Male Circumcision for HIV Prevention: Progress in Scale-up

1
Male Circumcision for HIV Prevention Progress
in Scale-up

• Dr. Kim Eva Dickson
• Medical Officer, HIV Department
• Prevention in the Health Sector Unit
• World Health Organization
• Geneva, Switzerland

2
Overview

• Research on MC for HIV prevention and other STI's
• The global recommendations
• The potential cost and impact of scaling up MC
  for HIV prevention
• Country progress in of MC programmes
• Opportunities and challenges
• Conclusions

3
Research

• 4 ecological studies
• 35 cross-sectional studies
• 14 prospective studies
• 3 randomized controlled trials
• Confirm that male circumcision provides
• approximately 60 protection against HIV

4
Impact on HIV incidence Evidence from
observational studies and RCTs
Effect size
Study
(95 CI)
Overall
0.42 ( 0.34, 0.52)
High-risk groups
0.29 ( 0.20, 0.42)
General Population
0.56 ( 0.44, 0.71)
South Africa
0.40 ( 0.24, 0.67)
Kenya
0.41 ( 0.24, 0.70)
Uganda
0.49 ( 0.28, 0.86)
.15
.2
.3
.4
.5
1
1.5

Effect size
5
Research Non HIV Benefits

• Male Circumcision provides
• partial protection against GUD Bailey IAS 2007,
  PLoS Med 2009, 6e1000187
• Partial protection against HPV Tobian et al, NEJM
  2009, Auvert et al, JID 2009
• Protects against HSV-2 acquisition
  Sobngwi-Tambekou et al, JID 2009 Tobian et al,
  NEJM 2009
• Little protection against urethral infections
• Some evidence of a protection against vaginal
  infections (TV, BV, GUD) in women Gray et al, Am.
  J. Obstet. Gynecol 2009
• The effect of circumcision on HIV in men is
  largely independent of the impact on STI

6
Recent Research Data

• Male to female transmission Among HIV-1
  serodiscordant couples in which the male was HIV
  ve, there was no increased risk and potentially
  decreased risk from MC on male-to- female
  transmission of HIV-1 (HR 0.63, 95CI 0.35
  1.10) Baeten JM et al, AIDS. 2009. Dec Epub
  ahead of print
• Effects of MC on penile microbiota MC
  associated with a significant decrease in
  anaerobic bacterial families.This may play a role
  in protection from HIV and other STIs (in males
  and females) Price et al, PLoS One. 2010. 5e8422

7
The Global Recommendations
WHO/UNAIDS Technical Consultation Male
Circumcision and HIV Prevention Research
Implications for Policy and Programming Montreux,
6- 8 March 2007
8
Global Recommendations

• Countries with high prevalence (gt15),
  generalized heterosexual HIV epidemics and low
  rates of MC should consider urgently scaling up
  access to MC services
• 13 countries identified Botswana, Kenya,
  Lesotho, Malawi, Mozambique, Namibia, Rwanda,
  South Africa, Swaziland, Tanzania, Uganda, Zambia
  and Zimbabwe
• Consider ethics, communication,
  culture, health systems,
  funding, gender,
  
  comprehensive prevention
  strategies

9
Impact of MC Scale-up
PLoS Medicine 2009 doi10.1371/journal.pmed.100010
9.g001
10
Cost and Impact of MC

• Scaling up of MC to reach 80 of adult and
  newborn males
• in 14 African countries by 2015
• Could prevent more than 4 million adult HIV
  infections over 15 years (2009 2025)
• Could result in cost savings of US20.2 billion
  between 2009 2025 with an overall investment of
  approx US 4 billion
• Would require almost 12 million MCs to be
  performed in the peak year, 2012

Source ( adapted) USAID/HPI (2009) The
Potential Cost and Impact of Expanding Male
Circumcision in Eastern and Southern
Africa http//www.malecircumcision.org/research/po
licy_briefs.htm
11
Botswana MC Program Costs and Cost Savings
(Estimates)
Adapted from USAID/HPI (2009) The Potential
Cost and Impact of Expanding Male Circumcision in
Botswana http//www.malecircumcision.org/research/
policy_briefs.htm
12
Almost Three years later

• What Progress has been made???

March Montreux Meeting WHO/UNAIDS Recommendation
s
2007
2008
2009
2010
13
Progress made on Male Circumcision to end 2009
Male circumcision prevalence at country level,
2006
Kenya Policy, strategy, Training, QA, expanded
service delivery, ME
Rwanda Situation analysis, pilot service delivery
in military
Uganda Situation analysis, policy development
Tanzania, Mozambique, Malawi Situation analysis,
pilot sites
South Africa, Zimbabwe Situation analysis, draft
policy, pilot sites
Zambia Policy note, Strategy, national and
regional trainings
Namibia Draft policy, draft communications
strategy, draft ME
Lesotho Situation analysis, policy development
underway, draft strategy
Botswana Situation analysis, strategy,
communications, training, expanded service
delivery, ME
Swaziland Policy, strategy and implementation
plan, QA
14
Advocacy

• Advocacy for MC has been vibrant
  at global, regional
  and country level.
• Regional MC experts meetings in
  May 2007 to review
  recommendations, another meeting
  in April 2008 in response to Africa Ministers of
  Health request
• Country level advocacy through joint UN and
  partner Missions
• Multi stakeholder consultations in all countries
  with key stakeholder group consultation e.g.
  traditional leaders in Lesotho and Kenya
  women's groups in Zimbabwe

15
Leadership and Partnerships

• Country Champions have provided leadership to
  accelerate progress
• - Botswana Ex- President Festus Mogae
• - Kenya Prime Minister Raila Odinga with Luo
  Council of elders
• National Task Forces in all countries
• Global level UN - WHO with UNAIDS, UNICEF, UNFPA
• Funding Agencies rapidly making funds available
  PEPFAR, Gates, GFATM
• Partnerships to support scale-up MC Partnership
  (PSI, Marie Stopes International, Jhpiego) MC
  Consortium (FHI, EngenderHealth, University of
  Illinois Chicago, Nyanza RHS)

16
Situation Analysis

• A situation analysis is to determine attitudes,
  beliefs, practices and socio cultural aspects
  of MC, policy and regulatory framework,
  health system readiness
• Comprehensive situation analyses completed in
  Botswana, Lesotho, Malawi, Namibia, Uganda,
  Zambia, Zimbabwe
• Rapid assessments in Swaziland (Key informants,
  Facility readiness), Rwanda (facility readiness)

17
Policy

• Notable flexibility in approach to policy
  development
• Botswana no separate policy but
  strategy with policy elements
• Zambia sent Information note to Cabinet
• Kenya developed policy guidelines
• Dedicated policies developed in Lesotho, Namibia,
  South Africa, Swaziland, Uganda and Zimbabwe
  (drafts completed)

18
Strategy

• Country strategies developed that include
• Objectives, target population, numbers of men to
  be reached, costs, service delivery strategies,
  resource mobilization, monitoring and evaluation
• Decision Makers' Programme Planning Tool to
  estimate cost, impact, pace of scale up
• Most countries have 'catch-up' strategies to
  reach adult men Botswana, Kenya, Swaziland,
  Zimbabwe, Zambia
• But longer term neonatal circumcision strategies
  also being considered in Botswana, Swaziland,
  Zambia

19
MC Strategy - Kenya

• MC integrated into National AIDS Strategic Plan
  III with
• goal to increase the proportion of men ages
  15-49 years who are circumcised in Kenya from 84
  percent to 94 percent by 2013
• Aim that each region reaches coverage of 80 by
  2013
• Improving safety of MC nationally, including in
  traditional settings
• Reduce risk compensation disinhibition
• MC targets translated into actual figures-
  150,000 per year for 5 years - to 'catch-up'
• MC expected to contribute to the reduction of new
  infections by half by 2013 (KNASP III goal)
• Resources to provide MC to 750,000 men over 5
  years approximately US 37-56 Million over 5 yrs

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Progress in other Key Elements

• Quality Assurance being implemented in Kenya, and
  Swaziland using WHO Guide and Toolkit
• Training programmes implemented in almost all
  countries
• Communication strategies under development in
  Kenya, Namibia, Swaziland UN Toolkit under
  development
• ME Indicators gradually being introduced into
  routine systems in Botswana, Kenya

21
Service Delivery

• How many circumcisions have been done?

22
MC Service Delivery Update, Jan 2010
Country Botswana Kenya South Africa Swaziland Zambia Zimbabwe
Begin date Apr 2009 Sept 2008 Jan 2008 Jan 2008 July 2009 May 2009
No. of MC's 4326 90 396 14 253 5122 16 801 3000
No. of MCs Nov Dec 09 580 36 000 1547 1816 6171 1510

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Kenya Rapid Results Initiative

• Approx 36,000 MCs done in 30 working days in 11
  districts
• Number of teams varied on a daily basis from 88
  at start to 95 at end
• MCs per team varied on a daily basis lower at
  start to higher at end
• Average MCs/team 9.6
• Highest MCs/team 22.8
• Approx cost per MC 30 (versus 50 outside of
  RRI)

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Snapshot of Country Progress, Jan 2010
Situation Analysis Policy
Quality Service Assurance Delivery
Training
National Coordinator Task Force
ME
               
               
               
               
               
               
               
               
               
               
               
               
               
Botswana
Kenya
Lesotho
Malawi
Mozambique
Namibia
Rwanda
South Africa
Swaziland
Tanzania
Uganda
Zambia
Zimbabwe
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Status of MC Scale-up in the US

• Consultation held in Atlanta April 2007
• External partners, broad range of subject matter
  experts, clinicians, academicians, and public
  health practitioners
• Issues were around neonatal circumcision, other
  health benefits, cost/equity, relevance to MSM
• Smith DK, et al. Male circumcision in the United
  States for the
• prevention of HIV infection and other adverse
  health outcomes
• report from a CDC consultation. Public Health
  Reports 2010
• Draft currently in CDC clearance
• Simultaneous reviews (mid 2010)
• Final version to incorporate input and published
  as MMWR Recommendations Reports

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Challenges and Constraints

• Human resource constraints for country
  programming at national level, staff already
  overloaded
• Gaining political support it has been a process
  to get political buy-in in some countries, also
  delays due to elections, set backs with change of
  government
• Funding countries not clear on what funds are
  available and how to access
• Traditional providers almost all countries have
  them but no clear guidance on how to involve them
• Implications for women how to monitor and
  evaluate for adverse societal effects

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Challenges and Constraints

• Service delivery challenges
• Human resource constraints - lack of personnel,
  staff mobility, staff burnout, task shifting not
  permitted in countries
• HIV testing promoting the uptake of testing
  prior to MC
• HIV positive men how service delivery sites can
  handle without stigma and discrimination
• Demand creation matching services to demand
• Communication communicating partial protection,
  risk compensation

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Many Constraints but..

• 'If you are building a house and
• a nail breaks, do you stop building,
• or do you change the nail?'
• Rwanda

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Apply Lessons Learned to Scale-up

• Because
• A stick is straightened while still young .
• Uganda

30
Lessons Learned

• Political commitment accelerates progress
• Country Champions make a difference
• Early engagement and consultation of key
  stakeholders prevents set backs
• Service delivery needs 'innovations' if scale-up
  is to be achieved e.g. task shifting/sharing,
  volunteers, devices, demand creation

31
Lessons Learned

• Development of tools and guidelines give
  direction to countries and help to focus
  technical support
• Subtle country peer pressure through experiences
  sharing helps to motivate countries to action
• Funding 'provides oil to the wheels' - PEPFAR,
  Gates, GFATM
• Leadership and coordination is critical

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