The U.S. Presidents Emergency Plan for AIDS Relief Title The U.S Presidents Emergency Plan for AIDS Relief PEPFAR Male Circumcision Technical Working Group

UPDATE ON MC SERVICE DELIVERY BY NOMI FUCHS-MONTGOMERY (OGAC) NAOMI BOCK (CDC ATLANTA) PEPFAR MALE CIRCUMCISION PARTNERS MEETING Commodities and Improved coordination of Male Circumcision for HIV Prevention The U.S Presidents Emergency Plan for AIDS Relief

UPDATE ON MC SERVICE DELIVERY BY NOMI FUCHS-MONTGOMERY (OGAC) NAOMI BOCK (CDC ATLANTA) PEPFAR MALE CIRCUMCISION PARTNERS MEETING Commodities and Improved coordination of Male Circumcision for HIV Prevention The U.S Presidents Emergency Plan for AIDS Relief

Evolution of PEPFAR Support for MC In FY07 prior to normative guidance, 7 countries received resources for preparatory activities In April 2007, following the release of normative guidance, countries received additional resources to respond to host country government interests In the FY08 and 09 there was no funding limitation for male circumcision activities; activities were required to follow host country government coordination and be consistent with local norms and policies PEPFAR now supports male circumcision activities in 14 countries, working with local governments, WHO, and other partners and donors in program planning and implementation

PEPFARs Role in MC Roll-Out Growing requests and support for MC activities –FY06: ~$600,000 –FY07: ~$16,000,000 –FY08: $26,694,448 with over $11 million supporting direct circumcision services –FY09: ~$28,000,000 Donor collaboration with the Gates Foundation in several countries PEPFAR support to WHO –Both funding and technical assistance from PEPFAR MC Task Force –Recommendations regarding utilization of WHO tools/resources Challenges with roll out –Human resources, scale/pace of role out, quality assurance, etc Evaluation of service impact at population level will take time

PEPFAR Funding for Male Circumcision

PEPFAR Funding Guidelines Host country support must demonstrated through MC discourse in National Policy, Partnership Framework, or a letter from Minister of Health requesting USG assistance PEPFAR funds cannot be used to train or equip traditional providers Children should not receive MC under general anesthesia using PEPFAR funds Governments are required to describe coordination with host country and other donors Approaches to MC scale up may focus on partnership frameworks

Data Requirements Countries will track and report the following: –Number of male circumcisions performed –Safety –Coverage either in geographic area or among target population –Communications activities in relation to both males and females

Priority Populations and Targets Countries are encouraged to prioritize services to high-risk populations based on local epidemiology to achieve maximum impact on HIV levels Delivering services to boys/men in age groups where HIV rates are or soon will be increasing (already or soon will become sexually active) produces faster desired results Local regions with higher HIV rates benefit more quickly Targets and goals regarding the number of males reached should be developed

Future Directions

Quality Programs

Quality Safety Minimum package of services Volume and coverage of MC services to achieve impact on HIV incidence

Increasing Volume and Coverage 2-pronged approach for MC program support

Increasing Volume and Coverage 2-pronged approach for MC program support Sustainable services Rapid roll out response for catch up MC

Sustainable Services Focus on successive partners of either neonates or adolescents Situational assessment on preferred population Policy/guidelines development Health care cadre allowed to provide neonatal MC Pre- and in-service training Service delivery

Rapid Roll Out Response for Catch up MC Dedicated staff Volunteers Task sharing Task shifting Optimized facility space Optimized patient flow

Quality Assurance Represents a major component of PEPFAR supported programs Complementary dual approach –Facility self assessment via WHO Guide and Toolkit –External assessments via PEPFAR- supported EQA teams Similar standards

Donor Coordination PEPFAR coordinates with B&M Gates Foundation on service delivery and research funding in multiple countries

Political Willpower Endorsement of MC by public figures and policy makers is a key to successful programs Champions for an HIV-free Generation are a group of international leaders who have successfully lobbied for MC support in various countries