CROI 2010CROI 20101717thth Conference on Retroviruses and Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
Male Circumcision for HIV Prevention: Male Circumcision for HIV Prevention: Progress in Scale-upProgress in Scale-up
Dr. Kim Eva DicksonMedical Officer, HIV Department
Prevention in the Health Sector UnitWorld Health Organization
Geneva, Switzerland
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
Overview
• Research on MC for HIV prevention and other STI's
• The global recommendations
• The potential cost and impact of scaling up MC for HIV prevention
• Country progress in of MC programmes
• Opportunities and challenges
• Conclusions
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
Research Research
• 4 ecological studies
• 35 cross-sectional studies
• 14 prospective studies
• 3 randomized controlled trials
Confirm that male circumcision provides approximately 60% protection against HIV
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
Impact on HIV incidence: Evidence from observational studies and RCTs
Effect size .15 .2 .3 .4 .5 1 1.5
Study
Effect size
(95% CI)
Overall 0.42 ( 0.34, 0.52)
High-risk groups 0.29 ( 0.20, 0.42)
General Population 0.56 ( 0.44, 0.71)
South Africa 0.40 ( 0.24, 0.67)
Kenya 0.41 ( 0.24, 0.70)
Uganda 0.49 ( 0.28, 0.86)
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
Research – Non HIV BenefitsMale Circumcision provides:
– partial protection against GUD Bailey IAS 2007, PLoS Med 2009, 6:e1000187
– Partial protection against HPV Tobian et al, NEJM 2009, Auvert et al, JID 2009
– Protects against HSV-2 acquisition Sobngwi-Tambekou et al, JID 2009; Tobian et al, NEJM 2009
– Little protection against urethral infections
– Some evidence of a protection against vaginal infections (TV, BV, GUD) in women Gray et al, Am. J. Obstet. Gynecol 2009
• The effect of circumcision on HIV in men is largely independent of the impact on STI
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
Recent Research DataRecent Research Data
• Male to female transmission – Among HIV-1 serodiscordant couples in which the male was HIV +ve, there was no increased risk and potentially decreased risk from MC on male-to- female transmission of HIV-1 (HR 0.63, 95%CI 0.35 – 1.10) Baeten JM et al, AIDS. 2009. Dec [Epub ahead of print]
• Effects of MC on penile microbiota – MC associated with a significant decrease in anaerobic bacterial families.This may play a role in protection from HIV and other STIs (in males and females) Price et al, PLoS One. 2010. 5:e8422
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
The Global RecommendationsThe Global Recommendations
WHO/UNAIDS Technical Consultation Male WHO/UNAIDS Technical Consultation Male Circumcision and HIV Prevention: Research Circumcision and HIV Prevention: Research
Implications for Policy and Programming Montreux, Implications for Policy and Programming Montreux, 6- 8 March 2007 6- 8 March 2007
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
Global RecommendationsGlobal Recommendations
• Countries with high prevalence (>15%), generalized heterosexual HIV epidemics and low rates of MC should consider urgently scaling up access to MC services
• 13 countries identified: Botswana, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe
• Consider ethics, communication, culture, health systems, funding, gender, comprehensive prevention strategies
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
Impact of MC Scale-up
PLoS Medicine 2009 doi:10.1371/journal.pmed.1000109.g001
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
Cost and Impact of MC
Scaling up of MC to reach 80% of adult and newborn males in 14 African countries by 2015:
• Could prevent more than 4 million adult HIV infections over 15 years (2009 – 2025)
• Could result in cost savings of US$20.2 billion between 2009 – 2025 with an overall investment of approx *US$ 4 billion
• Would require almost 12 million MCs to be performed in the peak year, 2012
Source (* adapted): USAID/HPI (2009) The Potential Cost and Impact of Expanding Male
Circumcision in Eastern and Southern Africa
http://www.malecircumcision.org/research/policy_briefs.htm
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
Botswana MC Program Costs and Cost Savings (Estimates)
0
5
10
15
20
25
US$
(Mill
ion) Annual cost
Annual saving
0
50
100
150
200
250
300
350
US$
(Mill
ion)
Cum costCum Saving
Adapted from: USAID/HPI (2009) The Potential Cost and Impact of Expanding
Male Circumcision in Botswanahttp://www.malecircumcision.org/research/policy_briefs.htm
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
Almost Three years later……
What Progress has been What Progress has been made…???made…???
2007 2008 2009March March
Montreux MeetingMontreux MeetingWHO/UNAIDSWHO/UNAIDS
RecommendationsRecommendations20102010
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
Progress made on Male Circumcision to end 2009Progress made on Male Circumcision to end 2009Male circumcision prevalence at country level, 2006
ZambiaPolicy note, Strategy, national and regional trainings
BotswanaSituation analysis, strategy, communications, training, expanded service delivery, M&E
SwazilandPolicy, strategy and implementation plan, QA
KenyaPolicy, strategy, Training, QA, expanded service delivery, M&E
RwandaSituation analysis, pilot service delivery in military
UgandaSituation analysis, policy development
LesothoSituation analysis, policy development underway, draft strategy
South Africa, ZimbabweSituation analysis, draft policy, pilot sites
Tanzania, Mozambique, MalawiSituation analysis, pilot sites
NamibiaDraft policy, draft communications strategy, draft M&E
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
AdvocacyAdvocacy
• Advocacy for MC has been vibrant at global, regional and country level….
• Regional MC experts meetings in May 2007 to review recommendations, another meeting in April 2008 in response to Africa Ministers of Health request
• Country level advocacy through joint UN and partner Missions
• Multi stakeholder consultations in all countries with key stakeholder group consultation e.g. traditional leaders in Lesotho and Kenya; women's groups in Zimbabwe
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
Leadership and PartnershipsLeadership and Partnerships• Country Champions have provided leadership to
accelerate progress - Botswana: Ex- President Festus Mogae - Kenya: Prime Minister Raila Odinga with Luo Council of
elders
• National Task Forces in all countries
• Global level UN - WHO with UNAIDS, UNICEF, UNFPA
• Funding Agencies rapidly making funds available; PEPFAR, Gates, GFATM
• Partnerships to support scale-up: MC Partnership (PSI, Marie Stopes International, Jhpiego) MC Consortium (FHI, EngenderHealth, University of Illinois Chicago, Nyanza RHS)
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
Situation AnalysisSituation Analysis
• A situation analysis is to determine attitudes, beliefs, practices and socio cultural aspects of MC, policy and regulatory framework, health system readiness
• Comprehensive situation analyses completed in Botswana, Lesotho, Malawi, Namibia, Uganda, Zambia, Zimbabwe
• Rapid assessments in Swaziland (Key informants, Facility readiness), Rwanda (facility readiness)
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
PolicyPolicy
Notable flexibility in approach to policy development:
• Botswana no separate policy but strategy with policy elements
• Zambia sent Information note to Cabinet
• Kenya developed policy guidelines
• Dedicated policies developed in Lesotho, Namibia, South Africa, Swaziland, Uganda and Zimbabwe (drafts completed)
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
StrategyStrategy• Country strategies developed that include:– Objectives, target population, numbers of men to be
reached, costs, service delivery strategies, resource mobilization, monitoring and evaluation
• Decision Makers' Programme Planning Tool to estimate cost, impact, pace of scale up
• Most countries have 'catch-up' strategies to reach adult men – Botswana, Kenya, Swaziland, Zimbabwe, Zambia
• But longer term neonatal circumcision strategies also being considered in Botswana, Swaziland, Zambia
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
MC Strategy - KenyaMC Strategy - Kenya• MC integrated into National AIDS Strategic Plan III with goal to increase the proportion of men ages 15-49 years
who are circumcised in Kenya from 84 percent to 94 percent by 2013 – Aim that each region reaches coverage of 80% by 2013– Improving safety of MC nationally, including in traditional settings– Reduce risk compensation disinhibition
• MC targets translated into actual figures- 150,000 per year for 5 years - to 'catch-up'
• MC expected to contribute to the reduction of new infections by half by 2013 (KNASP III goal)
• Resources to provide MC to 750,000 men over 5 years approximately US$ 37-56 Million over 5 yrs
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
Progress in other Key ElementsProgress in other Key Elements
• Quality Assurance being implemented in Kenya, and Swaziland using WHO Guide and Toolkit
• Training programmes implemented in almost all countries
• Communication strategies under development in Kenya, Namibia, Swaziland – UN Toolkit under development
• M&E Indicators gradually being introduced into routine systems in Botswana, Kenya
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
Service Delivery Service Delivery
How many circumcisions have been done?
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
CountryCountry Botswana Kenya South Africa
Swaziland Zambia Zimbabwe
Begin date Apr 2009 Sept 2008
Jan 2008
Jan 2008 July 2009
May 2009
No. of MC's
4326 90 396 14 253 5122 16 801 3000
No. of MCs Nov – Dec
09
580 36 000 1547 1816 6171 1510
MC Service Delivery Update, Jan 2010
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
Kenya Rapid Results Initiative• Approx 36,000 MCs done in 30 working days in
11 districts– Number of teams varied on a daily basis from 88 at
start to 95 at end
– MCs per team varied on a daily basis – lower at start to higher at end
• Average MCs/team = 9.6
• Highest MCs/team = 22.8
• Approx cost per MC = $30 (versus $50+ outside of RRI)
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
Snapshot of Country Progress, Jan 2010
Botswana
Kenya
Lesotho
Malawi
Mozambique
Namibia
Rwanda
South Africa
Swaziland
Tanzania
Uganda
Zambia
Zimbabwe
National
Coordinator Task Force
Situation
Analysis Policy Training
Quality Service
Assurance Delivery M&E
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
Status of MC Scale-up in the US
• Consultation held in Atlanta – April 2007*– External partners, broad range of subject matter experts,
clinicians, academicians, and public health practitioners – Issues were around neonatal circumcision, other health
benefits, cost/equity, relevance to MSM*Smith DK, et al. Male circumcision in the United States for the
prevention of HIV infection and other adverse health outcomes: report from a CDC consultation. Public Health Reports 2010
• Draft currently in CDC clearance
• Simultaneous reviews (mid 2010)
• Final version to incorporate input and published as MMWR Recommendations & Reports
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
Challenges and ConstraintsChallenges and Constraints
• Human resource constraints for country programming at national level, staff already overloaded
• Gaining political support – it has been a process to get political buy-in in some countries, also delays due to elections, set backs with change of government
• Funding – countries not clear on what funds are available and how to access
• Traditional providers – almost all countries have them but no clear guidance on how to involve them
• Implications for women – how to monitor and evaluate for adverse societal effects
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
Challenges and ConstraintsChallenges and Constraints
Service delivery challenges:
• Human resource constraints - lack of personnel, staff mobility, staff burnout, task shifting not permitted in countries
• HIV testing – promoting the uptake of testing prior to MC
• HIV positive men – how service delivery sites can handle without stigma and discrimination
• Demand creation – matching services to demand
• Communication – communicating partial protection, risk compensation
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
Many Constraints but…..
'If you are building a house and 'If you are building a house and a nail breaks, do you stop a nail breaks, do you stop
building, building, or do you change the nail?'or do you change the nail?'
RwandaRwanda
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
Apply Lessons Learned to Scale-upApply Lessons Learned to Scale-up
Because Because
A stick is straightened while A stick is straightened while still young …. still young ….
UgandaUganda
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
Lessons LearnedLessons Learned
• Political commitment accelerates progress
• Country Champions make a difference
• Early engagement and consultation of key stakeholders prevents set backs
• Service delivery needs 'innovations' if scale-up is to be achieved e.g. task shifting/sharing, volunteers, devices, demand creation
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections
Lessons LearnedLessons Learned
• Development of tools and guidelines give direction to countries and help to focus technical support
• Subtle country peer pressure through experiences sharing helps to motivate countries to action
• Funding 'provides oil to the wheels' - PEPFAR, Gates, GFATM
• Leadership and coordination is critical
CROI 2010CROI 201017th Conference on Retroviruses and 17th Conference on Retroviruses and
Opportunistic InfectionsOpportunistic Infections