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

2. 2 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

3. 3 Where We Work—May 2009

4. 4 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

5. 5 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

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

7. 7 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

8. 8 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

9. 9 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.orgwww.malecircumcision.org

10. 10 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)

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

12. 12 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

13. 13 Male Circumcision Partnership  PSI-led consortium working to scale up MC in Swaziland and 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 and Zambia

14. 14 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

15. 15 PEPFAR-Funded MC Programs, cont.  Botswana  Requires Assessment of the Botswana Public Health Care System’s Ability to Expand and 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

16. 16 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

17. 17 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

18. 18 PEPFAR-Funded MC Programs, cont.  Zambia  Adapt MC training materials  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 Distributing MC Supplies and Equipment in Ndola

19. 19 Future PEPFAR-Funded MC Programs  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 Jhpiego is planning PEPFAR-funded MC programs or activities in the following countries:

20. 20 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?”

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

22. 22 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

23. 23 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