Jhpiego Male Circumcision Programs Jabbin Mulwanda Kelly Curran

Jhpiego Male Circumcision Programs Jabbin Mulwanda Kelly Curran Technical Leadership Office 19 May 2009

About Jhpiego § An affiliate of Johns Hopkins University § 35 years working to strengthen the performance of healthcare workers and health systems around the world § Focused on transforming research into practice § Nearly 600 staff working in 55 countries 2

Where We Work—May 2009 3

Jhpiego’s Role in MC § MC policy and guidelines development § Service delivery § Orienting managers and providers § Procurement of key supplies and equipment (including infection prevention supplies) § Refurbishment of some sites § Assistance with client record keeping and data collection § Training MC service providers and counselors § Quality assurance and performance improvement § Assist in limited Operations Research 4

Jhpiego’s History in MC § 2002: Co-sponsored international consensus meeting on MC for HIV Prevention with USAID and PSI § 2003 -2005: Implemented pilot MC/male RH project in Lusaka, Zambia in collaboration with PSI/AIDSMark § USAID Population Funds 5

Zambia MC/MRH Learning Resource Package and Client Education Materials 6

Jhpiego’s History in MC § December 2005: Assisted WHO in developing international reference manual titled Male Circumcision Under Local Anaesthesia § 2006 -2007: Development of Training Materials to support reference manual content 7

Collaboration with WHO and UNAIDS § Adult MC course covers five competencies: § Group Education § Individual Counseling § Pre-surgical Assessment § MC Procedure § Post-operative Care and Counseling § June 2007: Field Test in Lusaka, Zambia § March, June 2008: Additional regional MC courses § January 2008: Regional MC Training of Trainers 8

Additional Collaboration with WHO and UNAIDS § Male Circumcision Situation Analysis Toolkit § Male Circumcision Quality Assurance Standards § Male Circumcision Operational Guidance All tools available at www. malecircumcision. org 9

Collaboration with WHO and UNAIDS, cont. § Participation in international/regional meetings: § Documenting Newborn MC Practices in Nigeria § Operations Research § MC Communications § MC MOVE § Conducted MC technical update for the College of Surgeons of East, Central and Southern Africa (COSECSA) 10

Next Steps § Develop newborn/pediatric MC courseware based on content in reference manual § Field-test newborn MC course 11

Zambia: Collaboration with PSI § Integrate MC services into stand-alone VCT centers (New Start) § Repurpose counseling rooms into procedure rooms § Advise on procurement of supplies/equipment § Development of emergency plan § Training of providers § Supportive supervision for providers 12

Male Circumcision Partnership § PSI-led consortium working to scale up MC in Swaziland Zambia; focus on engaging NGO, FBO and private sectors in MC § Partners include Jhpiego, Marie Stopes International and the Population Council § Funded by the Bill and Melinda Gates Foundation § Working in close collaboration with PEPFAR-funded MC programs in Swaziland Zambia 13

PEPFAR-Funded MC Programs § Jhpiego is currently implementing PEPFAR-funded activities or programs in the following countries; § Botswana § Ethiopia § Lesotho § Mozambique § South Africa § Tanzania § Zambia 14

PEPFAR-Funded MC Programs, cont. § Botswana § Requires Assessment of the Botswana Public Health Care System’s Ability to Expand Strengthen Male Circumcision Services (Facility Readiness Assessment) § Ethiopia § Federal MOH has made MC a component of national prevention strategy; focus on low MC prevalence regions § Build capacity of Surgical Society of Ethiopia to provide MC training and TA § First MC training in November 2008 uncovered unmet need for MC in Addis Ababa 15

PEPFAR-Funded MC Programs, cont. § Lesotho § Supported MOH with MC Scale-up (adult and newborn) § Reviewed national MC strategy documents § Six pilot sites identified § Facility readiness assessments planned for June, 2009 § Mozambique § Translation of key MC tools into Portuguese § Assessment of Surgical Capacity completed § Strengthening Surgical Services, Including MC, pilot planned at four sites 16

PEPFAR-Funded MC Programs, cont. § South Africa § Recruiting for the position of Biomedical Prevention Advisor, to be seconded to National Department of Health § Providing support to NDOH and SANAC to develop national MC policy § Tanzania § Adapted MC training materials to Tanzanian context § MC pilot planned for high HIV/low MC prevalence regions 17

PEPFAR-Funded MC Programs, cont. § Zambia § Adapt MC training materials Distributing MC Supplies and Equipment in Ndola § Develop Male Reproductive Health Kit (with partners) § Establish MC training centers at all provincial hospitals plus national military hospital § Procurement of supplies and equipment for public sector sites § Conduct MC training nationwide 18

Future PEPFAR-Funded MC Programs Jhpiego is planning PEPFAR-funded MC programs or activities in the following countries: § Namibia § First adult MC training planned for July, 2009 § Rwanda § Support to Rwanda Defense Force MC program § Swaziland § National MC scale-up in collaboration with MC Partnership; pilot test MC MOVE model 19

Challenges § Insufficient political commitment at the top. Tacit support is not enough; leadership is required to take MC to scale § Improved political commitment and leadership would help address many related challenges § Is the prospect of massive MC scale up too overwhelming? § Is it time to move from “this is why you should scale up MC” to “this is how you can scale up MC? ” 20

Challenges, cont. Poor condition of public sector surgical services in most countries in the region Pipes but no wash basin, Kitwe, Zambia § Dilapidated infrastructure § Insufficient number instruments § Erratic supply of consumables § Inconsistent electricity to power lamps, autoclaves § Running water a challenge 21

Challenges, cont. § Providers and managers often view MC as “extra work” rather than an integral component of the national HIV program § Certain countries are not embracing task-shifting § Lack of dedicated MC service in public and FBO facilities § However, providers in dedicated MC services reporting burn-out/boredom providing MC all day, every day 22

Lessons Learned to Date § Political commitment at all levels is critical § Participants with basic surgical skills can be trained to competency in 2 weeks § Training more that one provider per site is critical § Most sites need additional MC supplies and equipment § Invest in developing high performing/high volume sites for training § VCT counselors can play a key role in MC services as counselors/educators 23