EngenderHealth’s Work on Male Circumcision PEPFAR Male Circumcision Partner’s Meeting 19-20 May 2009 Paul Perchal, MA, Director, HIV/STI Program Mark Barone, DVM, MS, Senior Medical Associate

Overview of Presentation Brief background on EngenderHealth. Service delivery: APHIA II Nyanza MC activities, Kenya Men As Partners (MAP) MC activities in Tanzania and South Africa Research: Male Circumcision Consortium Project Shang Ring Pilot Study

EngenderHealth… U.S.-based international non-profit. Partners with governments, institutions, communities, and health care professionals to improve the quality of health care in the world’s poorest communities. Long history of introducing new clinical contraceptives and other reproductive health technologies in impoverished communities with limited resources. Currently has programs in more than 25 countries (MC work in Kenya, Tanzania, and South Africa). has a long history of introducing new clinical contraceptives and other reproductive health technologies in resource poor settings including, for example, female sterilization using minilaparotomy under local anesthesia, no-scalpel vasectomy, Norplant®, and manual vacuum aspiration for treatment of abortion complications As you will see during the presentation, our work in MC includes all of the following: Service delivery Policy development Communication Research

MC Funding Private USAID FY 07-08 800,000 500,000

APHIA II Nyanza MC Activities USAID-funded project in western Kenya. Supports MOH, private, & faith-based facilities in introducing MC for HIV prevention at 30 sites in 4 districts. Working at all levels of the health system. Working at all levels of the health system: district, sub-district & mission hospitals, health centers, dispensaries Map shows Nyanza in the corner of Kenya, on the shores of Lake Victoria and bordering Tanzania below and Uganda to the left Integrated approach to service delivery.

Supply-Demand-Advocacy Model Assess and upgrade sites. Provide start-up equipment and supplies. Provide training on MC Facilitate task shifting to non-physician clinicians. Establish MC outreach services on pre-scheduled days. Demand: Conduct district stakeholders meetings to raise awareness. Integrate MC messages in full range of BCC and community mobilization activities. Advocacy: Conduct orientations on MC for provincial and district officials. Advocacy work with community leaders. Provide technical support for provincial and district officials regarding MC guidelines.

Findings from Site Assessments – Equipment/Supplies Lockable cabinet 45% Autoclave 71% Other sterilization 26% Examination lamp 37% Examination couch 92% Surgical supplies 53% Surgical instruments 39% Dry heat or chemical sterilization. Since the assessment APHIA-II has ensured all the sites have the necessary equipment and supplies to perform MC safely. Supplying instrument kits can ensure services are available and of good quality:Needed instruments are available (specific instruments and adequate numbers). Instruments are of good quality. MC kits are currently supplied to facilities under APHIA II Nyanza: These kits differ some from the recommendations in the WHO MC manual.

APHIA II Nyanza MC Service Statistics October 2008-April 2009

Tanzania and South Africa Developed and field tested a needs assessment tool in Mwanza, Tanzania, in 2007. Our CHAMPION Project in Tanzania is currently conducting a national survey to help assess men’s attitudes, beliefs, and practices regarding HIV prevention and gender, including MC. Incorporates MC messages in Men as Partners (MAP) activities for PEPFAR supported HIV prevention services. One other area of our work that I would like to mention because of the great opportunity for synergy with MC activities is our work with men in what we call our Men as Partners program (MAP). Enhancing men’s awareness and support for their partners’ sexual & reproductive health choices Increasing men’s access to health services Mobilizing men to take an active stand for gender equity and against gender-based violence In general men tend not to come to preventive health services….and so we need to capitalize on opportunities to work with men when they do arise. MC will provide a platform for more comprehensive health services and education for men. MAP approaches and lessons learned could be very useful as we explore ways to engage men when they come for circumcision. Perhaps there might be an opportunity to start a Woman As Partners Program…women will play a role at least in some settings in encouraging or discouraging their partners from getting circumcised and certainly will play a role when we eventually begin to implement programs for infant circumcision.

Challenges in MC Service Delivery Limitations of task shifting vs. full time dedicated MC staff. A number of health providers lack motivation. Initially low uptake of HIV testing at time of MC. Unreliable supply of consumables. Lack of specific instruments needed, instruments of poor quality or insufficient numbers for high volume. Lack of support from some traditional leaders in non-circumcising communities. Some health providers lack motivation: Believe services are donor driven/special program. Providers expect to be compensated.

Male Circumcision Consortium Project EngenderHealth is responsible for leading the following 3 research studies: Assessing the human resource capacity and training needs to support MC roll-out. Assessing the safety, efficacy, and cost of non-physician clinicians providing MC services. Assessing the safety, efficacy, and cost of MC outreach services. Objective 1: To support the GOK and local stakeholders in implementing a national MC strategy. Objective 4: To generate evidence to inform the rollout and scale-up of MC services.

The Shang Ring for MC Developed & commercially available in China. A published study and other data suggest good safety profile. Benefits of the Shang Ring: Simple design; easy to use, learn & teach Short procedure time ( 3-10 minutes) Minimal bleeding Tight seal along wound Sutureless closure; excellent cosmetic results Design decreases risk of serious surgical errors

The Shang Ring MC Device

Shang Ring Pilot Study We will examine clinical outcomes and patient satisfaction in a small sample of Kenyan men in order to assess: Safety Efficacy (in terms of successful circumcision) Acceptability/satisfaction The pilot will also lay the groundwork for a larger RCT. Prospective, non-comparative study at one health facility. 40-50 men seeking MC will be enrolled, undergo MC with the Shang Ring and be followed for 6 weeks.