Male Circumcision for HIV Prevention in Kenya:
Three Years and Counting!
Dr Peter Cherutich, MD, MPHHead, HIV Prevention &Chair, VMMC Taskforce
Ministry of Public Health & Sanitation
International AIDS Conference, Rome, July 17, 2010: Mini Room 1
2
Burden of HIV
Province with the highest HIV prevalence (Nyanza) has the lowest MC level
48.8
95.580.9
97.4
96.4
98.486.5 86.5
0.0
4.0
8.0
12.0
16.0
20.0
Nairobi Central Coast Eastern NE Nyanza Rift Valley Western
HIV
prev
alen
ce (%
)
0.0
20.0
40.0
60.0
80.0
100.0
120.0
Circ
umci
sed
men
(%)
HIV Prevalence (15-64 years) % of Men Circumcised in that Province
Overall HIV Prevalence 6.3%, MC Prevalence-85%
3
Burden of HIV contd..
0
5
10
15
20
25
30
35
40
15-24 25-34 35-44 45-54 55-64
Perc
ent (
%) s
erop
ositi
ve
Age (yrs)
HIV+ Circumcised
HIV+ Uncircumcised
HIV+ Circumcised n 24 68 75 40 15% (ci) 1.3 (0.8-1.9) 5.3 (3.8-6.8) 7.1 (5.3-8.9) 4.3 (2.7-5.8) 2.3 (1.0-3.6)
HIV+ Uncircumcised n 13 51 43 30 7% (ci) 1.7 (0.6-2.8) 24.4 (18.3-30.5) 30.2 (20.8-39.6) 24.6 (15.9-33.2) 8.0 (1.4-14.5)
Service Delivery Minimum package• Counseling for MC; HIV Testing offered on opt-out basis• Clinical examination
Management of STI and other genito-urinary conditions• Surgical excision of foreskin using forceps guided method• Post operative care• Follow up
MC Service provision team (4)• Clinical Officer/Nurse: Surgeon• Nurse/Clinical Officer: Assistant Surgeon• Counselor, also trained on HIV Testing and Counseling• Hygiene/Infection Prevention Officer
5
Achievements.....290,000 in 3yrs
0
20000
40000
60000
80000
100000
120000
140000
160000
11663
80719
139905
56725
Number of MC'sExponential (Number of MC's)
Dec-08 Dec-09 Dec-10 Jun-11
6
On course to meet targets...
Nairobi Western (Teso)
Rift Valley Nyanza Total0
50000100000150000200000250000300000350000400000
16261 10099 6738
261814
294912
4950027000
68500
176500
350000
Number of MCs per region Target 2010/2011
And in context…
Courtesy: Emmanuel Njeuhmeli
8
Leadership Continued support by
political and cultural leaders
Government dedication Quick translation of
research to Policy and implementation
Task-shifting (Clinical Officers and Nurses perform MC)
Effective/efficient and passionate implementing partners
9
Innovation is key...
10
Opportunities that VMMC provides Increased access to HIV Prevention &Treatment
Approx 80% coverage of HIV Testing 30% of men get tested for first time
Assuming 2% HIV prevalence Identified 6000 new HIV diagnoses
Risk-reduction counseling and condom distribution
STI screening and ? surveillance During 2010 MC campaign identified 43/55376(<1%)
Revamp/establish male reproductive health IVU Med/WHO project-47 corrective surgeries 25 providers trained-skills transfer
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Key Lessons Learnt Deep commitment for impact-driven approach to
scale up Significant population coverage High intensity-3-5 years
Social change necessary for uptake Community ownership Meaningful engagement with political, cultural and social
leaders Efficient delivery mechanisms saves money
Social mobilization, team work, supply chain
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....50% reduction in costs
Period of time
Period of Time
(weeks) Total program
cost Cost for 30
working days MCs conducted in 30
working days MCs conducted in
1 year
Cost per MC
2010 MC program
(Jan 1 - Dec 31) 52 $6,984,105 $805,858 16,947 144,658 $48
2010/11 RRI (Nov -Jan) 6 $1,517,716 $1,517,716 55,376 XXXXX $27
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The future… Adoption of medical devices
Safer/as safe; cheaper/as cheap; less pain, no anaesthesia, greater flexibility for task shifting
Kenya considering PrePex, Shang Ring, Allisklamp
Continue to explore efficiencies MOVE concept
Community level ownership and contribution to MCs
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Acknowledgements Ministries of Health VMMC Taskforce Male Circumcision Consortium
FHI NRHS Engender Health
USG Gates Foundation UN family Jaramogi Oginga Odinga Foundation
