Transcript Integrating Medical Male Circumcision and HIV Prevention

Voluntary Medical Male Circumcision as
a Platform for Adolescent Sexual and
ReproductiveV Health Interventions
7th December 2011
Kawango Agot, PhD, MPH
Impact Research & Development
Organization, Kenya
HIV among Youth/Adolescents
• Youth (ages 15-24 years) represent a substantial
proportion of new HIV/AIDS cases globally1
o HIV prevalence is 3.4% among young females and 1.4% among males2
• In 13 of the VMMC countries, sex differential is 2- to 3-fold
• Young women acquire HIV mainly via sex with older
male partners
• Young men at less risk until a decade or two older, but
would benefit from information, skills and services
addressing HIV prevention during adolescence
• Youth are priority population for UNAIDS and PEPFAR
1. UNAIDS; Securing the Future Today: Synthesis of Strategic Information
on HIV and Young People (2011); 2. UNAIDS 2009 HIV Epidemic Data
Voluntary Medical Male
Circumcision (VMMC) and Youth
• To date, majority of MC clients have been <25 years
o >80% of the 90,000-plus clients circumcised during Kenya’s 2009 and
2010 Nov-Dec campaigns were <25 years
• There is high acceptability of MMC among parents and
guardians
• The “Back to School” campaigns draw large volumes
• Circumcised youth are beginning to exhibit behaviors
of superiority;  # of youth rushing for MMC to fit in
• Therefore, MC offers a unique opportunity to deliver
sexual and reproductive health (SRH) and HIV
prevention messages to large numbers of young males
Male Circumcision and HTC Uptake by Age
(Example from an Implementing Partner in Kenya*)
Age Groups
(Years)
Total
% of Total
Cumulative
Total
Circumci Circumcised
Total
Tested for
sed
Circumcised
HIV
% HTC
Uptake
1 – 10
9,544
7%
7%
1,927
20%
11 – 14
24,408
17%
24%
7,260
30%
15 – 19
60,186
42%
66%
37,617
63%
20 – 24
26,980
19%
85%
17,639
65%
25+
21,965
15%
100%
13,051
59%
143,083
100%
77,494
54%
Total
* Impact Research & Development Organization, Kenya
Multiple Educational Opportunities
During VMMC Process
• Pre and post-surgical
waiting periods
• Pre-op counseling
session
• Intra-operative
period
• Post-operative
follow-up
evaluations
Waiting Area, Tanzania
Group Education Session, Tanzania & Kenya
Kenya: Preparing for group education
ahead of mobile VMMC; an
opportunity for SRH intervention
Tz: Group education prior to
VMMC; an opportunity for SRH
intervention
MC and Youth Programming:
Current Collaborations (1)
Many PEPFAR-funded VMMC partners also provide
services for youth/adolescents
• Ethiopia, Mozambique: Military provides group
education and IEC materials to youth that include MC as
well as general risk-reduction
• Tanzania, Swaziland, Mozambique: Some partners share
staff and/or facilities across youth & VMMC programs
• Kenya: Tuungane Youth Program has VMMC services
integrated with SRH; VMMC is also integrated with
substance and alcohol abuse counseling & referrals
MC and Youth Programming:
Current Collaborations (2)
• Youth SRH and VMMC messaging often packaged
together:
o Families Matter! Program provides education on HIV prevention
and SRH; MMC now added
o South Africa: Soul City conducts HIV peer education and
outreach along with MMC demand creation
o Swazi: MC demand creation talk shows and road shows for
youth have strong HIV prevention messages
o Mozambique: Developing SRH messages for inclusion in MMC
demand creation campaigns and products
• Referral systems exist between programs
o Kenya and Zimbabwe have strong referral systems from other
youth HIV programs to MC and vice-versa
o In a Kenyan program, copies of referral coupons for MMC from
other programs are given to community mobilizers for follow up
Challenges to Harmonizing VMMC
and Youth SRH Programs
Despite current efforts
• Most VMMC programs not linked with Youth HIV prevention
services
• Success rate of youth accessing VMMC after referrals not known
(weak tracking systems)
• Many VMMC staff not trained on communication with youth
• Lack of time to administer SRH sessions with high volume model
• Most countries lack standardized HIV counseling curricula for
youth
• National policies often do not encourage HTC for clients <16 years
• Minors (<18 in most countries) require parental consent
Opportunities for Integration
• Develop normative guidance on HIV risk-reduction
activities for youth in VMMC context
o WHO developing intervention options and training materials that include
a strong focus on male gender constructs and their health effects
• Provide clear guidance and training to VMMC partners on
age-appropriate communication during client encounters
• Include youth services representatives on national VMMC
task forces/technical working groups
• Strategically place VMMC service sites within or near youth
resources
• Support national policies to offer HTC to all, regardless of
age
Case Study 1: WHO Model (Highlights)
• Package A: Basic package (5-10 hours, at a health facility)
o Can be divided into 3 parts: before, during and after MC
o Delivered to individuals or groups, by trained clinical or non-clinical staff
o Provide accurate info on HIV/AIDS and basic SRH information
o Engage adolescents in questioning gender norms
• Package B: Semi-expanded package (10-20 hrs)
o Can be provided in different settings
o Covers topics under Basic Package, and include discussion on sexuality
o Can also be implemented before, during and after surgery
• Package C: Expanded package (20-40 hours)
o Possible if contact with clients can be prolonged
o Covers topics under Basic Package, plus emphasis on sexuality and gender norms
Case Study 2: Kenya Models
• Church Model (mainly Catholic, Protestant and Evangelical):
o After primary school and before secondary school (≈14 years)
o Parents asked to release children for 1-2 weeks for residential teaching on SRH and
morality, followed by MC and a final session (1-3 days) combining parents and kids
o Increasingly popular in churches across the country; offers perfect opportunity for
structured SRH intervention
o Borrowed and modified by CMMB, a PEPFAR-funded project; implemented both in
circumcising and non-circumcising community with tremendous success
• Walter Reed Model: A medically trained person and a behavioral
Counselor join traditional MC team
o Traditional circumciser (TC) performs the operation but CO/Nurse oversees safety
• The CO/Nurse may be allowed to perform the surgery and TC performs rituals
o Behavioral counselor provides HIV testing; incorporates risk reduction counseling
o Positive aspects of culture passed on; practices counterproductive to HIV prevention
excluded
o Given the large numbers reached and extended seclusion period, perfect opportunity
for more rigorous SRH intervention
o Also relevant in countries with circumcision schools
Conclusions / Recommendations
• Most countries are circumcising large numbers of adolescents
and youth
• VMMC provides unique opportunity to provide effective SRH
education to adolescents, both in circ and non-circ
communities
• Recommended interventions require multiple hours,
sometimes multiple sessions; also require bulk of sessions to
be held outside clinic hours
• Shorter, effective interventions needed for implementation
during the surgery visit (pre- intra- and post-surgery)
• Effective linkages from VMMC to age-appropriate HIV
prevention and SRH programs need to be created
Thank you
Asanteni
Siyabonga
Tsikomo
Ke a Leboga
Obrigado
Amesege'nallo'