Scaling-up male circumcision programmes in the Eastern and Southern Africa Region Country update meeting HIV Testing and Counseling and Male Circumcision Experiences from Zimbabwe Karin Hatzold, MD, MPH Director HIV Services PSI Zimbabwe

Issues HTC/MC Low uptake of HTC in several MC country programs Risk of increased HIV transmission if large numbers of HIV + become circumcised and would not practice safer sex? T&C as “precondition” for MC might prevent uptake because of fear of positive status Stigmatization of HIV + men, who will not benefit from the intervention? HIV + men might seek MC services outside clinical settings? Integration and linkages between HTC and MC Services Re-testing for HIV at MC site of previously tested individuals

T&C uptake among MC clients in selected countries MC Country program Number of MCs conducted Proportion of MC clients tested for HIV prior to intervention Proportion circumcised HIV + status Proportion of tested, who tested at the MC site Botswana 6100 89% 100% Kenya 120, 000 56% 3% 70% Namibia 350 94% 98% Swaziland 9309 88% 2 % Tanzania 4702 99% 0.8% Zambia 29, 500 62% overall, 80% in ≥16 4% Zimbabwe 6070 0.5% 28%

Results from Zimbabwe

PITC and VCT in Zimbabwe 40% of the adult population in Zimbabwe knows their HIV status* Large network of VCT services centers and outreach teams since 1999 PITC implemented since 2007, over 800 health care facilities are providing T&C High level of awareness about HTC through Mass Media and IPC communications 1 Million Zimbabweans tested per year, 35% through VCT, 65% through PITC *Preliminary results from population based survey of 18-44 year old males and females conducted in six districts in Masvingo and Mashonaland East.

T&C as entry point for MC New Start nationwide network of T&C centers and outreach teams Tested 1.9 Million Zimbabweans, 40, 000 monthly, 50% are men, 75% test HIV negative MC counseling integrated in post-test counseling session to recruit HIV negative men for MC at 5 pilot sites High uptake of MC services when offered as additional HIV prevention intervention in counseling session Booking for MC at the T&C site and referral Communication between T&C and MC sites Follow up with booked clients

Routine Offer of HIV testing Quality of counseling process Group education session Individual counseling session Counseling guides, flipcharts Quality of counselor Use of nurses & other professionals Intensive Training and Refresher Courses Ongoing Supervision

MC service client flow VISIT 4 VISIT 1 VISIT 2 6-wk Review & Counseling One-on-one MC/ HTC Counseling 2-day Review & Counseling Reception MC Procedure VISIT 3 Group education Routine offer Testing Post-op Recovery/ Counseling Pre-op Assessment/ Counseling 7-day Review & Counseling This chart represents the client service flow through our MC program in Zambia. As you can see there are multiple opportunities for clients to discuss MC and other sexual health issues. 8 8

MC Communication messages Clear messaging on benefits of MC as additional HIV prevention intervention for HIV negative men, “primary” prevention T&C not mandatory, but recommended

MC and HIV + men In-depth counseling on known risks and benefits of MC with HIV positive status If client insists on MC, clinical staging and CD4 cell count to check medical condition Discussing care and treatment options with HIV positives Prevention and treatment of opportunistic infections ART Positive Living strategies MC might not be indicated or the best option Provision of on-site CD4 cell count using point of care devices Adequate referral into continuum of care

Acknowledgements MC programs in Botswana, Kenya, Namibia Swaziland, Tanzania, Zambia AIDS and TB unit MOHCW Zimbabwe PSI New Start network Clients accessing T&C and MC services in Zimbabwe

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