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, 6:e1000187 • 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, 95%CI 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. 5:e8422

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 (>15%), 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 doi:10.1371/journal.pmed.1000109.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 US$20.2 billion between 2009 – 2025 with an overall investment of approx *US$ 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/policy_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 Recommendations 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, M&E 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 M&E Lesotho Situation analysis, policy development underway, draft strategy Botswana Situation analysis, strategy, communications, training, expanded service delivery, M&E 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

20. 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 • M&E 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

23. 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)

24. Snapshot of Country Progress, Jan 2010 Situation Analysis Policy Quality Service Assurance Delivery Training National Coordinator Task Force M&E

25. 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

26. 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

27. 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

28. Many Constraints but….. 'If you are building a house and a nail breaks, do you stop building, or do you change the nail?' Rwanda

29. 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