Voluntary Medical Male Circumcision as a Platform for Adolescent Sexual and ReproductiveV Health Interventions 7 th December 2011 Kawango Agot, PhD, MPH Impact Research & Development Organization, Kenya

HIV among Youth/Adolescents Youth (ages years) represent a substantial proportion of new HIV/AIDS cases globally 1 o HIV prevalence is 3.4% among young females and 1.4% among males 2 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 Circumci sed % of Total Circumcised Cumulative Total Circumcised Total Tested for HIV % HTC Uptake 1 – 109,5447% 7%7% 1,92720% 11 – 1424,40817% 24 % 7,26030% 15 – 1960,18642% 66 % 37,61763% 20 – 2426,98019% 85 % 17,63965% 25+21,96515% 100 % 13,05159% Total143, % 77,49454% * 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 Tz: Group education prior to VMMC; an opportunity for SRH intervention Kenya: Preparing for group education ahead of mobile 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 '