This is the first in a week-long series exploring efforts to reduce HIV incidence via scaling up medical male circumcision (MC) in sub-Saharan Africa. Clinical trials have shown MC protects males by up to 60 percent from contracting HIV during vaginal sex. For more information, check out the Center’s recent report “Medical Male Circumcision as HIV Prevention – Follow the Evidence: The case for aggressive scale up.”
In the first installment, John Donnelly interviews Caroline A. Ryan, MD, MPH, director of technical leadership
at the Office of U.S. Global AIDS Coordinator. She has been a long-time key architect of the President’s Emergency Plan for AIDS Relief’s (PEPFAR) implementation.
Could you give an overview on PEPFAR’s activities to date regarding the scale up of male circumcision?
We have 14 countries now receiving PEPFAR funding for male circumcision. They are mostly in sub-Saharan Africa. Some money is in Guyana, but not a lot. We are beginning to see that countries are embracing this as part of a prevention portfolio, and they are investing a higher percentage each year into male circumcision, which is good.
We also see a change from countries at first integrating it into existing services to what would be a larger service delivery model that also takes advantage of mobile sites for particular campaigns. We’ve seen a number of countries, such as Kenya, Zambia and Swaziland, use campaigns during school breaks, for instance.
How do these campaigns work?
The first one was in November or December 2009 in the Nyanza province in (southwestern) Kenya. The target was 30,000 male circumcisions in 30 working days. It was the time of year when men were back from wherever they were working. The Ministry of Health and Sanitation led the campaign, and they were supported by seven nongovernmental organizations. They had stand-alone sites, but they also integrated mobile teams into the existing models. They ended up doing 36,000 male circumcisions in 30 days.
The mobile services are done in tents. There are tents for education, tents for counseling, a surgical tent and a recovery tent. They have teams, and one of the innovations in circumcision was a model pioneered by Bertrain Auvert in South Africa called the MOVE model (Model for Optimizing the Volume and Efficiency of Male Circumcision Services). Instead of one doctor and one nurse taking a patient from the prep to a post operation room, different people on a team have specific responsibilities. A nurse will do the prep, a doctor will do the surgery, another nurse will do the wound healing. It frees up doctors to do more circumcisions. Before MOVE, doctors were doing five to 10 circumcisions a day. Now a team with a defined task can do up to 40 circumcisions per day. It’s based on the LASIK eye surgery model.
Tanzania was the next country to do it – they did 105,000 circumcisions over a series of months. Now we are looking to Swaziland to do a similar thing. Its goal is to do 153,000 male circumcisions, targeting males between the ages of 15 and 49, over the course of a year. They will use 35 MOVE teams to do that.
What are the implications of doing this number of circumcisions?
Modeling shows that doing by 153,000 male circumcisions you avert 88,000 new infections and decrease incidence in Swaziland by 75 percent. You save $650 million in HIV care and treatment costs. Swaziland also will be able to identify through care and testing 23,000 clients, and anticipate that 4,800 men will need to start immediately on antiretroviral therapy. So we have started to budget for that. What’s amazing is if you think about infections averted. (Editor’s note: In Swaziland, according to the modeling, within one year the effort will prevent one new HIV infection for every three to four male circumcisions performed.)
What about the cost of circumcisions?
It is cost effective if it is less than $100. In the large mobile units, it’s looking like $35 to $100 per circumcision. It’s very variable. It was quite cheap in Kenya and Tanzania because they used existing manpower. In Swaziland, the cost is higher because we’ve provided more infrastructure help.
Why has it taken this long for countries to go to scale with male circumcision?
Some countries were quick on the uptake. Kenya did a very good job in getting it off the ground. Tanzania was quick as well. In all countries, it was important to make sure the government was fully engaged and this procedure was integrated into an overall prevention response. Education and demand creation and the MOVE model have helped us a lot. After the randomized control trials were stopped in March 2007 (because they showed clear efficacy), for some countries, the response has been slower because they wanted to do it as a medical model. They wanted to upgrade all the surgical (units). In contrast, we’ve endorsed this multiple model service delivery system that is not dependent on one surgeon, and one operating room. It’s also true that there haven’t been a lot of other donors out there. The Gates Foundation was there initially to help out, but we’ve only recently started to see male circumcision integrated into the Round 10 Global Fund funding.
What has PEPFAR’s contribution been so far to support male circumcision?
After the trials were stopped, we immediately made $15 million available to countries so they wouldn’t have to wait for another year. Kenya, Zambia, and Zimbabwe were ready to go right away. Other countries were slower, like Lesotho, where it’s been difficult to get traditional circumcisers engaged and on board. In the last three years overall, I would estimate PEPFAR has given close to $200 million to support male circumcision. In Swaziland alone, we’ve given them close to $30 million.
Swaziland’s effort is obviously important because it will be the first nationwide effort to circumcise all males between the ages of 15 and 49. How did this come about?
The Ministry of Health came to us and asked us for help. Swaziland has the highest HIV prevalence rates in the world. If the government was asking us to help them, we wanted to be responsive.
What’s does success look like in Swaziland?
I don’t think anyone is going to say male circumcision is not going to work. We want to see what the impact is on the population level in terms of decreasing incidence in women and men, and we see it as a way to get men into services early. It’s a proof of concept of HIV combination prevention. It may allow us to tell other countries, such as Lesotho, Zambia, or Malawi, that maybe the investment in one of these rapid scale-up programs is more cost effective than trying to integrate it into existing services.
Can you use this campaign in Swaziland to provide other services to men, which would be following the philosophy of the Obama administration’s Global Health Initiative?
We’ve integrated counseling and testing in the services. And because getting access to men is not always easy, and because Swaziland has a relatively high rate of gender-based violence, we are also using this opportunity to talk about gender-based violence in the counseling sessions.