Jhpiego-supported male circumcision (MC) campaigns in three African countries have expanded access to this important HIV prevention intervention and strengthened health services for clients in a concerted effort to avert thousands of new infections.
Working in partnership with health providers from Zambia, Tanzania and Swaziland, the campaigns exceeded goals for numbers of procedures performed and set the standard for health care delivery as part of a comprehensive HIV prevention package. Clients who decided to participate in the MC campaign received HIV counseling and testing; those who tested HIV-positive or who were found to have other health problems were referred for further care and connected with related services. Jhpiego’s work in this area emphasizes a whole-system approach that develops policy and guidelines, helps supply facilities, provides counseling and surgical skills training and offers follow-up supervision.
At the end of a Jhpiego-supported MC campaign, health providers have what they need to carry out subsequent campaigns and provide high-quality services at local facilities.
The three campaigns have demonstrated that the public sector has a critical role to play in the rapid scale up of safe MC services as part of a comprehensive HIV prevention package. Previous MC campaigns have relied heavily on providers from non-governmental organizations, but during these three campaigns Jhpiego-trained nurses, clinical officers and doctors from Ministry of Health facilities played a key role.
In Tanzania and Zambia, they provided the vast majority of the circumcisions, and in Swaziland, public sector nurses were trained and mobilized to work with volunteer expatriate doctors.
These skilled providers will continue providing services during both campaign and post-campaign service delivery. Their new MC counseling and surgical skills will eventually be transferable to other health services, providing a lasting benefit to their countries once adult MC services have been fully scaled up. In addition, this work has encouraged providers at professional associations to discuss task shifting and sharing, which play an essential roles in addressing staff shortages.
Male circumcision, one of the world’s oldest medical procedures, is the removal of the foreskin of the penis. Scientific studies have shown that men who are circumcised are about 60 percent less likely to be infected with HIV during heterosexual sex than men who are uncircumcised.
The World Health Organization has recommended MC as part of a comprehensive package of HIV prevention services, which includes condom promotion, screening and treatment for sexually transmitted infections and HIV testing and counseling. Mathematical modeling suggests that scaling up male circumcision to 80% of men in East and Southern Africa would avert more than four million new HIV infections and save more than US $20 billion in HIV treatment costs.
The Zambia campaign was supported by the U.S. Centers for Disease Control and Prevention. The efforts in Tanzania and Swaziland were supported by the U.S. Government’s flagship Maternal and Child Health Integrated Program (MCHIP), which Jhpiego leads. Here are summaries of the successful implementation of these projects:
- In Zambia, 5,148 circumcisions were conducted at Jhpiego-supported sites, exceeding the team’s original target of 4,000 procedures. The majority of the circumcisions occurred at 10 sites that had been identified for intensive support. Preliminary testing data show a significant improvement in the numbers of men agreeing to be tested—about 80 percent, up from about 40 percent at these sites. The extent of the coverage is important because experts estimate that for every seven male circumcisions in Zambia, one new HIV infection will be averted by 2025. This means that the campaign in August will avert an estimated 735 new HIV infections in Zambia. The intensive campaign began in August with a community outreach effort to publicize the circumcision sites and the free cost of the service. Megaphone trucks circulated through towns and villages, encouraging young men to undergo circumcision and participate in counseling and testing. Condoms were also distributed to clients. Partners included Population Services International.
- In six weeks, an HIV prevention campaign in Tanzania performed 10,352 circumcisions in Iringa, a region with the highest HIV prevalence rate in the country (about 16 percent of adults are living with HIV) and lowest circumcision rate. The total number of circumcisions far exceeded original targets and could potentially avert more than 2,000 new HIV infections. In this region, it takes 4.5 circumcisions to avert one new infection. Ninety-nine percent of clients were counseled and tested for HIV and provided with key information about HIV prevention; clients were also screened for sexually transmitted infections and given condoms. Working in cooperation with regional health authorities and several other partners, Jhpiego trained 100 doctors, nurses and HIV counselors for the project, developed client education and counseling materials, and set up five, high-volume male circumcision sites in public health facilities.
- Capitalizing on a three-week school holiday in Swaziland, the government-led MC campaign launched in August resulted in 7,165 procedures at 13 sites. Six of the sites exceeded their weekly targets of MCs consistently over the three weeks. The back-to-school campaign is the start of a year-long effort to circumcise 80 percent of men and adolescent males, ages 15–49, in the African kingdom. In Swaziland, it takes four circumcisions to avert one new infection. The goal of the HIV prevention intervention is to reach more than 150,000 clients and avert more than 35,000 new HIV infections in Swaziland by 2025. Jhpiego supported the provision of skilled nurses and doctors for the Ministry of Health’s back-to-school campaign with partners Futures Group, Population Services International, Marie Stopes International and Family Life Association of Swaziland.