Male Circumcision: - PowerPoint Presentation

Slide1

Male Circumcision: Policy & Programming

Program

Implementation

Challenges

& OpportunitiesSlide2

Knowledge Check

Answer the following questions to see how much you know about this topic.

Which of the following are examples of behavior change communication efforts that can complement male circumcision to provide the best defense against HIV? Select ALL that apply.

Partner limitation

Condom promotionAbstinenceAvoidance of cross-generational sexSo far there is no evidence that circumcised men are abandoning condoms. TrueFalse

Which of the following are challenges to rapid scale-up to achieve comprehensive male circumcision coverage in developing countries? Select ALL that apply.

Weak health systems

Skilled health professionals in short supply

No precedent of non-physicians performing surgical procedures

Conventional service models (one surgeon, working with one assistant) allow an average of only eight to ten male circumcisions per day.Slide3

Knowledge Check (continued)

Answer the following questions to see how much you know about this topic.

Scale-up of male circumcision offers no benefits to women

.

TrueFalseTraining more than one provider per site in male circumcision is critical. TrueFalse

There is no way to overcome the opposition by traditional male circumcisers to medical male circumcision.

True

FalseSlide4

Will Circumcised Men Think They Are 100% Protected and Be Encouraged to Increase High-Risk Sexual Behavior?

This is a valid concern. However, providing counseling before and after male circumcision (MC) can reduce risky behavior. In addition, modeling data suggest that risk compensation would have to be quite significant to undermine the protective effects of MC.

So far there is no evidence that circumcised men are abandoning condoms; data from the trials suggest that circumcised men find it easier to use a condom.

Highlights

Complementing MC with behavior change communication efforts (e.g., partner limitation, condom promotion, abstinence, and avoidance of cross-generational sex) is the best defense against HIV.Slide5

Will Circumcised Men Think They Are 100% Protected and Be Encouraged to Increase High-Risk Sexual Behavior? (continued)

See

“When I Was Circumcised I Was Taught Certain Things”: Risk Compensation and Protective Sexual Behavior among Circumcised Men in Kisumu, Kenya

.

(Riess et al. 2010)See also Risk Compensation Is Not Associated with Male Circumcision in Kisumu, Kenya: A Multi-Faceted Assessment of Men Enrolled in a Randomized Controlled Trial. (Mattson et al. 2008)Slide6

Will MC Help Women or Just Put Them at Greater Risk?

Recently circumcised HIV-positive men who resume sex too early appear to be at higher risk of transmitting the virus.

MC communication and counseling efforts that include both men and women should strongly address the importance of abstinence during wound healing (six weeks), regardless of HIV status, and especially for men of unknown or positive HIV status. Women and their partners should be made aware that MC is just one part of a 

combination HIV prevention strategy

.To achieve the greatest public health benefit, the target population for MC scale-up will be HIV-negative men.Slide7

Will MC Help Women or Just Put Them at Greater Risk? (continued)

MC Benefits for Women

Models show that MC scale-up would greatly reduce HIV incidence in women because women will be less likely to encounter an HIV-positive partner.

Other MC benefits for women include lower rates

bacterial vaginosis, and lower risk of human papillomavirus (HPV) and cervical cancer.Did You Know?Scaling up MC will reduce HIV incidence in women as well as men.Slide8

How Can MC Services Be Implemented in Countries That Have Limited Surgical Capacity Without Overburdening the Existing Health System?

This question is particularly important in developing countries where health systems are weak and skilled health professionals are in short supply.

In fact, most countries that are implementing MC for HIV prevention are facing these challenges. Slide9

How Can MC Services Be Implemented in Countries That Have Limited Surgical Capacity Without Overburdening the Existing Health System? (continued)

There are, however, strategies to ease the burden of MC scale-up – even in situations of limited surgical capacity. Several major strategies include:

Task shifting

– For minor surgery, many countries employ non-physicians (e.g., nurses or clinical officers) to do the whole procedure.

Efficiency approaches – Dedicated MC teams (i.e., teams of providers who just do MC, rather than having other clinical responsibilities) may be used so that human resources are not taken away from other surgical services.Expanded recruitment – Human resources for MC can be expanded by recruiting recently retired, or recently graduated, or unemployed health care workers.Volunteer service providers – Some countries are experimenting with bringing in volunteer service providers from other countries to address the shortage of local surgeons. This can include private practice doctors from other developing countries or volunteers from high-resource settings.Slide10

Will Rapid Scale-Up of MC Disrupt Other Health Services?

As MC services for HIV prevention are developed and expanded, they should not disrupt health systems and the implementation of other health programs.

Highlights: WHO

and UNAIDS recommend that programs implement

rapid provider training and certification to increase MC service safety and quality in the public and private sectors.Source: WHO and UNAIDS 2007b

See the self-paced, individual learning materials for

Male Circumcision under Local Anaesthesia

:

Course Guide for Trainers

(WHO

, UNAIDS, and Jhpiego 2010a)

and

Course Workbook for Participants

(WHO

UNAIDS, and Jhpiego 2010b)

. See also

Supplement: Diathermy and Service Efficiency

.

(WHO, UNAIDS, and Jhpiego 2010c).Slide11

Investing in Training and in Human and Material Resources Is Key to Successful MC Scale-Up.

HIV counseling and testing (HCT) counselors can be trained in MC counseling in four days, which includes a one-day practical component on the fourth day.

Health care providers with basic surgical skills can be trained to competency in two weeks. However, proficiency requires performance of additional procedures.

Training more than one provider per site is critical because MC is provided by teams of providers and counselors, working with support staff (e.g., cleaners and receptionists).

Following up trainees reinforces the transfer of learning to the service delivery site.Most sites need additional MC supplies and equipment to launch high-volume MC services.Investing in developing high-performing/high-volume training sites is recommended. Training curricula should address efficiencies such as task sharing, task shifting (where appropriate), use of diathermy (electrocautery) to stop bleeding, and the use of MC surgical kits.Slide12

How Can We Reach Millions of Men?

This is a major challenge

.

MC is an investment in the future that will ultimately reduce the burden on health care workers because fewer people will need HIV clinical care.

Currently, researchers are exploring models that can maximize surgical output or productivity and minimize the time and resources needed to perform high volumes of surgery. For example, Models for Optimizing Volume and Efficiency (MOVE) (WHO 2010) use principles of surgical efficiency, task sharing, and task shifting.

Highlights

Remember

:

Conventional service models – in which one surgeon works with one assistant – allow an average of only eight to ten MCs per day.

Source

: WHO 2010Slide13

How Can We Reach Millions of Men? (continued)

Initially, task shifting from doctors to clinical officers or nurses and "importing" volunteer health care providers from other countries will help reach the millions of men who need immediate MC services.

In addition, task sharing – using health care workers who are less highly trained to perform specific steps in the MC surgery that are less complex – can support rapid MC scale-up.

Teaching nurse-midwives to provide neonatal MC will eventually reduce the numbers of adolescents and adults who need MC.

Communication programs will need to work closely with MC service providers to ensure that demand is well matched to supply, rather than having long waiting lists at some sites while others are under capacity.Slide14

How Can We Get the Support of Traditional Male Circumcisers for Medical MC?

A boy in Kenya nears completion of his circumcision ceremony

.

The public health goal is provide safe MC services for non-circumcising communities who need medical MC to reduce HIV transmission.

However, to move forward with medical MC for non-circumcising communities, it is usually necessary to engage with traditionally circumcising communities and traditional circumcisers.See the WHO and UNAIDS report titled Traditional Male Circumcision in the Context of HIV Prevention

.

(WHO and UNAIDS 2010b)Slide15

How Can We Get the Support of Traditional Male Circumcisers for Medical MC? (continued)

 In 13 of the 14 priority MC countries, there are traditional circumcisers, and they need to be comfortable enough with the medical MC program not to oppose it.

To overcome opposition by traditional male circumcisers to medical MC, involve them in the MC program. In some settings traditional male circumcisers are willing to do the whole initiation ceremony and all of the education for the initiates, but have MC done by a skilled medical provider, accompanied by HIV prevention counseling (minimum package of services). When linking medical MC to traditional initiation, "culturally appropriate medical MC providers" are needed. This typically means all-male, all-circumcised teams.

Highlights

WHO and UNAIDS recommend that MC programs gather information on traditional practices and engage traditional practitioners to improve the safety of their services and counseling on sexual and reproductive health.In addition, see a summary of the WHO/UNAIDS conclusion and recommendations

:

The Socio-Cultural Context Should Inform MC Programming

.

Source

: WHO and UNAIDS 2007bSlide16

What Is the Best Age for MC?

Is it safe to circumcise a neonatal male?

Neonatal MC is safe for healthy babies if done under local anesthesia, by a trained health professional. Neonatal MC is much easier and cheaper to perform than adult MC. The wound heals much faster than in adolescents or adults. And, there is no concern about sex before wound healing.

If neonatal MC is easier and cheaper to perform than adult/adolescent MC, why not just circumcise neonatal males and forget about the adults/adolescents?

Neonatal MC is an important investment but it won’t have an impact on HIV incidence for about 20 years.Ideally, both adult/adolescent and neonatal MC should be scaled up simultaneously. However, to accelerate the population impact of MC for HIV prevention, adult/adolescent MC is positioned as a catch-up strategy.Did You Know?

A

separate Global Health eLearning course will address neonatal MC.Slide17

What Is the Best Age for MC? (continued)

Should we provide MC for older infants, toddlers, and young boys?

Older babies, toddlers, and young boys usually cannot hold still for MC under local anesthesia and there are risks with general anesthesia (putting the child to sleep for surgery).

So, if a male child is not circumcised as an infant, it is probably best to wait until he is an adolescent – or at least old enough to comply with MC under local anesthesia.Slide18

What Is the Best Age for MC? (continued)

Should MC be promoted for older men?

Keep

in mind that the maximum public health impact of MC for HIV prevention will only be achieved if

all sexually active men are attracted to MC programs. The age range targeted for adult/adolescent MC for HIV prevention is generally 15 to 49; however, this range will vary depending on national strategy.In eastern and southern Africa, peak HIV incidence is found among men in their thirties.Priority could also be given to HIV-negative men of any age who are at higher risk for HIV (e.g., men presenting with sexually transmitted infections, or HIV-negative men in discordant relationships).

Highlights: See

a summary of the WHO and UNAIDS conclusion and recommendations

:

Programs Should Be Targeted to Maximize the Public Health Benefit

.

(WHO and UNAIDS 2007b)Slide19

Should MC Services Be Vertical or Integrated?

Remember

: As we learned in the cost and impact session, the greatest cost-effectiveness and public health impact on HIV incidence can be achieved by using a

two-pronged implementation approach

that combines:Accelerated MC saturation for adults and adolescentsANDSustains neonatal MC programs that are fully integrated within maternal and child health programsSlide20

Should MC Services Be Vertical or Integrated? (continued)

Vertical adult/adolescent MC programs that provide the recommended minimum package of services may be useful during a short-term catch-up period (as illustrated in the graph

on the previous slide)

to expand access to safe MC services and to train providers in standardized procedures, especially where demand is high and health systems are weak. (WHO and UNAIDS 2007b)

Vertical, adult/adolescent MC programs can provide high-quality, comprehensive services. Like any MC program, vertical MC programs should be country-led.Ideas in Action: Engaging Stakeholders in Nyanza Province, Kenya, for MC Integration

When

integrating MC into existing district health care services, a meeting with the Provincial Health Management Team (PHMT) provided an opportunity to:

Sensitize the team on MC as a new Ministry of Health intervention

Give directions and set expectations

Assure PHMT support for training and provision of MC supplies and equipmentSlide21

Conclusion: Combination Prevention Is the Best Defense

MC's effectiveness in reducing female-to-male transmission of HIV has been proven beyond reasonable doubt.

When used in combination with HIV prevention strategies (e.g

., partner

reduction, using condoms, delay in onset of sexual relations, abstinence from penetrative sex), MC provides additional "back-up" protection just as a goalkeeper is the last line of defense in a football (soccer) match.Slide22

What Additional Research is Needed?

Research has already:

Proven that MC reduces female-to-male HIV transmission by about 60%

Demonstrated cost and impact of MC scale-up

Shown additional MC health benefits for both men and womenResearch is also under way to develop and assess simpler and safer methods

for performing MC in resource-limited settings,

including the use of suture-less, blood-free procedures and devices

.

Now, as MC programs are rolled out and scaled up, most research will need to focus on programmatic or operational implications.Slide23

Knowledge Recap

Answer the following questions to see how much you know about this session.

Which of the following are examples of behavior change communication efforts that can complement male circumcision to provide the best defense against HIV? Select ALL that apply.

Partner limitation

Condom promotionAbstinenceAvoidance of cross-generational sexSo far there is no evidence that circumcised men are abandoning condoms. TrueFalse

Scale-up of male circumcision offers no benefits to

women.

True

False

Training more than one provider per site in male circumcision is critical.

True

FalseSlide24

Knowledge Recap (continued)

Answer the following questions to see how much you know about this session.

Which of the following are challenges to rapid scale-up to achieve comprehensive male circumcision coverage in developing countries? Select ALL that apply.

Weak health systems

Skilled health professionals in short supplyNo precedent of non-physicians performing surgical proceduresConventional service models (one surgeon, working with one assistant) allow an average of only eight to ten male circumcisions per day.Neonatal male circumcision is safe for healthy babies if done under local anesthesia by a trained health professionalTrue

False

There is no way to overcome the opposition by traditional male circumcisers to medical male circumcision.

True

False

Accelerated adult/adolescent male circumcision may be useful as a short-term catch-up strategy for HIV prevention.

True

FalseSlide25

Program Implementation Challenges & Opportunities

Knowledge Recap Answer Key

Please note that the questions and answers match those in the

Knowledge Recap

. The number and order of questions in the Knowledge Check may differ.Which of the following are examples of behavior change communication efforts that can complement male circumcision to provide the best defense against HIV? Select ALL that apply. Partner limitation Condom promotion Abstinence Avoidance of cross-generational sex

a, b, c, and d ALL apply

So far there is no evidence that circumcised men are abandoning condoms.

a.

True

Scale-up of male circumcision offers no benefits to women.

b.

False: Models show that male circumcision scale-up would greatly reduce the HIV incidence in women. In addition, male circumcision reduces rates of bacterial vaginosis, human papillomavirus, and cervical cancer.

Training more than one provider per site in male circumcision is critical.

a.

True: Training more than one provider per site is critical because male circumcision is provided by teams of providers and counselors, working with support staff. Slide26

Program Implementation Challenges & Opportunities

Knowledge Recap Answer Key

(continued)

Please note that the questions and answers match those in the

Knowledge Recap. The number and order of questions in the Knowledge Check may differ.Which of the following are challenges to rapid scale-up to achieve comprehensive male circumcision coverage in developing countries? Select ALL that apply. Weak health systemsSkilled health professionals in short supply

Conventional service models (one surgeon, working with one assistant) allow an average of only eight to ten male circumcisions per day.

a, b, and d apply

Neonatal male circumcision is safe for healthy babies if done under local anesthesia by a trained health professional

True

There is no way to overcome the opposition by traditional male circumcisers to medical male circumcision.

b.

False: Opposition can be overcome by involving traditional male circumcisers in the male circumcision program. In some settings traditional male circumcisers are willing to do the initiation ceremony and education, but have the male circumcision procedure done by a skilled medical provider, accompanied by HIV prevention counseling (minimum package of services).

Accelerated adult/adolescent male circumcision may be useful as a short-term catch-up strategy for HIV prevention.

True