HIV/AIDS Program Spotlight
Innovations in HIV prevention: Jhpiego's work in male circumcision in Zambia
Male circumcision (MC) is fast emerging as a critical component in efforts to
reduce the spread of HIV in Sub-Saharan Africa. Findings from several studies have suggested
that MC substantially reduces the risk of HIV acquisition and transmission.
In a recent study
conducted in South Africa, for example, circumcised men were found to be 61% less likely to
acquire HIV than their uncircumcised counterparts.1 Models based on this evidence show that
increasing MC rates could have a substantial impact on reducing HIV incidence and prevalence
over time.2 There is also evidence from a study done in Uganda that MC may reduce the
likelihood of male-to-female transmission of HIV.3 Two additional trials are under way
in Kenya and Uganda, and are expected to provide more evidence on the protective effect
of MC in mid-2007.
In the meantime, as the evidence mounts, demand for MC services appears
to be rising in countries like Zambia, where overall prevalence of HIV is 16% and less
than 20% of men are circumcised.
"Clients used to say that they wanted to be circumcised
for better hygiene and sometimes for protection from sexually transmitted infections,
but these days more clients are saying they have heard it can help protect them from
HIV," says Dr. Kasonde Bowa, Consultant Urologist and head of the male reproductive
health/male circumcision (RH/MC) service site at Lusaka’s University Teaching Hospital
(UTH).
"Along with this increasing awareness of the relationship between lack of male
circumcision and HIV," says Mr. Rick Hughes, Country Director for Jhpiego in Zambia,
"there is a slow, but steadily growing, demand for the service."
Despite this demand,
the availability of safe, clinical MC services is limited, resulting in an "unmet need"
for the procedure among Zambian men. To help address this unmet need, Jhpiego—in partnership with the U.S.
Agency for International Development (USAID) and AIDSMark (Population Services
International)—implemented a pilot project from 2003 to 2005 to improve the quality
and accessibility of comprehensive MC and male RH services in Zambia.
In the initial
assessment, several potential barriers to addressing the unmet need for MC were
identified. These ranged from lack of standardization of the MC procedure among
providers performing it, to reluctance on the part of already-burdened facilities
to expend scarce resources (physicians, operating rooms, supplies) on a procedure
deemed "elective," to client concerns and misinformation about MC.
Jhpiego conducted a wide range of activities aimed at overcoming
such barriers, including:
- A stakeholders' meeting with public, private and
traditional practitioners;
- Creation of a technical working group dedicated to MC;
- Site assessments and site-strengthening activities
at three sites in Lusaka;
- Development and standardization of training and
patient education materials;
- Implementation of services at the three Lusaka sites,
which involved training and supervising staff while providing support for
essential commodities, with periodic incentives for providers to deliver
services during their time-off; and
- A male RH/MC training course for 18 health care
providers from seven provinces.
Through experiences gained over the life of this project, Jhpiego
has learned that provision of high-quality MC services requires:
- Competency-based
training of providers
to ensure that the MC procedure is performed "to standard," incorporating the
appropriate infection prevention and pain management practices
- A comprehensive package of male RH services
(of which MC is only part), including:
- Informed consent based on client education about the MC
procedure, including possible complications
- Client counseling about: the limitations of MC as an HIV
risk-reduction measure (i.e., MC reduces but does not eliminate HIV risk), and the
ongoing need to use other methods of protection; HIV testing and prevention;
postoperative instructions (e.g., danger signs, routine follow-up); and other
reproductive health topics—as well as links or referrals to other
services, as needed
- Client follow-up to ensure normal healing and assess
for complications
- Availability of surgical equipment,
consumable supplies (e.g., sutures, bandages) and clinic space dedicated
to client counseling, the MC procedure and postoperative recovery
Another lesson learned through this project is that adopting a
standardized technique for MC that is safe, simple and low-tech enables non-physicians
(e.g., clinical officers and nurses) to be trained in and perform the procedure
competently in an outpatient setting. This helps bypass the obstacle presented
by limited availability of physicians and operating rooms, thereby addressing
unmet need for MC more efficiently.
Current Programs and Activities
Since the end of this pilot project in 2005, Jhpiego has continued
its work in the field of MC. Jhpiego has helped facilitate continued capacity-building
and advocacy by Zambian clinicians trained through the UTH pilot project, both in
training providers in neighboring countries in MC and in participating in various
domestic and international fora on the topic.
Using the training package produced
for the Zambia project as the starting point, Jhpiego is currently working with
the World Health Organization (WHO) to develop a global reference manual—Male
Circumcision under Local Anesthesia. Recently, WHO requested assistance from
Jhpiego in producing the accompanying training materials.
Jhpiego is providing ongoing technical assistance to the male RH/MC
service site at UTH, while building support for a newly established RH/MC service
site at Livingstone General Hospital. Jhpiego is also continuing its collaboration
with several local partners to identify opportunities to expand MC efforts, and
investigate innovative approaches and solutions for scale-up of MC services.
"By making high-quality, comprehensive MC services safe and accessible, we are
providing a valuable service to this population,” says Hughes. “And improving
the ability of health care facilities to meet existing demand for MC helps lay the
groundwork for further scale-up to meet increased demand, which will likely occur
if results of the Kenya and Uganda studies substantiate those of previous studies.”
FOOTNOTES:
1 Auvert B et al. 2005. Randomized, controlled intervention trial of male circumcision
for reduction of HIV infection risk: The ANRS trial. PLoS Med 2(11): e298.
2 Williams B et al. 2006. The potential impact of male circumcision on HIV in Sub-Saharan
Africa. PLoS Med 3(7): e262.
3 Gray RH et al. 2000. Male circumcision and HIV acquisition and transmission: Cohort
studies in Rakai, Uganda. Rakai project team. AIDS. 14(15): 2371-2381.
More Information
For more information about Jhpiego's MC activities in Zambia,
please contact the Jhpiego/Zambia Office.
To read other spotlights, go to Program Spotlights.
For additional resources on male circumcision and HIV/AIDS, browse our
Information Sheets and/or
go to the HIV/AIDS section of our Publications Catalog.
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