable MMC, usually through group education sessions and individual counselling sessions with counsellors or nursing staff. Before the procedure is performed, facilities offer counselling on the procedure, risks and benefits of circumcision and existing HIV and STI prevention approaches. After the procedure, most facilities also offer counselling on post-operative care, risky sexual behaviour reduction, resumption of sexual activity and other male reproductive health topics. Clinicians and counsellors perform the ASSESSMENT OF MMC PROGRAMMES 21

majority of circumcision counselling. Further clarity on the MMC procedure could be provided while the patient is at the MMC site. For example, the McCord programme displays wall charts that illustrate the different steps involved at each stage. In most circumstances the procedure is quick (15 - 30 minutes) (South African Department of Health, 2008). Most countries’ programmes use the most time efficient method for circumcision, i.e. the Guided Forceps method. This is the simplest method and is the easiest to teach to providers. However, if the patient is at risk for excessive bleeding then the Sleeve Resection method should be used (Plus News, 2009). The patients involved are mostly adults aged 18-49 years, though this varies by country. An increased focus on neonatal and pre-pubescent MMC may be required in the future in addition to AMMC. The MOVE model describes a best practice setup and procedure for mass circumcisions. It is now a recommended best practice for countries where PEPFAR supports programmes. Therefore it may be necessary to ensure all countries are aware of this process and scale up using this operational model. Infrastructure and staffing affects the level of comfort felt by the patients. Most men prefer to be circumcised in a hospital setting (Kebaabetswe et al., 2003). While the provision of good staffing and infrastructure was indicated by many of the countries, further scale up may be required for improved services. Health facilities reported that they would be able to increase the number of MMCs performed if they had additional equipment and instruments, such as surgical tables, protective clothing, operating instruments, disposable prepacked kits, sterilisers, reliable electrical power, adequate water supply, medicines, as well as an available procedure room and more staff trained on how to perform the surgery (AVAC, 2012). Country specific information on effective practices in programme implementation is provided in Table 7. 22 ASSESSMENT OF MMC PROGRAMMES

TABLE 7: CONTINUED ASSESSMENT OF MMC PROGRAMMES 23

No analysis is provided for the Democratic Republic of Congo, Madagascar, Mauritius, or Seychelles as MMC is scarce and no programmes were publicised. Pre-procedure Pre-counselling is provided by a trained healthcare professional in Mozambique (Njeumeli et al., 2011), Namibia (Republic of Namibia Ministry of Health and Social Services, 2007), and Zimbabwe (WHO & UNAIDS, 2010; SADC HIV & AIDS Unit, 2011). Zambia has developed a quality assurance counselling tool for the country, also mandating pre-counselling by a trained healthcare professional (SADC HIV & AIDS Unit, 2011). In Lesotho, pre-counselling by a trained healthcare professional takes place at the MMC sites and covers risk compensation (Thomas et al., 2011). The same is true in Swaziland, where pre-counselling by a trained healthcare professional includes risk reduction strategies and information on risk compensation (WHO & UNAIDS, 2010). United Republic of Tanzania’s pre-counselling procedures includes information on assessing patients’ reasons for wanting to have MMC, the procedure itself and risk compensation (Wambura et al., 2009). In Malawi, pre-counselling is provided by trained healthcare professionals and risk compensation information is included (Maleta et al., 2008). However, programmes do not always provide clarity on the procedure at the outset to patients (Bengo et al., 2010). Pre-counselling is also offered for MMC in Angola, but since traditional MC is still so common, pre-counselling is often not conducted (Plus News, 2007). Safe MMC counselling guidelines have been forwarded to all MMC sites in Botswana. MMC counselling conducted at the sites includes the provision of information on risk reduction, the surgical procedure and behaviour change (Republic of Botswana, 2008). MMC sites also conduct counselling for parents of infants who are being circumcised (Republic of Botswana, 2008). Finally, in South Africa pre-counselling is provided by trained healthcare professionals and trained counsellors to educate patients on all safe sex and risk reduction strategies including partner reduction, condom use, etc. and adding VMMC. Risk compensation is explained and patients are encouraged to avoid increased risk after MMC. During counselling the procedure is explained to patients, and testing is offered. Patients are requested to sign informed consent and parental consent is obtained for minors. Often reasons for requesting MMC and referral sources are recorded as well (South African Department of Health, 2010). Procedure The health system in Angola is still developing so most MC is not performed by trained medical professionals (Plus News, 2007). In Botswana the process is not always made clear to MMC recipients prior to the procedure. Little neonatal and pre-pubescent MMC has been rolled out, and MMC is carried out in public and private clinics as well as hospitals (UNAIDS & NACA, 2010). In Lesotho procedures are not always methodical. Neonates and pre-pubescent males are not being targeted and infrastructure is not always adequate (Thomas et al, 2011). In Mozambique, a lower priority has been placed on neonatal and pre-pubescent MMC as opposed to AMMC. Infrastructure could be improved. Programmes take place in a variety of sites including public and private clinics and hospitals (Njeumeli et al., 2011). The same is true of Namibia (Republic of Namibia Ministry of Health

Add a comment

Related presentations

Related pages

The state of medical male circumcision | Health-e

Over 100 000 South African young men were circumcised in the last financial year in the government’ s programme to integrate medical male circumcision ...
Read more

Circumcision - Wikipedia, the free encyclopedia

Male circumcision is the surgical ... No major medical organization recommends universal neonatal circumcision, and no major medical ... state that male ...
Read more

Medical male circumcision - Right to Care

Electronic medical records; Our partners. Our funders. ... Circumcision services are offered in in Free State, Gauteng, ... Facts about medical male ...
Read more

The State of Medical Male Circumcision. 27/6/11 | www ...

Over 100 000 South African young men were circumcised in the last financial year in the government’s programme to integrate medical male circumcision ...
Read more

South Africa: The State of Medical Male Circumcision ...

Over 100 000 South African young men were circumcised in the last financial year in the government's programme to integrate medical male circumcision into ...
Read more

History of male circumcision - Wikipedia, the free ...

History of male circumcision ... the campaign for medical circumcision for the ... circumcision rates in the United States holds that 30% of ...
Read more

The Medical Benefits of Male Circumcision

W ith 2 new states recently joining 16 oth ers in eliminating Medicaid insurance for male circumcision, possible ballot initiatives to ban male ...
Read more

Medical male circumcision is 1 What are the health ...

Medical male circumcision is one of the most common ... state of health. ... The voluntary male medical circumcision trials in Uganda
Read more