1. EngenderHealth’s Work on Male Circumcision
PEPFAR Male Circumcision Partner’s Meeting
19-20 May 2009
Paul Perchal, MA, Director, HIV/STI Program Mark Barone, DVM, MS, Senior Medical Associate

2. Overview of Presentation
Brief background on EngenderHealth.
Service delivery:
APHIA II Nyanza MC activities, Kenya
Men As Partners (MAP) MC activities in Tanzania and South Africa
Research:
Male Circumcision Consortium Project
Shang Ring Pilot Study

3. EngenderHealth… U.S.-based international non-profit.
Partners with governments, institutions, communities, and health care professionals to improve the quality of health care in the world’s poorest communities.
Long history of introducing new clinical contraceptives and other reproductive health technologies in impoverished communities with limited resources.
Currently has programs in more than 25 countries (MC work in Kenya, Tanzania, and South Africa).
has a long history of introducing new clinical contraceptives and other reproductive health technologies in resource poor settings including, for example, female sterilization using minilaparotomy under local anesthesia, no-scalpel vasectomy, Norplant®, and manual vacuum aspiration for treatment of abortion complications
As you will see during the presentation, our work in MC includes all of the following:
Service delivery
Policy development
Communication
Research

4. MC Funding Private USAID FY 07-08 800,000 500,000

5. APHIA II Nyanza MC Activities
USAID-funded project in western Kenya.
Supports MOH, private, & faith-based facilities in introducing MC for HIV prevention at 30 sites in 4 districts.
Working at all levels of the health system.
Working at all levels of the health system: district, sub-district & mission hospitals, health centers, dispensaries
Map shows Nyanza in the corner of Kenya, on the shores of Lake Victoria and bordering Tanzania below and Uganda to the left
Integrated approach to service delivery.

6. Supply-Demand-Advocacy Model
Assess and upgrade sites.
Provide start-up equipment and supplies.
Provide training on MC
Facilitate task shifting to non-physician clinicians.
Establish MC outreach services on pre-scheduled days.
Demand:
Conduct district stakeholders meetings to raise awareness.
Integrate MC messages in full range of BCC and community mobilization activities.
Advocacy:
Conduct orientations on MC for provincial and district officials.
Advocacy work with community leaders.
Provide technical support for provincial and district officials regarding MC guidelines.

7. Findings from Site Assessments – Equipment/Supplies
Lockable cabinet 45%
Autoclave 71%
Other sterilization 26%
Examination lamp 37%
Examination couch 92%
Surgical supplies 53%
Surgical instruments 39%
Dry heat or chemical sterilization.
Since the assessment APHIA-II has ensured all the sites have the necessary equipment and supplies to perform MC safely.
Supplying instrument kits can ensure services are available and of good quality:Needed instruments are available (specific instruments and adequate numbers). Instruments are of good quality.
MC kits are currently supplied to facilities under APHIA II Nyanza: These kits differ some from the recommendations in the WHO MC manual.

8. APHIA II Nyanza MC Service Statistics October 2008-April 2009

9. Tanzania and South Africa
Developed and field tested a needs assessment tool in Mwanza, Tanzania, in 2007.
Our CHAMPION Project in Tanzania is currently conducting a national survey to help assess men’s attitudes, beliefs, and practices regarding HIV prevention and gender, including MC.
Incorporates MC messages in Men as Partners (MAP) activities for PEPFAR supported HIV prevention services.
One other area of our work that I would like to mention because of the great opportunity for synergy with MC activities is our work with men in what we call our Men as Partners program (MAP).
Enhancing men’s awareness and support for their partners’ sexual & reproductive health choices
Increasing men’s access to health services
Mobilizing men to take an active stand for gender equity and against gender-based violence
In general men tend not to come to preventive health services….and so we need to capitalize on opportunities to work with men when they do arise. MC will provide a platform for more comprehensive health services and education for men. MAP approaches and lessons learned could be very useful as we explore ways to engage men when they come for circumcision.
Perhaps there might be an opportunity to start a Woman As Partners Program…women will play a role at least in some settings in encouraging or discouraging their partners from getting circumcised and certainly will play a role when we eventually begin to implement programs for infant circumcision.

10. Challenges in MC Service Delivery
Limitations of task shifting vs. full time dedicated MC staff.
A number of health providers lack motivation.
Initially low uptake of HIV testing at time of MC.
Unreliable supply of consumables.
Lack of specific instruments needed, instruments of poor quality or insufficient numbers for high volume.
Lack of support from some traditional leaders in non-circumcising communities.
Some health providers lack motivation:
Believe services are donor driven/special program.
Providers expect to be compensated.

11. Male Circumcision Consortium Project
EngenderHealth is responsible for leading the following 3 research studies:
Assessing the human resource capacity and training needs to support MC roll-out.
Assessing the safety, efficacy, and cost of non-physician clinicians providing MC services.
Assessing the safety, efficacy, and cost of MC outreach services.
Objective 1: To support the GOK and local stakeholders in implementing a national MC strategy.
Objective 4: To generate evidence to inform the rollout and scale-up of MC services.

12. The Shang Ring for MC Developed & commercially available in China.
A published study and other data suggest good safety profile.
Benefits of the Shang Ring:
Simple design; easy to use, learn & teach
Short procedure time ( 3-10 minutes)
Minimal bleeding
Tight seal along wound
Sutureless closure; excellent cosmetic results
Design decreases risk of serious surgical errors

13. The Shang Ring MC Device

14. Shang Ring Pilot Study
We will examine clinical outcomes and patient satisfaction in a small sample of Kenyan men in order to assess:
Safety
Efficacy (in terms of successful circumcision)
Acceptability/satisfaction
The pilot will also lay the groundwork for a larger RCT.
Prospective, non-comparative study at one health facility.
40-50 men seeking MC will be enrolled, undergo MC with the Shang Ring and be followed for 6 weeks.