Voluntary Medical Male Circumcision Technical Considerations

1. Voluntary Medical Male Circumcision Technical Considerations Emmanuel Njeuhmeli, MD, MPH, MBA Senior Biomedical Prevention Advisor Co-Chair PEPFAR Male Circumcision Technical Working Group Office of HIV/AIDS / US Agency for International Development

2. Introduction • To reduce HIV incidence, MC should be provided to as many HIV-negative men who wish to have the surgery as quickly and safely as possible. • To achieve scale, the services could be provided as self-contained (in a tent or other temporary structure), time-limited, fully equipped, independently staffed, and fairly mobile.

3. Two Pronged Implementation Approach Prong 1: Adolescent/Adult male circumcision Programs should prioritize implementation of adult male circumcision with the goal of achieving saturation as quickly as possible given the country context. This first prong of our approach is a one-time intervention that don’t need to be sustain. Prong 2: Neonate circumcision The second prong is the implementation of neonate circumcision programs to be completely integrated and sustained within maternal and child health system. For boys >2 months of age: postpone MC until adolescence No use of MC under general anesthesia with PEPFAR funding

4. Minimum package of service • Interventions for male circumcision should be part of a package of prevention services which include • Pre-operative provider-initiated HIV testing and counseling provided on site or at community level; • Active exclusion of symptomatic STIs and syndromic treatment when indicated; • Provision and promotion of correct and consistent use of condoms; • Post-operative wound care and abstinence instructions; • Age-appropriate counseling on risk reduction, including reducing number and concurrency of sexual partners, delaying/abstaining from sex, • Active linkage to other HIV prevention, treatment, care and support services as needed

5. Voluntary (lack of coercion)Medical Male Circumcision (1) • To ensure voluntarism and informed consent, programs should • not only provide appropriate informed consent for clients, • but should also develop systems to monitor its delivery to guarantee client comprehension and to avoid practices perceived to be coercive. • Special consideration for adolescents and neonates • Depending on the need for overcoming barriers for VMMC uptake, countries may consider offering reimbursement for travel for clients. Reimbursement or compensation for wages that may be lost during surgical recovery should be used cautiously, to avoid the appearance of coercion. • Other enablers should be adapted for the specific geographic and population context and must be monitored closely to avoid inappropriate or unethical practices.

6. Voluntary (lack of coercion)Medical Male Circumcision (2) • Clinicians who work overtime to provide VMMC services should be compensated for their time at a scale consistent with national standards. Furthermore, clinicians should not be compensated on a per-procedure basis, to avoid actual or perceived motivation for clinicians to coerce clients to undergo the procedure. • Peer mobilizers may be effective in increasing demand for VMMC. Programs that use peer mobilizers must develop systems to monitor their activities to assure the recruited clients are well-informed about VMMC and have not been pressured to attend the program. The TWG is currently developing monitoring tools to address this

7. Linkage to care and treatment program (1) • VMMC programs provide a rare opportunity to reach men in the healthcare setting who might not otherwise be accessible. • Hence, VMMC must capitalize on the opportunity and work hard to incorporate HIV testing and counseling into VMMC service. Strong linkages with HIV testing and counseling programs (HTC) are critical.

8. Linkage to care and treatment program (2) • In areas where VMMC is being scaled up, VMMC should be recommended to all HIV negative males who receive HIV testing and counseling services in any HTC setting, especially HTC services for men at high risk of HIV acquisition from heterosexual sex (STI clinic clients). • This should also be a key component of prevention packages for HIV negative men, and particular priority should be given to discordant couples where the man is HIV-negative. • Moreover, adolescents (<16 years of age) should be offered HTC and programs should ensure counseling messages are age-appropriat

9. Linkage to care and treatment program (3) • Implementers should adhere to WHO guidance on provider initiated HIV testing and counseling (PITC), including the minimum standards of pre-test information, informed consent, post-test counseling based on sero-status, maintaining confidentiality and use of point of care rapid HIV testing algorithms, as appropriate. • Quality assurance systems for both HIV testing and HIV counseling components should be in place for ensuring high quality HTC services in these settings.

10. Linkage to care and treatment program (4) • All male circumcision services should include linkages to HIV care and treatment for clients seeking male circumcision services and found to be HIV-infected. • It is important to ensure comprehensive post-test counseling, including the information that currently circumcision for HIV-positive men is not recommended due to potential increased complication rates following the surgical procedure for men with immunodeficiency. • Circumcision for HIV-positive men should only be encouraged when medically indicated. • Inclusion of male circumcision in prevention packages for discordant couples where the man is HIV-negative should be prioritized.

11. Linkage to care and treatment program (5) • All VMMC services should prioritize active linkages to HIV care and treatment services for clients seeking male circumcision services and/or their female partners who are found to be HIV-infected. • ART, when taken as prescribed, has significant care and prevention benefits. • ART can significantly inhibit HIV viral load and replication, reduce the morbidity and mortality experienced by PLHIV, and reduce the risk of HIV transmission to sex partners. • This may require that sites develop and implement novel mechanisms to facilitate and confirm successful linkage to care (e.g., escorting clients from the MC center to the ART center, or enabling staff to register clients for ART at the MC center). • MC represents a rare and valuable opportunity to provide HTC to men and link them to care.

12. Strategic target to achieve impact • Working in conjunction with partner country governments, PEPFAR programs should help establish annual national and PEPFAR-funded adult VMMC coverage targets that are sizable enough to appreciably reduce HIV incidence quickly. • Any gaps between PEPFAR-funded and national VMMC targets should be addressed. Annual targets should be framed in the broader context of the country’s overall VMMC scale-up strategy.

13. Calibrating Supply with Demand (1) • VMMC program effectiveness is achieved by calibrating • demand (number of men seeking services) • with supply (capacity of the system to deliver MC services) • while targeting older adolescent and adult males. • The lack of familiarity with MC among many high-risk, high HIV prevalence communities and general misinformation about the surgical procedure are major challenges to program implementation and success. • Moreover, the sensitivity of HIV/AIDS as a topic and the personal nature of the surgery require that MC policymakers and program implementers address communities’ beliefs, preferences and needs when implementing MC communication campaigns.

14. Calibrating Supply with Demand (2) • To facilitate successful implementation, programs should develop and implement public information campaigns that clearly and simply describe the risks and benefits of MC and place it into the larger HIV prevention context. • Further, addressing firmly held cultural beliefs and gender issues, and avoiding unintended consequences, such as greater risk taking by circumcised men and their partners, is required. • Countries should have appropriate strategies, channels, techniques, and tools for mobilizing demand and addressing the myriad of challenges with VMMC communications.

15. Advocacy • Programs should design an MC advocacy strategy and define advocacy issues based on country context and evidence. • Countries need to define and prioritize target audiences (supporters and detractors) for MC advocacy and understand the different concerns and needs of each audience, while being cognizant of any underlying or unspoken issues. • Finally countries should address emerging concerns and manage expectations for all target audiences for MC, which is a continuous and iterative process.

16. Gender Considerations • Male circumcision services should include gender components that addresses male norms and behaviors, promotes safer sexual behaviors including denouncing sexual violence against women, and activities to monitor for increased gender-based violence/coercive sex experienced by women. • Opportunities should be explored for ensuring effective counseling for MC clients so that their behavior does not put women at greater risk for HIV infection or gender-based violence, and for integrating or linking other male health services and programs that promote gender equitable norms with MC services. • Both men and women need to be beneficiaries of campaigns and education programs to explain and emphasize partial protectiveness of MC and the indirect benefit to women

17. Commodities Management • Adequate commodities management systems for surgical procedures, STI drugs, and integrated HIV testing need to be identified prior to initiating services are refined throughout scale-up. • Standard list of commodities • These considerations must include resources and technical expertise in waste management and supply chain management

18. Capacity Building (1) • Programs should address appropriate and adequate training for professionals in providing surgical services and mechanisms for assuring initial and continued competency. • Health care providers committed/designated to providing a higher volume of services should be prioritized. • Any surgical training for male circumcision should follow surgical procedures based on the WHO/UNAIDS/JHPIEGO Technical Manual for Male Circumcision under Local Anesthesia.

19. Capacity Building (2) • PEPFAR funds • may not be used to support VMMC provided under general anesthesia, • and young males (between 61 days old to approximately 14 years of age) that may not have the maturity to assent or cooperate with VMMC under local anesthesia should be deferred until at least 15 years of age. • Only surgical methods and/or devices recommended by WHO should be used in service delivery programs • WHO/UNAIDS/JHPIEGO. Manuel for Male Circumcision under Local Anesthesia. January 2008. http://www.who.int/hiv/pub/malecircumcision/local_anaesthesia/en/index.html • For efficiency, forceps guided surgical technique can be promoted

20. Traditional Circumcision • At this time, due to high rates of surgical complications in non-clinical settings, US Government funds cannot be used to train or provide support for traditional providers to perform male circumcision. • However, funding can be used to support prevention information, education and evaluations of complications stemming from non-medical circumcision within this context

21. Quality Assurance • Mechanisms for quality assurance, quality standards and quality of care within the program, including plans for surgical complication management, must be in place. • Countries are encouraged • to follow the WHO Quality Assurance Guidance and Tools for facility self-assessment • and to engage with the Male Circumcision Technical Working Group to schedule and participate in routine External Quality Assurance assessments

22. Monitoring & Evaluation (1) • Programs supporting VMMC must include requirements for monitoring systems and reporting of VMMC indicators to allow for progress towards established targets can be tracked. • Monitoring of VMMC includes the following: collection of service delivery data for frequent, timely dissemination, use MOH (or other) standardized forms/tools for service data collection, training of staff on use of the forms, and a description of how findings are shared with considered by implementation stakeholders

23. Monitoring & Evaluation (2) • Programs should monitor communication activities (e.g., program implementation) to ensure efficiency. • The following are activities to monitor communication: • tracking the number of VMMC communication materials produced and diffused (e.g., communication guides and materials for community mobilizers), • identify salient issues as new activities and products are planned, • differentiate paid advertising from unpaid coverage, • and explore the development of a media intensity index (i.e., a means of quantifying the volume of materials produced and disseminated)

24. Additional resources can also be found at: www.malecircumcision.org.

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