Voluntary Medical Male Circumcision PEPFAR South Africa through USAID VMMC Partners Meeting

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Voluntary Medical Male Circumcision PEPFAR
South Africa through USAID VMMC Partners Meeting

• Emmanuel Njeuhmeli, MD, MPH, MBA
• Senior Biomedical Prevention Advisor
• Co-Chair PEPFAR Male Circumcision Technical
  Working Group
• Office of HIV/AIDS / US Agency for International
  Development

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• Voluntary Medical Male Circumcision (3 mn)
• Quality Assurance (5 mn)
• Self Assessment Quality Assurance
• External Quality Assurance
• Standards for MC
• Preliminary Findings (30 mn)
• Areas of strong performance
• Challenges
• Issues
• Recommendations (10 mn)
• Next Steps for EQA Team (2 mn)

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Voluntary Medical Male Circumcision for HIV
Prevention
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Scientific Evidence

• Over 50 studies to date, most of them in Africa
• Epidemiological
• Biological
• Inner membrane surface of the foreskin highly
  vulnerable to HIV infection
• Up to nine times more vulnerable than cervical
  tissue
• Three RCTs
• South Africa, Uganda and Kenya
• Strong association between
• Lack of male circumcision
• Higher risk of heterosexual (female-to-male) HIV
  transmission
• MC has a strong protective effect against HIV
  acquisition.
• Estimated by WHO/UNAIDS to be around 60

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Male Circumcision Target Countries
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20,373,693M adult 15-49 years men to be
circumcised across all 14 countries
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Cumulative Number and Percentage of HIV
Infections Averted between 2011 to 2025 by
scaling up MC
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Indirect Impact on women
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Importance of the Implementation Coverage

• Decreasing the MMC coverage target from 80 to
  50 results in a
• decline in the number of HIV infections averted
  from 3.4M to 1.1M
• In Zimbabwe from 41.7 of new HIV infection
  averted to 23.6 of new HIV infection averted
• On the other hand, increasing target MMC coverage
  from 80 to 100 results in
• an increase in the number of HIV infections
  averted from 3.4M to 5M
• In Zimbabwe from 41.7 of new HIV infection
  averted to 50.5 of new HIV infection averted

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Importance of the Implementation Pace

• Also as expected, reducing the time to achieve
  80 MMC coverage from 5 years to 1 year leads to
• an increase in the number of HIV infections
  averted from 3.4M to 4.1M
• In Swaziland, from 33.9 of new HIV infection
  averted to 41.5 of new HIV infection averted
• a decrease in the cost per HIV infection averted,
• and an increase in net savings per HIV infection
  averted.
• Increasing time to achieve 80 MMC coverage from
  5 years to 10 or 15 years does the reverse.
• In Swaziland, 23.6 of new HIV infection averted
  for 10 years implementation

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Number of MC needed per Infection Averted from
2011 to 2025
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Number MC done as off April 2011
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Achievement toward Target of 80 coverage
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Voluntary Medical Male Circumcision Quality
Assurance
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Quality Assurance (QA)?

• QA is the process of evaluating a program or
  system against known and accepted standards
• Define quality
• Provide basis for measuring and recognizing
  quality
• Provide guidance for improving quality
• Goals of quality with MC include
• Safety
• Efficiency and productivity to achieve impact on
  HIV incidence (MC as a public health
  intervention)
• Provision of a minimum package of services in
  addition to surgery

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External Quality Assurance (EQA) for MC?

• Provides objective assessment to guide
  improvements
• Creates incentives for clinics to align services
  with national standards and donor guidelines
• Facilitates achievement of MC service targets
• Complements WHO QA self-assessment tool
• Promotes public recognition and confidence in the
  MC services provided

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PEPFAR Standards for MC

• In addition to public health impact and
  efficiency, PEPFARs standards focus on
• SOPs, guidelines, policies
• Facilities, supplies and equipment
• Clinical record keeping monitoring and
  evaluation
• Minimum package of services and linkages
• Staffing
• Surgery, including pre- and post-op and follow-up
  care
• Communication to Clients
• Waste management

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Voluntary Medical Male Circumcision External
Quality Assurance in South AfricaPreliminary
Findings

• Emmanuel Njeuhmeli, MD, MPH, MBA
• Senior Biomedical Prevention Advisor
• Co-Chair PEPFAR Male Circumcision Technical
  Working Group
• Office of HIV/AIDS / US Agency for International
  Development

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Preliminary Findings

• This assessment was for VMMC Site supported by
  USAID only
• 14 sites was visited
• 5 in Gauteng
• 1 Free State
• 2 in KwaZulu-Natal
• 6 in Mpumalanga
• 5 Partners supporting those sites
• CHAPS for 2 sites
• Right to Care for 7 sites
• MATCH for 2 sites
• ANOVA for 2 sites
• PHRU/ANOVA for 1 site
• Sites were
• Hospitals Public and Private
• NGO

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PEPFAR Standards for MC

• In addition to public health impact and
  efficiency, PEPFARs standards focus on
• SOPs, guidelines, policies
• Facilities, supplies and equipment
• Clinical record keeping monitoring and
  evaluation
• Minimum package of services and linkages
• Staffing
• Surgery, including pre- and post-op and follow-up
  care
• Communication to Clients

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Findings (1)

• Not all sites have all the SOP, Guidelines,
  Policies and records in place
• Patient Rights Policies
• Staff Job Description
• Personnel files
• Inform Consent Process Guidelines
• HIV/AIDS Counseling and Testing Guidelines
• STI Guidelines
• Supplies and Equipment Inventory/Reports
• Medication Inventory List
• Emergency Guidelines
• Waste Management Guideline and SOPs
• Quality Control Register for HIV Tests
• Equipment maintenance registers
• Infection Prevention and Control Policies and
  Procedures
• MC Surgery Guidelines
• Complications/AE management Guideline
• Other ME Tools

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Findings (2)

• Most partners dont have those documents at site
  level but keep them in their office and we have
  not seen them
• Some sites have developed their own SOP,
  guideline documents and those adaptation does not
  translate accurately the NDOH guidelines

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Challenges

• Lack of specific National guidelines that sites
  can use or refer to and this lead each partners
  to develop their own guidelines
• Lack of WHO adverse event management guidelines
• Where national guidelines are existing , they are
  not being present at site level, for example
• STI
• HTC National guideline
• Waste management

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Recommendations

• Partners should use existing guidelines from WHO,
  NDOH
• Partners should work with PEPFAR and the NDOH to
  fill the gap on guidelines that are not developed
  yet

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PEPFAR Standards for MC

• In addition to public health impact and
  efficiency, PEPFARs standards focus on
• SOPs, guidelines, policies
• Facilities, supplies and equipment
• Clinical record keeping monitoring and
  evaluation
• Minimum package of services and linkages
• Staffing
• Surgery, including pre- and post-op and follow-up
  care
• Communication to Clients

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Findings

• Most facilities have adequate and dedicated space
  for male circumcision
• Sites are using existing supply chain management
  for supplies and equipment
• We were not able to assess the Hospital SCMS
• We found them to be adequate in most sites
• Site keep limited stock of supplies in some sites
  just for one week and we have reported stock out
  of some supplies in some sites
• Some site lack of equipments
• Chairs for the waiting room, group counseling
• TV in the group counseling, waiting room and
  recovery room

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Recommendations

• Dedication of space for VMMC is critical for site
  efficiency and to reach public health impact with
  this intervention
• Site space needs to be designed in respect of
  client flow as described by WHO MOVE document
• Sites need to have adequate equipment
• Sites need to keep stock for at least one month
  to avoid stock out

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PEPFAR Standards for MC

• In addition to public health impact and
  efficiency, PEPFARs standards focus on
• SOPs, guidelines, policies
• Facilities, supplies and equipment
• Clinical record keeping monitoring and
  evaluation
• Minimum package of services and linkages
• Staffing
• Surgery, including pre- and post-op and follow-up
  care
• Communication to Clients

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Findings (1)

• All clinics keep records of the VMMC services
  provided
• In two MMC clinics, the client records were not
  kept on site
• Majority of the clients (gt88 on average) are
  above the age of 15.
• In VMMC clinics on average 5 of clients test
  positive for HIV.
• Completeness of records ranges from 70 for
  client history and physical examination to 100
  for clients demographic information.

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Findings (2)

• The type of procedures performed in all the MMC
  clinics are not recorded, however clinic managers
  reported that forceps guided is the only surgical
  method used.
• All sites also use diathermy for hemostasis but
  this isnt recorded anywhere in the clients
  charts reviewed.
• Consent forms are missing in 10 of clients
  files.
• 50 of the files documented at least one follow
  up post circumcision.
• Majority of these follow ups 75 were for clients
  who return to the clinic after 2 days for their
  first post op reviews
• and 25 at the second day post MC.

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Best Practices

• Age of clients very well reported and most of the
  sites request birth certificate to verify the age
  of the client
• Sites requesting parents or guardians to sign
  consent form when client are accompanied minors
• Standard surgical method, use of electrocautery
  and definition of adverse events
• One site uses a ONE recording format that has
  most of the information that need to be completed
  for one client. This approach of having one
  standardized recording format that has provisions
  for recording demographics of the client,
  counseling and testing, consent, history and
  physical examination, surgical procedure note,
  post procedure follow up, adverse events
  recording and management, referral notes will
  help reduce paper work, reduce the chance of
  missing pages from client files and provides
  opportunity to have all documents in one record
  rather than multiple pages

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Challenges

• Completeness of records need to be 100 for all
  necessary information
• Date of surgery
• History and physical examination
• Type of service providers
• Type of surgical methods
• Intro Op adverse events
• Use of diathermy
• Post op follow up
• Adverse events
• There are no standardized client record forms,
  HTC forms, consent forms, referrals, adverse
  event reporting and management forms and post
  operative care forms.
• The absence of comprehensive monitoring and
  evaluation system for VMMC is pushing partners to
  develop their own system and tools. This makes
  standardized reporting and experience sharing a
  challenge.
• In addition, the presence of multiple recording
  formats that are not properly introduced to
  service providers caused the quality of the
  records to be low.
• The monitoring information isnt changed into
  electronic formats as expected, but everything is
  done manually. This proves to be cumbersome and
  affects the completeness as well as quality of
  data and reports.

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Issues

• Standards recording and reporting tools for the
  national VMMC program are not available.
• Client files kept outside MMC clinics.
• Counseling and testing
• Incomplete records in most sites
• Mandatory testing in some sites
• Consent Form
• Missing consent signed forms in the client record
  in most sites
• At least one MMC site had no consent form signed
  on client records
• No records of parents or guardians consent for
  minors in the client records
• Consent form for testing missing in client
  records in most sites
• No provincial or national adverse events
  management system in place
• Monitoring of adverse events
• Management of adverse events

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Recommendations

• One monitoring and evaluation system for the VMMC
  program in RSA is critical to effectively monitor
  progress, assure safety and plan for expansion.
• Recording and reporting can and should be
  computerized and data should be accessible for
  NDOH for decision making real time
• Standardized recording and reporting tools needs
  to be developed as part of the monitoring system
• Consensus amongst partners and donors on one
  monitoring system, orientation and training of
  providers on standardized tools are important
  considerations for the VMMC programs in RSA
  supported BY PEPFAR
• Clients records need to be kept on site
• HIV Counseling and Testing is not mandatory
• Consent Forms need to be signed and kept in
  clients file and parents should consent for
  minors , consent need to be signed for testing
  and the surgery
• Date of Surgery, history and physical examination
  
• Need to be carefully recorded in ALL clients
  files
• Even though type of providers, use of
  electrocautery and surgical methods are standard,
  need to be reported in client file
• Adverse event
• National or provincial adverse event monitoring
  and management system need to be design and
  implemented

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PEPFAR Standards for MC

• In addition to public health impact and
  efficiency, PEPFARs standards focus on
• SOPs, guidelines, policies
• Facilities, supplies and equipment
• Clinical record keeping monitoring and
  evaluation
• Minimum package of services and linkages
• Staffing
• Surgery, including pre- and post-op and follow-up
  care
• Communication to Clients

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Findings

• Generally sites visited provide the minimum
  package of services
• HIV testing and counseling,
• Risk reduction counseling,
• Screening and treatment of STIs.
• Only few sites refer clients for STI services
  outside VMMC.
• Clinics Linkage to care and treatment is also
  implemented in different facilities at different
  levels.
• VMMC clinics provide little or no information to
  women and partners about the services.
• No couple counseling services are provided

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Best Practices

• Discovery- clients who test positive and CD4
  count below 350 are escorted to care and
  treatment clinics to be enrolled.
• Such active linkage between MC and other services
  need to be strengthened

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Challenges

• Follow up of clients after referral, according to
  most of the sites, has proved challenging.
• There is no mechanism to confirm if clients
  actually accessed services at the receiving end
  of the referrals.
• Especially referrals to care and treatment are
  not receiving feedbacks about clients.
• In addition, the VMMC service has little to offer
  to women in the form of access to information,
  opportunity to access couple counseling and
  testing and risk reduction.
• Although a couple of sites reported efforts to
  educate women, in general there is a lack of IEC
  materials that targets women and families.
• Also providers are not trained to provide couples
  counseling in the VMMC clinic.

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Issues

• Clinics make decisions to circumcise clients who
  test positive and have a CD4 count of gt200 and lt
  350.
• While this cut off for CD4 along with clinical
  assessment works well in all the clinics clients
  who, according the national guidelines, need to
  be enrolled for care and treatment as a priority
  are lost in favor of performing circumcision.
• The linkage to care and treatment after
  circumcision is weaker than the linkage before
  circumcision. clinics need to prioritize
  enrollment to care and treatment over
  circumcision.

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Recommendations

• Active referral system need to be design and
  implemented to track clients referred to other
  services mainly care and treatment.
• Possible utilization of dedicated personnel (case
  manager, peer educator, expert client) to provide
  active referral and linkage
• A recording and reporting mechanism to track and
  document where clients went, when they accessed
  services.
• A simple SMS system to provide and or exchange
  feedbacks between referring and receiving clinics
  can be helpful.

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PEPFAR Standards for MC

• In addition to public health impact and
  efficiency, PEPFARs standards focus on
• SOPs, guidelines, policies
• Facilities, supplies and equipment
• Clinical record keeping monitoring and
  evaluation
• Minimum package of services and linkages
• Staffing
• Surgery, including pre- and post-op and follow-up
  care
• Communication to Clients

42
Findings

• No standard composition of the site staff
• Most sites have staffs working 5 days a week but
  with variation of time per day
• Physicians time is variable from part time to
  full time
• Some of the staffs do not provide MC counseling.
  They were not trained

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Best Practices

• Very motivated, hard working and competent staff.
• The site has enough number of nurses dedicated
  for MC.
• A good number of counselors who are dedicated for
  all types of counseling.

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Challenges

• Each site have different composition of teams
  MOVE team
• Some sites have no dedicated physician(s) for MC
  clinic.
• Some clinic does not open full time
• Some of the staffs do not offer counseling
  because they were not trained
• Most of the site have no data manager

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Recommendations

• Each site need to have a standard composition of
  the MC team and each MC site need to have a
  dedicated physicians
• The ration of physician nurse recommended in
  the WHO MOVE document is 1 physician for 4 fixe
  nurses and 1 mobile nurse for 4 clients/surgical
  bed
• Clinic should maximize use of staff time and
  facility space by having either one or two
  surgical team
• All the staffs working at the clinic need to be
  trained on risk reduction counseling
• Each site should have a data clerk or data
  manager who will be responsible for data
  management, record keeping and reporting.

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PEPFAR Standards for MC

• In addition to public health impact and
  efficiency, PEPFARs standards focus on
• SOPs, guidelines, policies
• Facilities, supplies and equipment
• Clinical record keeping monitoring and
  evaluation
• Minimum package of services and linkages
• Staffing
• Surgery, including pre- and post-op and follow-up
  care
• Communication to Clients

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Findings

• Most of the standards are met.
• Mixture of Lignocaine and Marcaine is used for
  Local anesthesia. Standard dose is used for all
  clients
• One artery forceps broke during procedure.
• The MOVE model used by all facilities

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Best Practices

• MOVE model is applied.
• Good surgical procedure.
• Sterile techniques are followed
• Attention to the client throughout of the
  procedure.
• The surgical bays are very well arranged and all
  the necessary equipments and the waste bins are
  located at the surgical bay. This is very
  efficient way to minimize contamination and
  maintain high level of waste management.

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Challenges (1)

• Using the standard dose for Local anesthesia
  instead of weight based dosage.
• No marking of the intended point of incision is
  done prior to the placement of forceps by some
  providers
• The recommended vertical mattresses for 3, 9 and
  12 o clock positions are not applied by some
  providers
• Duration of surgery is not recorded. No clock in
  the surgical bay in most sites
• Waste bins are very far from the surgical bays in
  some sites, this led the nurse to run from the
  surgical bay to the disposing area whenever he
  touches unsterile surrounding environment.

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Challenges (2)

• The recovery room for the clients is not clearly
  defined. This may lead to not providing proper
  post op recovery services which includes the 30
  minutes observation with taking the vitals.
• Diathermys inactive rod is handled by the client
  during the electrocautery.
• Screening of the client is done in the surgical
  theatre and is brief in some sites
• Hand cleaning is not standard for surgical
  procedure.
• Only ring blocking is done while administering
  local anesthesia
• No segregation of medical wastes at the point of
  origin.

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Challenges (3)

• Post op written instructions are not given to all
  clients.
• Partially applied surgical techniques, such as
  picking up needles with fingers instead of pick
  up forceps.
• Task sharing is not practiced in some sites.
  Surgeon does all steps of the procedure from
  injecting anesthesia to final stitches. Nurses
  bandage the penis.

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Recommendations (1)

• Weight based dosage should be used to every
  client. This means that every clients weight
  should be taken during the pre op examination.
• Marking is recommended in WHO manual, so it is
  also recommended that the intended incision line
  is marked prior to placement of forceps. This
  reduces the chance of cutting too much of the
  foreskin.
• Waste bins should be kept in every surgical bay
  to minimize unnecessary movements and risk of
  contamination.
• While the diathermy is great, the distance
  between the active rod and the inactive rod is
  very long, since the inactive rod is hand held by
  the client. The electric current travels long
  distance to complete the circuit

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Recommendations (2)

• The recovery room should be considered and
  special staff should be available at the recovery
  to serve clients according to WHO
  recommendations.
• Screening of all clients needs to be done prior
  to clearing clients for surgical procedure. The
  screening should be thoroughly done and not
  brief.
• Ring block with Dorsal Penile Nerve block is the
  recommended techniques for administration of
  local anesthesia.
• It is recommended that medical wastes are
  segregated from the point of origin into
  infectious/hazardous and non infectious wastes.

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Recommendations (3)

• Sterile procedures and techniques should be
  applied throughout the procedure as it will
  minimize chances of causing infections
• Efforts should be made to make sure that every
  client is given post op written instructions.
• Recovery monitoring and post op care should be
  stressed to make sure that every client access
  these services.
• Duration of the procedure is one of the standards
  for MMC (and any other surgical procedure). It is
  also important to provide each surgical bay with
  wall clock.
• There is a need to implement MOVE model for
  efficiency and to maximize surgeons time. This
  will increase the clients volume.
• If surgery is done under sterile techniques,
  there is no need for routine antibiotics as post
  op prophylaxis.

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PEPFAR Standards for MC

• In addition to public health impact and
  efficiency, PEPFARs standards focus on
• SOPs, guidelines, policies
• Facilities, supplies and equipment
• Clinical record keeping monitoring and
  evaluation
• Minimum package of services and linkages
• Staffing
• Surgery, including pre- and post-op and follow-up
  care
• Communication to Clients

56
Best Practices (1)

• Several best practices were observed, and these
  standards should be celebrated and continued.
• Many of the clinics have strong outreach, and
  demand for VMMC services is strong overall.
• The majority of the clinics display signage on
  VMMC, HIV prevention, risk reduction, etc.
• Most of the clinics exhibit signage outside of
  the VMMC facility, and eleven of the twelve
  clinics display Brothers for Life posters
  inside their clinics.
• Most of these facilities also offered Brothers
  for Life pamphlets/flyers and/or other take-away
  IEC materials on VMMC and HIV prevention.

57
Best Practices (2)

• Several best practices were observed, and these
  standards should be celebrated and continued.
• Several components of the group session and the
  individual pre- and post- HIV testing and
  counseling sessions were excellent overall.
• In all group counseling sessions, counselors made
  clients feel comfortable, managed group dynamics
  effectively, and encouraged group interaction.
• Most group counselors used teaching aids such as
  pictures and props, and the vast majority
  demonstrated correct usage of male condoms and
  offered complimentary male condoms to clients.
• All group counselors observed discussed the
  required six weeks of abstinence following VMMC.
  
• Lastly, all sites offering HCT services insured
  privacy by providing private rooms for individual
  HIV testing and counseling.

58
Challenges (1)

• IEC materials
• Although many clinics display signs outside of
  the clinic facility, most fail to mention VMMCs
  effect on HIV prevention.
• Many signs are not visible from the street.
  Therefore, clients need to enter the facility
  grounds to realize that VMMC services are offered
  on-site.
• Most facilities do have some type of IEC
  materials, flyers and pamphlets seemed in short
  supply in many clinics, especially when taking
  supplies of all relevant local languages into
  account, and these materials were not always
  being provided to clients.
• None of the sites were taking the opportunity to
  play video messages on VMMC, HIV prevention, and
  risk reduction, even though clients were
  frequently waiting at facilities for several
  hours or even the better part of the day. Not
  utilizing a TV fails to take advantage of a
  valuable messaging opportunity.

59
Challenges (2)

• Group and individual counseling sessions
• In general, most counseling sessions fail to
  repeat and re-emphasize key HIV prevention and
  risk reduction messages such the importance of
  partner testing, the partially protective nature
  of VMMC, the required 6-weeks of abstinence
  including abstinence from masturbation, and the
  importance of combining VMMC with other HIV
  prevention strategies in order to stay negative.
• It seems that individual counselors tend to
  assume that clients previously receive the
  required messages in the group session and
  therefore miss out on the chance to reinforce key
  taking points and promote a deeper understanding.
  
• Only a minority of group counselors discussed the
  need to abstain from masturbation. Those that
  did discuss masturbation were usually prompted
  due to a question from a client. Including a
  discussion about masturbation is critical, as
  clients may not understand that masturbation will
  delay healing.

60
Challenges (3)

• Group and individual counseling sessions
• Only a few group counselors demonstrated female
  condoms or offered free samples.
• Many group counselors failed to explain that STI
  screening was a key criterion for determining
  eligibility for VMMC.
• In certain sites, the space for group counseling
  is inadequate. A few clinics offer group
  settings in the lobby a space that is extremely
  busy, with doctors, nurses, and clients going in
  and out. Therefore, privacy and client attention
  span are major concerns. Many clients were
  distracted by movement in the hallway, and
  several were even called out of initial group
  sessions to fill out admissions paperwork. This
  is troubling, because it makes it easy for
  individuals to miss out on certain key messages.
• Clients who come late are not always offered
  group counseling sessions, thus they miss out
  completely on this experience. Given that risk
  reduction messages need to be repeated to have an
  impact on behavior, allowing a client to skip a
  group session is inappropriate.

61
Challenges (4)

• Individual post-op counseling sessions
• While counselors did tend to discuss general
  wound care, many failed to talk about potential
  adverse events or the warning signs requiring
  immediate attention.
• Most post-op counselors failed to explore
  knowledge about HIV transmission and prevention,
  discuss information about HIV/AIDS, provide
  prevention counseling, stress the importance of
  partner testing, repeat that VMMC is only
  partially protective against HIV, or discuss a
  personal prevention strategy.
• Counseling supervision
• The VMMC and HIV counseling supervisor is
  frequently shared by other clinics and/or only
  available on select days of the week.
• Additionally, several challenges with correct
  messaging were observed, and the lack of
  counseling supervision could be exacerbating this
  problem.

62
Challenges (5)

• Lastly, at several clinics, clients receive
  counseling services on the other side of the
  hospital rather than at the VMMC clinic.
  Therefore, it is difficult to assess whether or
  not the quality standards are being adhered to
  and if the messaging if consistent and
  appropriate.

63
Recommendations (1)

• Male Circumcision Promotion Efforts
• The VMMC program in South Africa should adopt a
  National branding
• Each clinic should have a sign outside which is
  visible from the street, not just inside of the
  hospital or facility, which mentions VMMCs
  proven effect on HIV prevention.
• IEC
• Development of standard set of IEC materials
  needed at site level to be use by all sites
• standardized videos should be produced for VMMC
  to ensure consistent messaging going forward.
• Each clinic should increase the availability of
  IEC materials on VMMC, HIV prevention, and risk
  reduction overall and insure that each
  pamphlet/flyer is available in all relevant local
  languages.
• Each clinic should add a TV and DVD player so
  that VMMC and/or HIV prevention messages may be
  broadcasted during the client waiting period.

64
Recommendations (2)

• The partners should consider looking into MTVs
  PEPFAR-sponsored Shuga series or other
  pre-prepared material so as to not miss out on
  this valuable messaging opportunity.
• More effort needs to be put into matching
  site-specific supply with demand.
• While certain sites were booked until September
  and/or sending away clients on a daily basis,
  others will need to put far more effort into
  outreach to match supply with demand as their
  capacity for VMMC increases.
• Education and Counseling Resources and Procedures
• All site should use the National HTC guidelines
  
• All counselors should incorporate more risk
  reduction and HIV prevention messages into group
  and individual sessions. These key messages
  should be repeated and re-enforced throughout
  each step of client communication.
• All counselors must communicate that VMMC is only
  partially protective and discuss the importance
  of combining VMMC with other prevention
  strategies in order to stay negative.

65
Recommendations (3)

• Initial VMMC Education and Counseling
• All clients should participate in the full group
  sessions without distraction, so the space and
  client flow at certain sites must be re-examined.
  
• Privacy should be insured so that the group feels
  comfortable to ask questions in a safe and secure
  environment.
• Group counseling should incorporate specific VMMC
  teaching aids such illustrative photos and props
  such as dildos, demonstration vulvas, etc.
• Group counselors must demonstrate correct and
  consistent condom use for male and female
  condoms. A full demo of a female condom with a
  demonstration vulva where possible will improve
  the condom presentation overall.
• Group counselors must explain the 60 protective
  effect of VMMC, discuss that VMMC does not
  directly protect clients partners from acquiring
  HIV, communicate that STI screening is part of
  evaluation for VMMC, and clarify the importance
  of abstaining from all form of sexual activity,
  including masturbation, for six-weeks post-op.

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Recommendations (4)

• Individual HIV Testing and counseling need to
• Explore knowledge about HIV transmission and
  prevention,
• Discuss information about HIV/AIDS,
• Provide prevention counseling,
• Stress the importance of partner testing,
• Prepare the client mentally for his HIV test
  results before the test,
• Repeat that VMMC is only partially protective
  against HIV, and
• Discuss a personal prevention strategy with each
  and every client.
• Counselors should highly encourage, though not
  mandate, clients to test for HIV prior to VMMC.
• Post-operative VMMC Counseling need to
• Provide information on the warning signs
  requiring immediate attention and how to address
  any potential adverse events,
• Re-emphasize the six-week period of abstinence
  including masturbation, and
• Remind the client that VMMC should be combined
  with other strategies to prevent HIV
  transmission.
• There should be a private room for post-operative
  exams and counseling sessions.

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Recommendations (5)

• Routine Follow-up Counselors must
• discuss the partially-protective nature of VMMC
  and
• remind clients of the required 6-weeks of
  abstinence, including abstinence from
  masturbation
• Gender Issues
• More attention needs to be put into targeting
  women with relevant messaging regarding VMMC and
  HIV prevention.
• All of the information sessions, from the initial
  group session to the post-operative follow-up
  session, need to include messaging which promotes
  respect for women and female partner(s).
• IEC materials need to target women with the
  benefits of VMMC and allow them to become
  informed in order to support and encourage male
  partners to pursue VMMC for HIV prevention.
• A comprehensive set of IEC materials needs to be
  compiled to ensure that all facilities are using
  a comprehensive, 360 degree, standardized
  communications approach targeting both men and
  women.

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4 years ½ after WHO-UNAIDS Recommendations
Neither the elegance of the science nor the
strength of the effect predict the ease of
implementation." David Stanton 2009
69
Achieving Pace Scale

• Community buy in and engagement of traditional
  leaders
• Political Will and Country Ownership
• Strategic communication
• Strong Leadership and Coordination from the MOH
  with the National and Provincial MC Task Force
• Enough resources for service delivery
• Technical support from partners
• Capacity to change the strategy as new
  information become available
• Task shifting to nurses
• Mobility of service delivery taking services to
  people has proven highly effective
• Dedication of sites with campaign style
  continuous service delivery more productive
  mixed staffing models (public and private/NGO)
• Practicality temporary services (adult MC)
• Innovation

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Next Steps

• Prepare site-specific reports to share with USAID
  Mission, Provincial DOH, partners and sites
• Continue the communication for improvements and
  implementation of recommendations
• Finalize the Site Operational Guidance and tools
  in annexes to be use at site level
• Work with the PEPFAR SA and the NDOH to define
  IEC materials needed at site level and branding
  for the VMMC program in South Africa

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Assessment Team

• Emmanuel Njeuhmeli, USAID Washington
• Rebecca Fertziger, USAID Pretoria
• Olga Mashia, USAID Pretoria
• Pamala Horugavye, USAID Washington
• Tigistu Adamu, MCHIP HIV Team Leader
• Abubakari Mwini, MC Program Manager ICAP Tanzania
• Partners and Site Managers

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Many Thanks To

• The NDOH
• Provincial Department of Health in Gauteng,
  Mpumalanga, Free State, and KZN
• District Managers
• Wendy Benzerga of USAID Pretoria
• PEPFAR Liaison in Gauteng, KZN, Mpumalanga and
  Free State
• Hospital Managers
• Hospital Sites MC Managers
• Partners
• All the dedicated staffs
• Drivers