Much attention has been paid to the launch of an aggressive medical male circumcision (MC) campaign in Swaziland that starts this month, a program aiming to circumcise 80 percent of the small nation’s men aged 18-49 by the year’s end with significant support from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) program. In the fifth installment in a week-long series regarding MC on Science Speaks, the PEPFAR Swaziland team provides answers to some of the key questions regarding the ambitious Swazi initiative, including an outline of the HIV epidemic in-country where 26 percent of the adult population is infected.
When does the aggressive medical male circumcision initiative launch in Swaziland? What does it entail?
The “Accelerated Saturation Initiative” is a plan approved by the Swazi Cabinet and implemented by the Swazi Ministry of Health. It aims to make medical male circumcision available to all Swazi communities within one year since the science suggests that speed and coverage are critical to attaining the greatest reduction of new HIV infections. The plan is being launched as “Soka Uncobe” (“Circumcise and Conquer” in siSwati) this month, and it supports the government’s goal of achieving 80 percent prevalence of male circumcision in Swazi men aged 18-49. Service delivery has been available at key locations, which have already performed over 20,000 circumcisions to date. Once the campaign is in full swing, the program will help the Swazi government reach their ambitious goal of 152,000 cumulative male circumcisions before the end of 2011.
To ensure that lessons are drawn from the experience of the Soka Uncobe Campaign, an information and evaluation platform has been developed. This includes basic on-site monitoring and evaluation, cost effectiveness studies, a quality assurance monitoring system, linkages to a care tracking system for HIV-positive individuals, and a large, first-of-its-kind national HIV impact evaluation called Swaziland HIV Incidence Measurement Survey (SHIMS). SHIMS is sponsored by the Ministry of Health, and supported by the U.S. Centers for Disease Control and Prevention and Columbia University’s ICAP program. The SHIMS data will be based on a nationally representative sample of households and adults age 18-49. When linked to other programmatic data, it will address key questions about the impact of the male circumcision scale-up and other elements of the combination prevention strategy, notably wider and earlier access to antiretroviral treatment and evidence-based sexual risk reduction programs.
How did you scale up resources for this program? Specifically, how did you accumulate enough health care workers to perform the operation? Are they all Swazi nationals?
A central principle of the Soka Uncobe campaign is that it is additive to Swaziland’s health care system and does not draw human resources away from ongoing services. With Swazi doctors in short supply, physicians from other African countries have volunteered in impressive numbers. However, the Swazi government felt that only local nurses should be used for the Soka Uncobe campaign. A quantification by the Swaziland Nurses Association showed that there are enough retired nurses, recent graduates and ‘moonlighting’ nurses (those on regular leave) to fill the demand. Using Swazi nurses has the residual benefit of developing a new cadre of nurses trained in assisting with male circumcision procedures and in post-operational checkups and care.
What does the HIV epidemic look like in Swaziland?
Swaziland is at the epicenter of the global HIV/AIDS pandemic, with the world’s highest prevalence rates of HIV and TB. Twenty-six percent of Swaziland’s adult population (aged 15-49) is infected with HIV, while prevalence amongst pregnant women attending ante-natal care facilities stands at a staggering 42 percent. HIV incidence is estimated at 2.6 percent, which means that 32 new infections occur each day in the country. Life expectancy has dropped to an estimated 43 years due to HIV, and 40 percent of Swazis are under 15, based on the most recent census data available (2007). An estimated 191,000 people living with HIV/AIDS are in need of care and/or treatment services, including 14,000 children. Approximately 80 percent of TB cases are estimated to be HIV-positive. By conservative estimates, more than a third of all children in Swaziland are orphaned or vulnerable. Swaziland’s population of just over a million people is in decline, with 36 people dying from AIDS every day. Traditional family structures have all but collapsed, and only 22 percent of children are raised in two-parent households. Women are disproportionately affected, comprising more than 55 percent of all HIV-infected adults. Illness and death associated with HIV/AIDS are enormous drains on the national economy, national health system, and other social support networks needed to combat the epidemic.
Various studies have identified main drivers of the epidemic: multiple concurrent sexual partners, low levels of male circumcision, inconsistent use of condoms and long periods of premarital sexual activity. Gender-based inequalities and violence, poverty and income disparities persist in the country and create significant barriers to effective HIV prevention interventions.
Despite the circumstances, significant progress has been made over the last few years in the implementation of HIV prevention, care, treatment and support programs in Swaziland. With support from the PEPFAR program, the antiretroviral therapy program now reaches approximately 60 percent of the eligible population (at CD4 count threshold of 350). Eight-five percent of pregnant women attending sites are reached with prevention of mother-to-child transmission services.
What does the actual roll out of these services look like? How will it be done?
With adult and adolescent male circumcision, it’s a catch up process. The emphasis is on reaching 80 percent coverage with the Soka Uncobe campaign, and then leaving services in place for boys and young men who were not able to participate in the campaign. Much like a vaccination project, it has been developed to quickly and safely provide a public health benefit to every community, rather than relying on people to travel to the closest hospital.
In Swaziland, there are approximately seven “fixed” male circumcision sites: health facilities that have surgical space or a pre-fabricated structure, such as a mobile trailer where male circumcision is an ongoing service. These sites are complemented with mobile medical units (not unlike M.A.S.H. units) that can be rapidly deployed in most settings. These units can withstand different climates and different settings. They can be easily moved to different locations to meet demand, while also meeting infection prevention and hygiene requirements. The Ministry of Health plans to implement a ‘surge’ capacity of up to 32 service delivery teams operating at one time. If demand for services is sufficiently high, the plan calls for two surges separated by a rest period for the medical teams.
How is it being marketed to men? What do they think about it? What do women think about it?
Various marketing campaigns are taking place throughout Africa to increase knowledge about circumcision and encourage men to get circumcised. This has mostly been seen in posters and billboards. The Swaziland Soka Uncobe campaign will feature of a mix of traditional, ‘above-the-line’ mass media and community outreach. Field testing of the media strategy suggested that women will play an active and important role in supporting their partners to get circumcised, especially in terms of observing the six-week abstinence period following the procedure. In Swaziland, it is imperative to engage the chiefs and traditional leaders of each community well before the services arrive. Swazi government support has been strong, and a multi-sectoral Cabinet committee was formed to assist the project, including representation from the Ministers of Tinkhundla (traditional and community leadership) and Sports, Youth and Culture.
A unique aspect of Soka Uncobe is its focus on working with the private sector by engaging employers and labor leaders in industries with higher risk. Companies that employ a mobile or seasonal workforce, such as timber, sugar and mine companies, play a critical role in the effort. The first scale-up in the formal campaign is being dubbed “Back to Cane Cutting”. In late March, sugar cane companies will give their employees a few days of leave to get circumcised and have some recovery time before beginning the annual harvest.
But the biggest motivator for male circumcision services is the protection from HIV that circumcision affords. In a country with the practice of having multiple concurrent sexual partners and the highest HIV prevalence in the world, the goal of national stakeholders is to have people view male circumcision as one of several critical HIV prevention choices that men and their partners can make to live healthier lives and save their country.
How is this different from past attempts to circumcise males?
This is different because it’s a population-level activity meant to saturate the male population. Since Swaziland is a very small country with a very high prevalence of HIV and a very low prevalence of MC, it provides a very good case study on the relationship between MC and HIV infections prevented. Scientific models developed by the U.S. government predict that this scale up in Swaziland will prevent approximately 45 percent of new infections between now and 2025. Furthermore, by 2025, the number of new infections each year is projected to be reduced by more than 80 percent compared with what would have happened had no intervention occurred. Over time, as the prevalence among men decreases, the infection rate among women should also begin to fall.
Why is this initiative just happening now? Why not sooner?
Trials that confirmed that MC was efficacious were completed in 2006, however, the World Health Organization needed to develop normative guidance on the subject – which it released in 2007. Since that time, it has been an ongoing process to secure country buy-in. Engaging countries is challenging due to cultural challenges in communities where circumcision is uncommon. If it is a practice, it is in the context of a tribal ritual process that may be limited to some tribes, and it may not be done safely and effectively.
In Swaziland specifically, the aim was originally 80 percent of adult and adolescent males with MC services over five years. Based on encouraging campaigns in Tanzania, Kenya and other countries, government officials revised the timeline to one year. During the planning process, PEPFAR provided both technical and personnel resources to expedite the implementation of the campaign.
In March or April of 2010, the Swazi Cabinet approved the current plan, which the U.S. government agreed to support. Since then, U.S. government personnel have worked to align PEPFAR resources in support of the national plan. Starting this month, the program will begin phasing in service delivery to match the demand created by the Soka Uncobe campaign.
How has the Swazi government been participating in the ASI? Have they made a financial contribution?
The Swazi Ministry of Health has taken the policy lead on the Soka Uncobe campaign and is coordinating the implementation. The Swazi government has protected its health sector budget in the midst of a challenging budget environment, and has committed to cover all antiretroviral costs starting in 2011. The Government of Swaziland asked PEPFAR to support the national MC plan as one of the five ‘pillars’ of our “Swaziland – United States PEPFAR Partnership Framework on HIV/AIDS.” U.S. support for the Soka Uncobe campaign not only enables the United States to fulfill our commitments under the Partnership Framework, but it also is an opportunity to support a groundbreaking project that is additive to Swaziland’s national HIV/AIDS response.
After the Swaziland ASI is completed, will there be a scale up of neonatal circumcision? What will that look like?
The Ministry of Health, supported principally by UNICEF and PEPFAR, is currently working to introduce and scale up neonatal circumcision. Following Soka Uncobe, the focus will be on maintaining a certain level of adult male circumcision services for boys and young men who are ‘ageing’ into the target audience for the procedure, while building the capacity of health clinics and hospital maternity wards to deliver neonatal circumcision.