Kenya MC Rapid Results Initiative Process, Results, Challenges, Lessons Learnt Presented by: Kawango Agot Impact R&D Organization; MC Consortium

Why rapid scale up of MC? Models show large benefits of MC in low circumcision, high HIV prevalence communities, with one HIV infection averted for every 5-15 circumcisions performed over a 10 year time period. The impact and cost-effectiveness of MC programs will depend on the HIV prevalence, the uptake of MC by adult men, and the speed with which services are scaled up. In Nyanza Province, the current site of most MC services, it is estimated that 80% MC uptake over 10 years could result in the male HIV prevalence decreasing from 17% to 7%, and female prevalence from 22% to 10% If scale-up could be achieved more rapidly, the impact over the same period of time would be significantly greater.

Rapid Results Initiative (RRI) RRI is a strategy used by government ministries and departments to tackle large scale change efforts through a series of small-scale, result-producing and momentum building initiatives In Public Health in Kenya, RRI approach has typically been used to accelerate nationwide uptake of services such as immunization, HIV Testing and Counseling, etc. Strategy applied to MC in Nov/Dec 2009, on a pilot basis: – About 40,000 were circumcised between Oct 2008 and Oct 2009 – RRI target: 30,000 circumcisions performed in 30 working days

Summary of process Set up a coordinating committee at provincial level; held several planning meetings, including with district MOH leadership to set goals and strategies; three sub-committees formed: – Service delivery (oversee staff, supplies, disinfection, M&E, etc) – Communication and Social Mobilization – Logistics (transport, funds flow, etc) Identical coordinating structure replicated at district level Service providers organized in teams, with experienced team leaders and district coordinators overseeing day-to-day activities Mostly, experienced and inexperienced staff worked together Weekly review meetings held to address challenges, make revisions Field supervision of service provision done daily; data forms reviewed in the field weekly; forms sent to central data center for review and entry. Exercise launched and closed by Provincial Commissioner; media present Ministry of Education and other government ministries involved

MC TARGETS BY REGION AND TIMELINE (TO REACH 80% AMONG CURRENTLY NON-CIRCUMCISED AND 94% NATIONALLY)

Service package MC Service package Counseling for MC; PITC offered on opt-out basis Clinical examination Management of STI and other genito-urinary conditions Surgical excision of foreskin using forceps guided method Post operative care Follow up MC Service provision team (4) RCO/Nurse: Surgeon Nurse/RCO: Assistant Surgeon MC Counselor, also trained on VCT/PITC Hygiene/Infection Prevention Officer

Procession during the RRI launch MC educ/consenting; PITC (Note: staff is female) Provincial Director of Health at a MC site Banner at a health facility inviting MC clients

Summary of RRI results 36,077 MCs performed in 30 working days. 28,672 (78%) done by two partners in seven districts: – An average of 10.2 MCs (range 8-12) done per team daily – 39% of men tested at MC venues; 17% tested as part of but prior to RRI (56% total); 3% were HIV infected. – 55% MCs done on ≥15 year-olds; 23% among year- olds. – AE rate was 1.9% (1.83% moderate, 0.05% severe); however, of the 6,595 who returned for f/u visits, 8.4% had AEs. – Follow-up rate at the MC venues was 23%.

Key challenges Obtaining parental consent for minors, especially year-olds. Sustaining demand for services erratic, and marked fluctuations interfered with staff and supplies allocation. Lower than expected rates of testing (56%) and seven- day follow-up (23%). Availability of MOH staff unpredictable at times, affecting planning especially in mixed teams (MOH + non-MOH). National data tools not out at the time and all partners did not use identical forms, hence limited ability to compare all data across partners.

Key lessons learnt Effective in increasing MC service uptake and program roll out. Built momentum for increased public support for and normalization of MC (there was high demand by parents in urban centers for circumcision of young sons). The public ready for MC, esp. if services are taken close to them. MC services can be provided safely in diverse settings. RRI for MC is cost effective (US$ 39 during the RRI vs. US$ 86 in the preceding 13 months, thus a 56% saving). Social mobilization for stable client flow is the most important determinant of efficiency. Engaging non-health depts, other NGOs and all sectors of community could make MC a movement in Nyanza rather than just a public health exercise.

Recommendations Expand MC services within and beyond the formal health sector to address unmet demand Adopt RRI as a strategy for scaling up MC (for short periods to reduce staff burnout) Conduct integrated RRI for MC and HTC for greater impact Re-engineer MC messaging to increase uptake by older, sexually active men Invest more resources in social mobilization for MC uptake Reduce emphasis on post operative follow-up as a measure of MC program success Put in place equipment, supplies and coordination strategies prior to start-up; monitor quality of services/data frequently

Acknowledgements Nyanza Community and Political Leadership. Ministry of Public Health and Sanitation Ministry of Medical Services MC Partners: – Impact Research & Development Organization (CDC) – Nyanza Reproductive Health Society (CDC) – Family AIDS Care and Education Services (CDC) – APHIA II Nyanza, including Engenderhealth (USAID) – Catholic Medical Missions Board (CDC ) National & Nyanza Provincial Male Circumcision Taskforces Family Health International Nyanza Provincial Commissioner and Provincial Administration PEPFAR (CDC, USAID)

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