croi 2010 17 th conference on retroviruses and opportunistic infections male circumcision for hiv...

CROI 2010CROI 20101717thth Conference on Retroviruses and Conference on Retroviruses and

Opportunistic InfectionsOpportunistic Infections

Male Circumcision for HIV Prevention: Male Circumcision for HIV Prevention: Progress in Scale-upProgress in Scale-up

Dr. Kim Eva DicksonMedical Officer, HIV Department

Prevention in the Health Sector UnitWorld Health Organization

Geneva, Switzerland

CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and


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



Research 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



Impact on HIV incidence: Evidence from observational studies and RCTs

Effect size .15 .2 .3 .4 .5 1 1.5

Study

Effect size

(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)



Research – Non HIV BenefitsMale 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



Recent Research DataRecent 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



The Global RecommendationsThe Global Recommendations

WHO/UNAIDS Technical Consultation Male WHO/UNAIDS Technical Consultation Male Circumcision and HIV Prevention: Research Circumcision and HIV Prevention: Research

Implications for Policy and Programming Montreux, Implications for Policy and Programming Montreux, 6- 8 March 2007 6- 8 March 2007



Global RecommendationsGlobal 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



Impact of MC Scale-up

PLoS Medicine 2009 doi:10.1371/journal.pmed.1000109.g001



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



Botswana MC Program Costs and Cost Savings (Estimates)

0

5

10

15

20

25

US$

(Mill

ion) Annual cost

Annual saving

0

50

100

150

200

250

300

350

US$

(Mill

ion)

Cum costCum Saving

Adapted from: USAID/HPI (2009) The Potential Cost and Impact of Expanding

Male Circumcision in Botswanahttp://www.malecircumcision.org/research/policy_briefs.htm



Almost Three years later……

What Progress has been What Progress has been made…???made…???

2007 2008 2009March March

Montreux MeetingMontreux MeetingWHO/UNAIDSWHO/UNAIDS

RecommendationsRecommendations20102010



Progress made on Male Circumcision to end 2009Progress made on Male Circumcision to end 2009Male circumcision prevalence at country level, 2006

ZambiaPolicy note, Strategy, national and regional trainings

BotswanaSituation analysis, strategy, communications, training, expanded service delivery, M&E

SwazilandPolicy, strategy and implementation plan, QA

KenyaPolicy, strategy, Training, QA, expanded service delivery, M&E

RwandaSituation analysis, pilot service delivery in military

UgandaSituation analysis, policy development

LesothoSituation analysis, policy development underway, draft strategy

South Africa, ZimbabweSituation analysis, draft policy, pilot sites

Tanzania, Mozambique, MalawiSituation analysis, pilot sites

NamibiaDraft policy, draft communications strategy, draft M&E



AdvocacyAdvocacy

• 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



Leadership and PartnershipsLeadership 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)



Situation AnalysisSituation 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)



PolicyPolicy

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)



StrategyStrategy• 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



MC Strategy - KenyaMC 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



Progress in other Key ElementsProgress 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



Service Delivery Service Delivery

How many circumcisions have been done?



CountryCountry 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

MC Service Delivery Update, Jan 2010



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)



Snapshot of Country Progress, Jan 2010

Botswana

Kenya

Lesotho

Malawi

Mozambique

Namibia

Rwanda

South Africa

Swaziland

Tanzania

Uganda

Zambia

Zimbabwe

National

Coordinator Task Force

Situation

Analysis Policy Training

Quality Service

Assurance Delivery M&E



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



Challenges and ConstraintsChallenges 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



Challenges and ConstraintsChallenges 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



Many Constraints but…..

'If you are building a house and 'If you are building a house and a nail breaks, do you stop a nail breaks, do you stop

building, building, or do you change the nail?'or do you change the nail?'

RwandaRwanda



Apply Lessons Learned to Scale-upApply Lessons Learned to Scale-up

Because Because

A stick is straightened while A stick is straightened while still young …. still young ….

UgandaUganda



Lessons LearnedLessons 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



Lessons LearnedLessons 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

croi 2010 17 th conference on retroviruses and opportunistic infections male circumcision for hiv...

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