Male Circumcision for HIV Prevention in Kenya: Service Delivery beyond Nyanza Dr Peter Cherutich, MD, MPH Deputy Director National AIDS/STD Control Programme (NASCOP) Male Circumcision Meeting, Arusha 2010

2007 KAIS: Male circumcision and HIV National HIV Prevalence: 7.1% National MC Prevalence: 85 % With the evidence that has accumulated over several years, Nyanza province still has a low coverage of voluntary medical male circumcision. Province with the highest HIV prevalence (Nyanza) has the lowest MC level Province with the second highest HIV prevalence (Nairobi) has second lowest MC level

The VMMC Journey….. Sept 06 Nov 06 Dec 06 Feb 07 Mar 07 May 07 Aug 07 Kisumu trial stopped, DMS gives press statement 1st Kenya HIV Prevention Summit, Kisumu results shared 1st Kenya MC stakeholder meeting DMS approves Policy on Male Circumcision Sept 06 Nov 06 Dec 06 Feb 07 Mar 07 May 07 Aug 07 Sept 07 MC Taskforce recommends to DMS Policy on Male Circumcision ESA Africa Consultation Meeting on MC in Nairobi Kisumu results published in the Lancet 2007; 396:643–656. WHO/UNAIDS endorse MC at Montreux Dr. Mores & the MCC team

… The VMMC Journey Jan 08 Mar 08 April 08 Jul 08 Sept 08 Oct 08 Nov 08 MC RRI in 11 districts Over 35,000 men circumcised in 30 days Policy for MC in Kenya published Task force reconvenes on 30th January Consultation meeting with LCE in Oyugis Letter from LCE to DMS 2nd Kenya Prevention Summit 2nd Stakeholder meeting in Nyanza Announcement by GOK of National MC Programme Jan 08 Mar 08 April 08 Jul 08 Sept 08 Oct 08 Nov 08 Jun 09 Nov 09 Ministry allows nurses to perform MC Nyanza health facility assessment completed Mbagathi: working meeting for subcommittees Creation of Nyanza Provincial MC Taskforce 1st Stakeholder meeting in Nyanza

VMMC policies and Guidelines MC policy guidance Clinical Manual for MC under LA MC 5 year strategy in line with KNASP III MC communication strategy MC M&E tools 5 5

MC Scale up – Need Nyanza 1,239,040 640,584 480,438 Rift-Valley Province Est. Adult pop. (15-49) Est. Adult Uncircumcised 15-49 Est. demand based on 75% acceptability Nyanza 1,239,040 640,584 480,438 Rift-Valley 1,972,960 238,728 179,046 Nairobi 887,920 161,601 121,201 Western 880,000 106,480 79,860 Coast 667,920 18,702 14,026 Eastern 1,214,400 44,933 33,700 Central 1,020,800 46,957 35,218 North-Eastern 317,680 9,213 6,910 Total 8,200,720 1,267,187 950,398 Looking at all provinces, the over 1.2 M males (15-49) year olds is an under estimate. If we included 10-14 year old, this # is much higher, requiring more funds. On average, we will need 200,000MCs per year to undertake these, and assuming average cost of $70/MC, we may be talking of close to $15M/year on average. 6

MC TARGETS BY REGION AND TIMELINE (TO REACH 80% AMONG CURRENTLY NON-CIRCUMCISED AND 94% NATIONALLY) 7

Nairobi Metropolitan Cosmopolitan-high demand for VMMC Facility assessments done Engagement of various stakeholders Technical Political More partnerships are being established

Western Province Pockets of non-circumcising communities bordering Uganda-Teso and Samia GoK through support from World Bank Plan to offer 5000 MCs by end 2010 Preparatory activities and training ongoing Service delivery to start July 2010

Rift-Valley Province Around Lake Turkana and diaspora of non-circumcising communities Very encouraging support from political, religious and government officials Plans underway for a dedicated partners to start routine service delivery Various partners are already working among circumcising communities e.g Walter Reed

MC Achievements versus Targets in VMMC strategy   Targets 2009-10 Achievement* Nyanza 76,500 90,000 Rift Valley 28,500 400 Nairobi 19,500 900 Western 12,000 Nil Others 13,500 Nil  Total 150,000 91,300 (60.8%) The MC strategic plan and KNASP III highlights annual targets for the nest 5 years. This recognizes high initial start up costs, even though fewer targets will be achieved. Hoping that optimal performance of over 200,000 MCs will be done through out Kenya by the 3rd year. Cumulatively 120,000 MCs have been done 11

Quality assurance 2 EQA visits-April and November 2009 National government led Quality Improvement Team established Local Training done, domestication in process QI teams in 3 districts

Key Challenges Coordination and mobilization of partners Rationalization of partners, no new partners Targeting resources to those in greatest need Potential replacement of out-of-pocket MCs service Matching supply and demand Ensuring efficiency is the guiding principle Vertical versus integrated approach Reaching older men!

Opportunities World Cup 2010 Revitalization of male reproductive health Community health strategy Improves access Synergies with other programmes e.g HIV testing and counselling Sustained political and technical leadership MC now widely accepted across communities

Ahsante! 15

Acknowledgements VMMC Taskforce Male Circumcision Consortium USG FHI NRHS Engender Health USG Gates Foundation UN family