In this second post in a week-long series exploring efforts to reduce HIV incidence via scaling up medical male circumcision (MC) in sub-Saharan Africa, Meredith Mazzotta speaks with Kelly Curran, director of HIV and Infectious Diseases at Jhpiego, an affiliate of John’s Hopkins University.
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.”
Tell me about Jhpiego’s role in medical male circumcision (MC) campaigns in sub-Saharan Africa. Where do you get your funding?
Jhpiego provides capacity building and service delivery support to assist African Ministries of Health, Defense Force health systems and NGOs expand safe and comprehensive medical male circumcision (MC) services. We have trained MC service providers and trainers in 13 of the 14 President’s Emergency Plan for AIDS Relief (PEPFAR) priority countries for MC scale up, and are currently supporting MC service delivery in ten countries.
The majority of our MC funding comes from PEPFAR via the U.S. Agency for International Development, the Centers for Disease Control and Prevention or the Department of Defense (to support MC programs in military health systems). We are also a partner of PSI on the Bill & Melinda Gates Foundation-funded Male Circumcision Partnership. Jhpiego also invests some of our own organizational resources in male circumcision.
In countries where you are involved, what role do you feel MC programs are playing as points of entry for care for men?
Historically in Africa men and adolescent boys have had very little contact with the health system. MC changes that by providing a concrete HIV prevention service that is in high demand among young men. In structured MC programs, men are provided with a package of services that includes education and counseling about HIV and other reproductive health issues, HIV testing, STI screening and condom promotion. Men who test positive for HIV are referred to care and treatment. Following counseling but prior to the surgery men receive a physical exam which provides another opportunity for referral to care for men who are identified with urological problems or another issue, for example, hypertension.
How much involvement have you seen from women in MC activities – mothers, wives, etc. – whether that’s accompanying men, getting tested themselves, encouraging men to do this…
Women play a critical role in MC as partners, as parents and as service providers. Some men bring their female partners to the MC clinic and we encourage these couples to be counseled and tested for HIV as a couple. Even in settings that are widely considered to be male dominated, women often have tremendous influence in the circumcision decision of their partner or son. I frequently hear MC clients say that they have chosen to get circumcised at the urging of their girlfriend, and I am aware of a couple of cases in which a woman has accompanied her partner into the MC procedure room. Women also have a key role to play as providers of MC services, and men from communities that don’t circumcise traditionally have accepted female providers as MC counselors, surgeons and surgical assistants.
Have most countries been receptive to these interventions? Where has there been pushback from the local government and why?
Fourteen countries in East and Southern Africa have been identified as priority countries for medical MC interventions, based on their high HIV prevalence and low circumcision rates. All 14 of these countries have taken some steps towards planning for or expanding MC as an HIV prevention strategy, but some countries are further along than others in terms of service availability.
In my experience, ministries of health in the region recognize that MC is an important and evidence-based HIV prevention strategy. That said policymakers in some countries have raised valid concerns about the impact of MC on the health system. The East and Southern Africa regions are experiencing a critical shortage of skilled health care workers, and policymakers rightly worry whether MC can be rapidly and widely scaled up without undermining other key surgical and health services, such as emergency obstetric care. Fortunately, MC country programs have now developed some excellent efficiency models that optimize the productivity of the existing health workforce. MC is a minor surgery that can and should be provided in a procedure room under local anesthesia rather than an operating theatre. There are also encouraging efforts to engage untapped human resources capacity in MC programs. For example, the planned campaign in Swaziland is actively recruiting unemployed, recently retired and “on leave” nurses to support MC service provision.
What is Lesotho doing in terms of MC?
The government of Lesotho is considering how best to integrate MC into its existing health system, which faces a critical shortage of human resources and which is under severe strain given the very high HIV prevalence in the country. The Ministry of Health and Social Welfare has asked Jhpiego for assistance in designing a neonatal or Early Infant Male Circumcision program.
What about funding? Do you see PEPFAR being able to fund these initiatives solo going forward?
PEPFAR has played a very key technical and financial role in supporting the launch of MC services in the region and is very committed to evidence-based prevention initiatives such as MC. However, PEPFAR is not the only donor funding MC. The Global Fund and the Gates Foundation are also important donors, and of course the World Health Organization (WHO) and UNAIDS play a critical technical leadership and advocacy role. In addition, many countries, particularly middle income countries such as Botswana and South Africa, are contributing financially to their own MC programs.
You mentioned the Global Fund. What have you seen in terms of countries applying for Global Fund grants for MC campaign support?
Some countries have successfully applied for MC funding from the Global Fund, although so far Global Fund contributions to MC are relatively modest. One challenge with the Global Fund application process is that proposals tend to cover a large content area—many countries submit comprehensive prevention, care and treatment proposals. I am aware of one country in the region that submitted a Round Ten proposal that included a large MC component, but the overall proposal was not funded, meaning that this country now needs to find an alternative funding source for its planned MC program. In future proposal rounds countries may want to consider MC-specific proposals to the Global Fund.
The Fund tends not to be directive with its applicants, rather they respond to country-driven proposals. To date not too many countries have requested MC funding, and some of those that did have not been funded for one reason or another. I personally was very disappointed that Malawi’s Round Ten proposal was not funded, since it included an ambitious plan for scaling up MC thanks to considerable advocacy and support from the MC community. I would love to see the Global Fund issue a future call for proposals focused on new, evidence-based HIV prevention approaches such as male circumcision, and eventually microbicides and pre-exposure prophylaxis once those are ready for implementation.
Tell me more about the monetary contributions made by countries themselves.
Some of the middle-income countries do indeed make financial contributions to their MC programs in terms of having a specific line item for MC in their ministry of health (MOH) budgets. But even lower-income countries do contribute “in kind” to the expansion of MC services. For example, in Tanzania and Zambia, regional or provincial health authorities have made space available for MC and have assigned full-time staff to MC clinics in public sector hospitals and clinics. The salaries of these staff are paid by their governments, not by donors.
What about private donors? What effect does a lack of funding have on support from country governments?
One thing I would like to see is more involvement in MC from major employers in the region. Some of the mining companies in South Africa played a key role in leading the expansion of antiretroviral therapy services; it would be great to see them equally involved in this high-impact HIV prevention intervention. We have had a successful partnership with Unilever in the Iringa region of Tanzania. Unilever runs a large tea plantation and they have worked with regional health authorities and Jhpiego to help their farm workers access MC services during slow periods in the growing season. Ultimately, it is in the interest of employers to keep their workforce healthy and HIV-free, and giving some time off to men to access MC services is a great long-term investment in workforce health and productivity. In Swaziland, labor unions and government ministries beyond the Ministry of Health are becoming more involved in the MC program, which is encouraging.
In response to your question about the effect of lack of funding on support for MC among country governments, my experience is that for most ministries of health, knowing that MC funding and technical support will be there is key to making a decision to move ahead with MC for HIV prevention. No one wants to launch a service—particularly a service like MC that has high latent demand—if that demand cannot be met. The available evidence suggests that efforts to quickly reach high coverage of MC will lead to the biggest HIV prevention benefit. In order to achieve high coverage of safe and comprehensive services in a short period of time most countries in the region will require both technical and financial support.
There are big efforts going on right now in Tanzania and Swaziland to circumcise large portions of the male population– will large campaigns like this continue? If so, where do you think the next big MC push will be? Where should it be?
Mathematical modeling suggests that rapid scale up of MC will avert more HIV infections than a slower roll-out of services. In other words, moving fast to provide MC to a large number of men saves more lives and keeps more families intact. Jhpiego is honored to play a role in government-led efforts to dramatically expand access to MC in Tanzania and Swaziland. Kenya is another country that has successfully demonstrated that campaign approaches can reach very large numbers of men in a short period of time.
Given the successful experience of MC campaigns to date I think that this approach will continue to expand throughout the region. The Iringa region in Tanzania is now pursuing a plan that includes baseline periods where MC is offered at static sites combined with periodic campaigns in which service availability is expanded through outreach sites and additional human resources. Demand for MC continues to be extremely high in Iringa. And Kenya is actually on track for saturation; they are probably at about 40 percent coverage already following an extremely successful campaign in late 2010 in which approximately 50,000 men were circumcised in six weeks.
Any high HIV and low circumcision prevalence country could use a campaign approach, but it may be particularly attractive to countries with relatively small numbers of men to be reached, or with MC programs that are geographically focused on a small number of provinces or regions with high HIV prevalence. In countries with large and/or geographically dispersed populations it may be more realistic to think about a series of MC campaigns rather than a single campaign.
A lot of these accelerated MC initiatives are focusing on adolescent and adult males. How big of a role could neonatal circumcision play in keeping HIV prevalence rates down and who is taking on this scale up?
Neonatal circumcision is the key to the success of MC as a long-term and sustainable HIV prevention strategy. Neonatal circumcision has many advantages; it is safer and less expensive than adult MC. MC for HIV prevention is really a two-pronged strategy that includes a “catch-up phase” focused on rapidly providing MC services to a large number of adults and adolescents, and a long-term phase supporting the integration of neonatal circumcision into maternal and child health services.
Jhpiego has been working with WHO and other partners to develop and field-test an Early Infant MC (EIMC) training package. We are using the term “early infant” because circumcision can be safely provided under local anesthesia to baby boys up to two months of age, which is wonderful because it allows us to reach baby boys – including those who may have been born at home – at the six-week immunization visit. We envision EIMC as a service that is integrated into existing maternal and child health services and which reinforces prevention of mother-to-child transmission programs. A number of MC implementing partners, including Jhpiego, are in the process of introducing EIMC in the region.
It is important to keep in mind however that the primary focus of MC programs in high HIV prevalence countries should be the massive and rapid expansion of services for adults and adolescents in order to quickly bring down HIV incidence at community level. On average, baby boys will not be exposed to HIV sexually for 15 or 20 years, whereas adults and adolescents are at risk NOW. Our advice to countries in this region is to focus efforts in the first couple of years on developing a strong adult and adolescent MC program. Once a strong adult MC program is in place, the country can turn its attention to developing a long-term, sustainable and integrated program of Early Infant MC.