Karin Hatzold is senior director of HIV Services at Population Services International in Zimbabwe
In 2011 – thirty years into the HIV epidemic – a key challenge facing the global health community is how to scale up HIV prevention and treatment in resource-limited areas with high HIV prevalence, such as sub-Saharan Africa.
Three randomised control trials conducted in this region have provided evidence that male circumcision significantly reduces female-to-male transmission of HIV by up to 60 percent, while simultaneously reducing the risk for syphilis, chancroid and human papillomavirus (HPV) infection which is a risk factor for penile and cervical cancer.
WHO and UNAIDS recommend voluntary medical male circumcision (VMMC) as an effective and cost-efficient intervention to reduce HIV incidence in 14 priority countries in southern and eastern Africa with low prevalence of male circumcision and high prevalence of HIV.
A number of these countries are stepping up to the challenge.
With support from donors including the U.S. PEPFAR program, the Bill and Melinda Gates Foundation, the UK Department for International Development (DFID) and the Global Fund for AIDS, TB and Malaria, several countries have rolled out campaigns during the last five years to increase awareness and uptake of VMMC services among adult men and adolescents aged 15–49 years.
Population Services International (PSI) and its partners currently assist governments in seven of these countries—Botswana, Kenya, Mozambique, South Africa, Swaziland, Zambia and Zimbabwe—to increase VMMC demand and uptake and to provide technical support for service delivery.
Since 2007, PSI-supported programmes have provided VMMC services to over 135,000 men and adolescent boys– 22 percent of the approximately 609,000 males circumcised in the region to date.
A STEP FORWARD IN HIV PREVENTION
During the first half of 2011 alone, PSI and its respective national partners have already provided more than 37,000 VMMCs. As a result, these countries are demonstrating that quality, scale and speed are not mutually exclusive goals in HIV prevention.
The bedrock of success behind these efforts has been a sustained commitment to communication and efficiency. In southern and eastern Africa, PSI and its local partners schedule VMMC campaigns around school holidays to enhance participation, particularly among adolescents.
Prior to the launch, campaign organisers leverage media and interpersonal communication to increase VMMC awareness and demand among households, schools and communities.
For example, during the April-May 2011 campaign in Zimbabwe, organisers collaborated with popular reggae star Winky D, who wrote songs to engage young people.
Simultaneously, PSI/Zimbabwe and its local communications partners started a dialogue with traditional, religious and community leaders, including school head masters and teachers, to strengthen understanding of the health benefits of VMMC and increase community support. As a result, the campaign received overwhelming demand for and uptake of services.
To improve efficiency of VMMC service delivery – vital for an intervention that is most effective when coverage extends to 80 percent or more of the male population – PSI and its partners use MOVE (Models of Optimizing Volume and Efficiency) – a framework based on task sharing and/or task shifting and surgical efficiency models.
With task sharing, surgeons perform only the most complex steps in the male circumcision surgical procedure, leaving the other steps to nurses and clinical staff.
In task shifting, non-physician cadres of medical providers, such as nurses and clinical officers, are trained to perform the surgical procedure. Under MOVE, teams use simple surgical techniques, pre-packed supplies and disposable instruments to perform the procedure. Moreover, VMMC is treated as a bedside procedure, allowing more than one surgical bay per surgeon.
The results of MOVE implementation have been dramatic. During the 2011 Zimbabwe campaign alone, MOVE helped PSI and its partners provide more than 7,000 VMMCs within less than thirty days, serving between 250 to 350 clients per day. PSI and its partners have used similar approaches to conduct successful VMMC campaigns in Swaziland and Zambia.
As more countries apply the MOVE framework to scale up VMMC services, the potential for delivery output is significant.