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Pioneering HIV Prevention Strate

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					MSI Innovations
 Pioneering HIV prevention strategies in rural Kenya:
 a case study of Marie Stopes International’s male
 circumcision outreach project




July 2009                                                                     by Erica Nelson and Heidi Quinn




  SuMMARy                                                                      Introduction
  The HIV epidemic continues to grow, in spite of global efforts to
  prevent the disease. Millions of people die each year of preventable         Comprehensive and targeted HIV
  HIV infections. It is projected that 60 million new HIV infections will      prevention is key to slowing or
  occur by 2015, if current rates are not reversed.1                           reversing the global HIV epidemic.
                                                                               In December 2006, the results from
  In 2006, new research confirmed for the first time that male circumcision    three separate studies confirmed
  could reduce the risk of HIV infection for heterosexual men by up to         male circumcision (MC) as, “the first
  60%.2-4 Marie Stopes International (MSI) responded quickly to these          new biomedical HIV-prevention
  significant findings by pioneering a new outreach model for male             strategy in over a decade”.5 The
  circumcision (MC) provision in Western Kenya and the Nyanza Province,        potential impact on preventing
  a region with the lowest MC rates and the highest HIV infection rates        the spread of HIV by expanding the
  in the country. MSI was the one of the first organisations to deliver        provision of male circumcision is
  this critical HIV prevention service directly to Kenyans living in remote    substantial. Mathematical modelling
  and rural areas. Responding to evidence that MC could potentially            has shown that, if all sexually
  avert up to three million deaths in 20 years if all sexually active men      active men were circumcised in
  in sub-Saharan Africa were circumcised, MSI now plans to bring this          sub-Saharan Africa, a region with
  innovative outreach model to Malawi, Zambia and Swaziland.                   the highest HIV-infection rates in the
                                                                               world, six million new HIV infections
                                                                               and three million HIV-related deaths
                                                                               could be prevented over the next
                                                                               20 years.6
In the light of these compelling       a shortage of skilled practitioners      and neighbouring Western Kenya.
research findings, the World Health    pose serious challenges to the
Organization (WHO) and the Joint       expansion of MC services.8               For the past two decades, MSI has
United Nations Programme on            This paper illustrates how MSI’s         provided comprehensive sexual and
HIV/AIDS (UNAIDS) issued a joint       successful pilot project offers a        reproductive health (SRH) services
recommendation to the global           promising model of MC service            in Kenya, including the delivery of
public health community, urging        provision and HIV prevention in          surgical family planning services to
organisations to integrate MC          rural and hard-to-reach areas of         rural and hard-to-reach communities.
services into existing country-level   sub-Saharan Africa and beyond,           MSI’s ability to bring SRH services
HIV/AIDS prevention programmes.7       preventing the spread of HIV and         to remote areas has relied on close
In response, MSI launched a            potentially saving thousands of lives.   collaboration with local private
pioneering MC mobile outreach                                                   medical institutions and government-
pilot project in Western Kenya and                                              run health posts. The success of
the Nyanza Province in June 2007,
working through local Partner Marie    Bringing HIV                             these local health partnerships is
                                                                                demonstrated by the scale of MSI’s
Stopes Kenya (MS Kenya).
                                       prevention                               work to date. In the past four years,
                                                                                MSI provided over 140,000 safe
As MSI was already a leading
provider of long-term and permanent    services to                              sterilisation procedures to women in
                                                                                the Nyanza Province alone.
family planning methods in rural
and hard-to-reach areas in Kenya,      communities                              These long-standing partnerships
the team was able to act quickly to
deliver MC services to the Nyanza      in need                                  with local leaders and community
                                                                                health workers enabled MSI to
Province and Western Kenya. With                                                overcome resistance to circumcision
nearly two decades of experience                                                in areas of Nyanza and Western
in Kenya providing paramedicalised     In Kenya, 7.8% of the population         Kenya where this is not a traditional
family planning i to remote            – or 1.4 million adults – are living     practice. Furthermore, as part
communities through existing private   with HIV/AIDS. Every year, there are     of a national Male Circumcision
and government health posts,           150,000 HIV-related deaths.9 Nyanza      Consortium, MSI helped to build
MSI was able to develop their MC       Province, home to the traditionally      support among key government
outreach model efficiently. Between    non-circumcising Luo ethnic group,       stakeholders for scaled-up MC
June 2007 and December 2008,           has the highest HIV prevalence rates     services. In 2008, 86% of MC service
MSI circumcised 5,344 men and          in the country at 15.4%.9 By 2007,       recipients came from traditionally
adolescents throughout the Nyanza      overwhelming evidence gathered           non-circumcising ethnic groups,
Province and in Western Kenya – an     from the Kisumu randomised control       demonstrating the success of MSI’s
average of 20 circumcisions per day.   trial in Kenya had pushed MC from        culturally appropriate MC outreach
                                       research into practice.3 In response,    strategies and its MC sensitisation
In sub-Saharan Africa, cultural        MSI launched an innovative MC            campaign.
hurdles, financial constraints and     mobile outreach project in Nyanza
                                                                                The MC mobile outreach model
                                                                                built on existing practices within
  Fact box                                                                      MSI used to deliver surgical family
                                                                                planning services to remote, low-
  • MSI provided 5,344 MCs to men and boys in the Nyanza                        resource settings. The five-person
    Province and Western Kenya through mobile outreach between                  outreach team brought with them the
    June 2007 and December 2008                                                 necessary medical equipment and

  • the five-person mobile outreach team consisted of two nurses,
    one HIV voluntary counselling and testing (VCT) counsellor, one               FOOTNOTES
    healthcare assistant and one driver/nursing aid                               i
                                                                                      “Paramedicalised family planning” consists of
                                                                                      training health workers and health technicians
  • through a community sensitisation initiative, MSI reached over                    to provide surgical family planning services
    100,000 individuals in Nyanza Province with information about                     such as male and female sterilisations and
    MC and HIV prevention messages                                                    intrauterine device (IUD) insertions.
                                                                                      Paramedicalisation is a necessary strategy to
  • if all sexually active men in sub-Saharan Africa were circumcised,                deliver family planning services to remote and
                                                                                      rural populations in resource-poor countries
    some six million new HIV infections and three million HIV-related                 where there are drastic shortages of doctors
    deaths could be prevented in the next 20 years. 6                                 and nurses.




2 MC as a HIV prevention strategy
temporary water supplies to perform
safe and sterile MCs in health posts,                 MC outreach at a glance
schools and community buildings.
They worked closely with local                        At each outreach site the team provided clients with the following
community health workers both                         services free of charge:
during and after the MC service
visit to track any complications                      • forceps-guided method of circumcision using local anaesthetic in
and ensure follow-up care when                          a sterile surgical setting iv
necessary. Visiting 20 sites per                      • information on the MC procedure, wound care, HIV testing and HIV
month, MSI provided 5,344 free MC                       prevention counselling, provided in a confidential setting
procedures between June 2007 and
December 2008.                                        • individual counselling and informed consent for the MC
                                                        procedure, including for minors with consenting guardians
The pilot project targeted both                       • STI diagnosis and treatment
sexually active and non-sexually
                                                      • discharge counselling on wound care and STI prevention
active men and adolescents ii. MSI
screened all potential clients for                    • condoms.
sexually transmitted infections (STIs)
before performing the surgery, in
addition to giving all participants                 MC procedures in places where                               Recommendations
HIV prevention education and                        health resources are lacking. This
counselling afterwards. In cases                    “task-shifting” of simple, low-risk                         Countries that wish to scale
where HIV-positive men wanted to                    surgical procedures to nurses and                           up access to MC services
be circumcised, the outreach team                   paramedical personnel is key to                             should consider the following
provided the service only when these                future MC outreach projects, given                          recommendations:
men met specific physical health                    the significant shortage of doctors
criteria and agreed to extensive post-              in rural and remote areas of                                • develop outreach models
procedure HIV prevention counselling.               sub-Saharan Africa.                                           to bring services directly to
                                                                                                                  individuals living in remote and
MSI’s comprehensive service                                                                                       rural areas
provision and quality of care kept
complication rates to a minimum.                    Conclusion                                                  • work with existing national
An integrated research study of                                                                                   health infrastructures by training
240 pilot project participants found                                                                              medical and paramedical
that the competence of the MC                       MSI’s pilot project offers a                                  personnel to deliver safe MC
provider and the use of the forceps-                successful model for the rapid                                procedures
guided technique contributed to an                  expansion of MC services in
extremely low complication rate of                  hard-to-reach rural areas – a model                         • develop a comprehensive
1.3%.10 iii These results show that                 that is easy to replicate and has                             HIV prevention strategy that
it is possible to train outreach team               the dramatic potential to reduce                              includes condom distribution,
members quickly to deliver safe                     HIV infection rates in sub-Saharan                            HIV prevention education and
                                                    Africa and beyond. The MC mobile                              capacity building of health
                                                    outreach model shows what is                                  workers at the local level
  FOOTNOTES
                                                    possible through an innovative
     No one who requested MC services was
                                                    integration of HIV prevention                               • work closely with local leaders to
  ii


  refused, provided they met the necessary health
  criteria and were able to give informed consent   strategies within an existing network                         ensure MC services are culturally
  (or had consent provided by a legal guardian).    of SRH health services. MSI will                              appropriate, thus improving
  In communities where circumcision is part of      now bring mobile MC services to                               community acceptance of the
  traditional “coming of age” rites of passage,
  MSI provided MC services on request to boys
                                                    remote areas of Malawi, Zambia                                services.
  aged 8–13. The target of the MC outreach          and Swaziland to help prevent the
  project was sexually active men and               spread of HIV.
  adolescents aged 13–29.

   In a study among 1,007 males in Western
  iii


  Kenya, Bailey et al. found that 25% of              FOOTNOTES
  circumcised males experienced an “adverse           iv
                                                         The forceps-guided technique is a “simple step-by-step procedure, which can be learnt by surgeons and
  event” as a result of poor training, lack of
                                                      surgical assistants who are relatively new to surgery. It can be used in clinics with limited resources, and it
  appropriate clinical settings, and inadequate
                                                      can be done without an assistant.” From WHO/UNAIDS/Jhpiego, Manual for male circumcision under local
  patient follow-up (Bailey et al., 2007).
                                                      anaesthesia, http://www.who.int/hiv/pub/malecircumcision/who_mc_local_anaesthesia.pdf




                                                                                                                         MC as a HIV prevention strategy 3
                                                                                                               For more
                                                                                                               information
                                                                                                               contact:
                                                                                                               Walter Odhiambo
                                                                                                               Deputy Country Manager
                                                                                                               Marie Stopes Kenya
                                                                                                               Kindaruma Road
                                                                                                               Kilimani, Off Ngong Road
                                                                                                               Nairobi, Kenya
                                                                                                               Tel: +254 20 3870 182/196/227
                                                                                                               Email: info@mariestopes.or.ke


                                                                                                               Heidi Quinn
                                                                                                               Regional Technical Advisor
   REFERENCES                                                                                                  Marie Stopes International
    1. Global Prevention Working Group. Bringing              guidance for scaling up male circumcision        1 Conway Street
       HIV Prevention to Scale: An urgent global              services for HIV prevention. 2008.               Fitzroy Square
       priority. Geneva, 2007.
                                                            9. National AIDS and STI Programme Ministry of
                                                                                                               London
    2. Auvert B, Taljaard D, Lagarde E, Sobngwi-               Health Kenya. Kenya AIDS indicator survey,      W1T 6LP, UK
       Tambekou J, Sitta R, Puren A. Randomized,               preliminary report. 2008.
       controlled intervention trial of male circumcision
                                                                                                               Tel: +44 (0) 20 7636 6200
                                                            10. Obhai G, Ngo T. At the cutting edge: scaling
       for reduction of HIV infection risk: the ANRS
                                                                up male circumcision through Marie Stopes      Email:
       1265 Trial. PLoS Med 2005;2(11):e298.
                                                                reproductive health outreach programmes in     heidi.quinn@mariestopes.org
    3. Bailey RC, Moses S, Parker CB, Agot K,                   Kenya. London, 2009.
       Maclean I, Krieger JN, et al. Male circumcision
       for HIV prevention in young men in Kisumu,           Web resources
       Kenya: a randomised controlled trial. Lancet
                                                            Male circumcision for HIV prevention
       2007;369(9562):643-56.
                                                            clearinghouse                                      Pioneering HIV prevention
    4. Gray RH, Kigozi G, Serwadda D, Makumbi F,            http://www.malecircumcision.org                    strategies in rural Kenya: a
       Watya S, Nalugoda F, et al. Male circumcision
                                                            UNAIDS recommendations on male circumcision        case study of Marie Stopes
       for HIV prevention in men in Rakai, Uganda: a
                                                            as HIV prevention                                  International’s male circumcision
       randomised trial. Lancet 2007;369(9562):657-66.
                                                            http://www.unaids.org/en/PolicyAndPractice/        outreach project By Erica Nelson
    5. AIDS Vaccine Advocacy Coalition. A new way           Prevention/MaleCircumcision                        and Heidi Quinn
       to protect against HIV? Anticipating the results                                                        published by
                                                            Male circumcision situation analysis toolkit
       of male circumcision studies for AIDS                                                                   Marie Stopes International
                                                            http://www.who.int/hib/pub/malecircumcision/
       prevention: a special publication of the AIDS
                                                            sa_toolkit                                         1 Conway Street
       Vaccine Advocacy Coalition. 2006.
                                                            WHO/UNAIDS/Jhpiego Manual for male                 Fitzroy Square
    6. Williams BG, Lloyd-Smith JO, Gouws E,
                                                            circumcision under local anaesthesia               London
       Hankins C, Getz WM, Hargrove J, et al. The
       potential impact of male circumcision on HIV
                                                            http://www.who.int/hiv/pub/malecircumcision/       W1T 6LP
       in Sub-Saharan Africa. PLoS Med
                                                            who_mc_local_anaesthesia.pdf                       United Kingdom
       2006;3(7):e262.                                      Male circumcision quality assurance: a guide to
                                                            enhancing the safety and quality of services       Tel: + 44 (0)20 7636 6200
    7. World Health Organization and UNAIDS. New
                                                            http://www.who.int/hiv/pub/malecircumcision/       Fax: + 44 (0)20 7034 2369
       data on male circumcision and HIV
                                                            qa_guide                                           Email: info@mariestopes.org
       prevention: policy and programme
       implications: conclusions and
                                                                                                               Website: www.mariestopes.org
                                                            Marie Stopes International Research and Metrics
       recommendations. 2007.                               Team publications
                                                            http://www.mariestopes.org/Health_programmes/
                                                                                                               Registered charity number: 265543
    8. World Health Organization and Joint United
                                                            Research.aspx
       Nations Programme on HIV/AIDS. Operational
                                                                                                               Company number: 1102208



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