UPDATE ON MALE CIRCUMCISION IN UGANDA Dr. Jackson Amone Uganda MC-NTF Secretariat Presention at Arusha, Tanzania from 8th – 10th June, 2010

Background Total population of Uganda is 32 million (UBOS 2009 Projection) HIV prevalence: 6.4% MC Prevalence 25% (Source: UHSBS 2004/05) The proportions contributed by either traditional MC or religious related MC are not known

MC Prevalence in Uganda (2004/05) 3

Uganda with generalized HIV epidemic 2.3% 8.2% Uganda total: 6.4 3.5% Benefit of MC higher in generalized epidemic especially when MMC prevalence is low 5.3% 6.5% 6.9% 8.5% The map shows that different regions of Uganda are heterogenously affected by HIV infection, with the highest prevalence recorded in Kampala and the lowest prevalence in the West Nile region. Kampala – 8.5% 5.9%

Background cont’ MC Partnerships: Support partners include: WHO, UNAIDS, UNICEF, PEPFAR(USAID & CDC), FHI and Makerere University School of Public Health Implementing partners include: IRCU, Health Communication Partnership, Makerere University Walter Reed project, Rakai Health Research Science project, STAR EC &E, Ministry of Defence/DOD and HIPS

Leadership MOH providing leadership, guidance and stewardship for MC National Task Force for MC in place and championing MC activities Development Partners especially the UN Family (UNAIDS/WHO/UNICEF/UNFPA) are providing international policy direction A MC Focal Point will be appointed soon

Situation Analysis Situation analysis was conducted in 2008/9 to determine the acceptability and feasibility of MC promotion in Uganda completed and disseminated to stakeholders, Mapping survey of MC services completed

Policy & Regulations The SMC Policy has been developed Communication Strategy has been developed The National Launch of the SMC Policy and Communication Strategy is scheduled for mid June 2010 Provisional legal assessment of existing policies done

Strategy & Operational plan SMC has been included in : National HIV Strategic Plan developed by UAC, Health Sector Strategic Plan III Health Sector HIV/AIDS Strategic Plan The operational plan for SMC is under development In the meantime, the start up activities are being implemented

Training on SMC Nationwide training to be initiated soon Some little funding identified by WHO Health workers from a select number of facilities are being trained at the Rakai Health Sciences Research Project (RHSP) and other MC projects: So far, 232 surgeons, theatre nurses and counsellors have been trained in the last one & half years (Oct 8th 2009-March 10th, 2010) RHSP acting as Training Centre of Excellence Members of NTF trained on the application of DMPPT

Quality Assurance QA tools are being initiated by MOH in collaboration with Association of Surgeons in Uganda. WHO guidelines are being adapted for Uganda context MC-NTF Quarterly Meetings continue to review educational materials for advocacy and providing guidance to circumcising Health facilities

Male Circumcision Research Rakai Health Science Research Project is conducting some studies: To investigate proficiency of trained clinical officers in performing MC To determine safety of conducting MC without surgical gowns., Tracking of MC clients and Testing of foreskins as risk factor for HIV transmission

MC Research Cont’ Makerere University school of Public Health (MUSPH) did/doing: A study to model the effectiveness of MC in HIV prevention A study to determine whether MC is directly effective in HIV prevention among women who are partners to circumcised men

MC Service Delivery Hospitals and Health Centres are providing MC services as part of the general surgery (integrated approach) Makerere University Walter Reed and Rakai Health Science Research institutions are providing MC services (project mode) - Kayunga and Mukono districts MC target estimated in the country is 2.4 million and increase MC prevalence from 25% to 40% MC PEPFAR implementing projects reported 5,340 clients circumcised within 1.5 years of implementation (Oct 2008-March 2010)

Monitoring & Evaluation Monitoring indicators MC services are being developed by NTF in collaboration with HIV/AIDS surveillance and HMIS units of MOH. Infection control guidelines are in place.

Lessons learnt Establishment of MC services is a process that needs support of stakeholders right from inception. Coordination & collaboration of MC is critical in tapping resources & experiences from established MC projects A mix of vertical & integrated approaches to MC are essential in MC roll-out

Challenges Low prevalence of MC Inadequate funding for MC scale up Need to remodel facilities for MC services Need to decentralize training to RRH to get adequate numbers of MC trainers Policy issues on Task Shifting/Sharing of MC work to/with Nurses & Clinical Officers is still being debated - will require change of regulations Security of logistics and supplies for MC is still inadequate

Innovations Working with Traditional Circumcisers to minimise SMC de-campaigns, Using of existing facilities to deliver MC services before full-scale up and Involvement of media houses as advocates for SMC services

Way Forward Expedite development of tech. guidelines for MC Launch & disseminate MC policy and communication strategy. Print and disseminate advocacy materials for MC Development of MC strategic plan Scale up social mobilisation Organize MC national training programme with support of Rakai Health Research Project and National & Regional Referral Hospitals

Way Forward Strengthen surgical theatres and commodity security Continue to build and sustain partnership for SMC Integrate MC data in HMIS

I thank you