The U S President s The U S President s

The U. S. President’s The U. S President’s Emergency Plan for AIDS Relief PEPFAR Title Male Circumcision Technical Working Group

The U. S President’s Emergency Plan for AIDS Relief PEPFAR MALE CIRCUMCISION PARTNER’S MEETING Commodities and Improved coordination of Male Circumcision for HIV Prevention UPDATE ON MC SERVICE DELIVERY BY NOMI FUCHS-MONTGOMERY (OGAC) NAOMI BOCK (CDC ATLANTA)

The U. S President’s Emergency Plan for AIDS Relief PEPFAR MALE CIRCUMCISION PARTNER’S MEETING Commodities and Improved coordination of Male Circumcision for HIV Prevention UPDATE ON MC SERVICE DELIVERY BY NOMI FUCHS-MONTGOMERY (OGAC) NAOMI BOCK (CDC ATLANTA)

Evolution of PEPFAR Support for MC • In FY 07 prior to normative guidance, 7 countries received resources for preparatory activities • In April 2007, following the release of normative guidance, countries received additional resources to respond to host country government interests • In the FY 08 and 09 there was no funding limitation for male circumcision activities; activities were required to follow host country government coordination and be consistent with local norms and policies • PEPFAR now supports male circumcision activities in 14 countries , working with local governments, WHO, and other partners and donors in program planning and implementation

PEPFAR’s Role in MC Roll-Out • Growing requests and support for MC activities – FY 06: ~$600, 000 – FY 07: ~$16, 000 – FY 08: $26, 694, 448 with over $11 million supporting direct circumcision services – FY 09: ~$28, 000 • Donor collaboration with the Gates Foundation in several countries • PEPFAR support to WHO – Both funding and technical assistance from PEPFAR MC Task Force – Recommendations regarding utilization of WHO tools/resources • Challenges with roll out – Human resources, scale/pace of role out, quality assurance, etc • Evaluation of service impact at population level will take time

FY 07 FY 08 Countries FY 09 e a bw ba m Zi bi Za m a ga nd U ni a nz a Ta a nd la az i Sw ric Af da an w R ia am ib N e i aw qu bi am ut h So M oz M al ho ot Le s a ny Ke ia op a w an hi Et Bo ts Funding Level PEPFAR Funding for Male Circumcision 10000000 8000000 6000000 4000000 2000000 0

PEPFAR Funding Guidelines • Host country support must demonstrated through MC discourse in National Policy, Partnership Framework, or a letter from Minister of Health requesting USG assistance • PEPFAR funds cannot be used to train or equip traditional providers • Children should not receive MC under general anesthesia using PEPFAR funds • Governments are required to describe coordination with host country and other donors • Approaches to MC scale up may focus on partnership frameworks

Data Requirements • Countries will track and report the following: – Number of male circumcisions performed – Safety – Coverage either in geographic area or among target population – Communications activities in relation to both males and females

Priority Populations and Targets • Countries are encouraged to prioritize services to high-risk populations based on local epidemiology to achieve maximum impact on HIV levels • Delivering services to boys/men in age groups where HIV rates are or soon will be increasing (already or soon will become sexually active) produces faster desired results • Local regions with higher HIV rates benefit more quickly • Targets and goals regarding the number of males reached should be developed

Future Directions

Future Directions Quality Programs

Quality • Safety • Minimum package of services • Volume and coverage of MC services to achieve impact on HIV incidence

Increasing Volume and Coverage 2 -pronged approach for MC program support

Increasing Volume and Coverage 2 -pronged approach for MC program support • Sustainable services • Rapid roll out response for “catch up” MC

Sustainable Services Focus on successive partners of either neonates or adolescents • Situational assessment on preferred population • Policy/guidelines development • Health care cadre allowed to provide neonatal MC • Pre- and in-service training • Service delivery

Rapid Roll Out Response for “Catch up” MC • • • Dedicated staff Volunteers Task sharing Task shifting Optimized facility space Optimized patient flow

Quality Assurance • Represents a major component of PEPFAR supported programs • Complementary dual approach – Facility self assessment via WHO Guide and Toolkit – External assessments via PEPFARsupported EQA teams • Similar standards

Donor Coordination PEPFAR coordinates with B&M Gates Foundation on service delivery and research funding in multiple countries

Political Willpower • Endorsement of MC by public figures and policy makers is a key to successful programs • “Champions for an HIV-free Generation” are a group of international leaders who have successfully lobbied for MC support in various countries