Voluntary Medical Male Circumcision PEPFAR South Africa through

Скачать презентацию Voluntary Medical Male Circumcision PEPFAR South Africa through

cf3c92d434e53267bdbd51712c0103a1.ppt

Количество слайдов: 72

Voluntary Medical Male Circumcision PEPFAR South Africa through USAID VMMC Partners Meeting 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

Voluntary Medical Male Circumcision for HIV Prevention

Scientific Evidence Over 50 studies to date, most of them in Africa • Epidemiological • Biological – Inner membrane surface of the foreskin highly vulnerable to HIV infection – Up to nine times more vulnerable than cervical tissue • Three RCTs – South Africa, Uganda and Kenya Strong association between • Lack of male circumcision • Higher risk of heterosexual (female-to-male) HIV transmission • MC has a strong protective effect against HIV acquisition. • Estimated by WHO/UNAIDS to be around 60%

Male Circumcision Target Countries

20, 373, 693 M adult 15 -49 years men to be circumcised across all 14 countries Number of Adult 15 -49 years male circumcision needed to reach 80% coverage in 5 years 5, 000 4, 333, 134 4, 500, 000 4, 245, 184 4, 000 3, 500, 000 3, 000 2, 500, 000 1, 949, 292 2, 101, 566 1, 912, 595 1, 746, 052 2, 000 1, 500, 000 376, 795 1, 000 345, 244 377, 788 500, 000 40, 000 1, 373, 271 1, 059, 104 330, 218 183, 450 an da ut h Af r Sw ica az ila nd Ta nz an ia U ga nd a Za m bi Zi a m ba bw e w ia So R N bi am ib qu e i w oz am al a M M ho so t Le ny a Ke ia hi op Et Bo ts w an a -

45. 0% 40. 0% 1, 000 35. 0% 800, 000 30. 0% 25. 0% 600, 000 20. 0% 400, 000 15. 0% 10. 0% 200, 000 5. 0% 0. 0% an a Le so th o M al M aw oz i am bi qu e N am N ya ib nz ia a, Ke ny a R w an So da ut h Af r Sw ica az ila nd Ta nz an ia U ga nd a Za m bi Zi a m ba bw e Bo ts w Number of HIV infections averted 1, 200, 000 Percent of infections averted by MMC Cumulative Number and Percentage of HIV Infections Averted between 2011 to 2025 by scaling up MC

Indirect Impact on women

Importance of the Implementation Coverage • Decreasing the MMC coverage target from 80% to 50% results in a – decline in the number of HIV infections averted from 3. 4 M to 1. 1 M – In Zimbabwe from 41. 7% of new HIV infection averted to 23. 6% of new HIV infection averted • On the other hand, increasing target MMC coverage from 80% to 100% results in – an increase in the number of HIV infections averted from 3. 4 M to 5 M – In Zimbabwe from 41. 7% of new HIV infection averted to 50. 5% of new HIV infection averted

Importance of the Implementation Pace • Also as expected, reducing the time to achieve 80% MMC coverage from 5 years to 1 year leads to – an increase in the number of HIV infections averted from 3. 4 M to 4. 1 M – In Swaziland, from 33. 9% of new HIV infection averted to 41. 5% of new HIV infection averted – a decrease in the cost per HIV infection averted, – and an increase in net savings per HIV infection averted. • Increasing time to achieve 80% MMC coverage from 5 years to 10 or 15 years does the reverse. – In Swaziland, 23. 6% of new HIV infection averted for 10 years implementation

w an Et a hi op ia Ke ny Le a so th o M a M oz law am i bi qu e N am ib ia R w So an da ut h Af Sw rica az ila Ta nd nz an ia U ga nd a Za m bi Zi a m ba bw e Bo ts Number of MC needed per Infection Averted from 2011 to 2025 70 60 10 59 50 44 40 30 26 20 19 8 8 5 13 7 10 5 5 8 4 0

Number MC done as off April 2011 300, 000 250, 863 250, 000 200, 000 141, 793 150, 000 81, 849 100, 000 50, 000 12, 793 4, 689 10, 963 219 3, 409 1, 694 2, 515 42, 317 25, 465 9, 052 21, 315 Bo ts w an Et a hi op ia Ke ny Le a so th o M a M oz law am i bi qu e N am ib ia R w So an da ut h Af Sw rica az ila Ta nd nz an ia U ga nd a Za m bi Zi a m ba bw e -

bi q w i al a 0% ue N am ib ia R w So an da ut h Af Sw rica az ila Ta nd nz an ia U ga nd a Za m bi Zi a m ba bw e am oz M 4% M th o 70% Le so ya 20% Ke n a io pi a 10% Et h w an Bo ts Achievement toward Target of 80% coverage 66% 60% 50% 40% 30% 12% 14% 0% 1% 1% 0% 3% 3% 0% 4% 1% 0%

Voluntary Medical Male Circumcision Quality Assurance

Quality Assurance (QA)? QA is the process of evaluating a program or system against known and accepted standards – Define quality – Provide basis for measuring – and recognizing – quality – Provide guidance for improving quality Goals of quality with MC include: – Safety – Efficiency and productivity to achieve impact on HIV incidence (MC as a public health intervention) – Provision of a minimum package of services in addition to surgery

External Quality Assurance (EQA) for MC? • Provides objective assessment to guide improvements • Creates incentives for clinics to align services with national standards and donor guidelines • Facilitates achievement of MC service targets • Complements WHO QA self-assessment tool • Promotes public recognition and confidence in the MC services provided

PEPFAR Standards for MC In addition to public health impact and efficiency, PEPFAR’s standards focus on A. B. C. D. E. F. G. H. SOPs, guidelines, policies Facilities, supplies and equipment Clinical record keeping; monitoring and evaluation Minimum package of services and linkages Staffing Surgery, including pre- and post-op and follow-up care Communication to Clients Waste management

Voluntary Medical Male Circumcision External Quality Assurance in South Africa Preliminary Findings 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

Preliminary Findings • This assessment was for VMMC Site supported by USAID only • 14 sites was visited – – • 5 Partners supporting those sites – – – • 5 in Gauteng 1 Free State 2 in Kwa. Zulu-Natal 6 in Mpumalanga CHAPS for 2 sites Right to Care for 7 sites MATCH for 2 sites ANOVA for 2 sites PHRU/ANOVA for 1 site Sites were – – Hospitals Public and Private NGO

PEPFAR Standards for MC In addition to public health impact and efficiency, PEPFAR’s standards focus on A. B. C. D. E. F. G. SOPs, guidelines, policies Facilities, supplies and equipment Clinical record keeping; monitoring and evaluation Minimum package of services and linkages Staffing Surgery, including pre- and post-op and follow-up care Communication to Clients

Findings (1) • Not all sites have all the SOP, Guidelines, Policies and records in place – – – – Patient Rights Policies Staff Job Description Personnel files Inform Consent Process Guidelines HIV/AIDS Counseling and Testing Guidelines STI Guidelines Supplies and Equipment Inventory/Reports Medication Inventory List Emergency Guidelines Waste Management Guideline and SOPs Quality Control Register for HIV Tests Equipment maintenance registers Infection Prevention and Control Policies and Procedures MC Surgery Guidelines Complications/AE management Guideline Other M&E Tools

Findings (2) • Most partners don’t have those documents at site level but keep them in their office and we have not seen them • Some sites have developed their own SOP, guideline documents and those adaptation does not translate accurately the NDOH guidelines

Challenges • Lack of specific National guidelines that sites can use or refer to and this lead each partners to develop their own guidelines • Lack of WHO adverse event management guidelines • Where national guidelines are existing , they are not being present at site level, for example – STI – HTC National guideline – Waste management

Recommendations • Partners should use existing guidelines from WHO, NDOH • Partners should work with PEPFAR and the NDOH to fill the gap on guidelines that are not developed yet

Findings • Most facilities have adequate and dedicated space for male circumcision • Sites are using existing supply chain management for supplies and equipment – We were not able to assess the Hospital SCMS – We found them to be adequate in most sites – Site keep limited stock of supplies in some sites just for one week and we have reported stock out of some supplies in some sites – Some site lack of equipments • Chairs for the waiting room, group counseling • TV in the group counseling, waiting room and recovery room

Recommendations • Dedication of space for VMMC is critical for site efficiency and to reach public health impact with this intervention • Site space needs to be designed in respect of client flow as described by WHO MOVE document • Sites need to have adequate equipment • Sites need to keep stock for at least one month to avoid stock out

Findings (1) • All clinics keep records of the VMMC services provided – In two MMC clinics, the client records were not kept on site • Majority of the clients (>88% on average) are above the age of 15. • In VMMC clinics on average 5% of clients test positive for HIV. • Completeness of records ranges from 70% for client history and physical examination to 100% for clients demographic information.

Findings (2) • The type of procedures performed in all the MMC clinics are not recorded, however clinic managers reported that forceps guided is the only surgical method used. • All sites also use diathermy for hemostasis but this isn’t recorded anywhere in the clients charts reviewed. • Consent forms are missing in 10% of clients files. • 50% of the files documented at least one follow up post circumcision. – Majority of these follow ups 75% were for clients who return to the clinic after 2 days for their first post op reviews – and 25% at the second day post MC.

Best Practices • Age of clients very well reported and most of the sites request birth certificate to verify the age of the client • Sites requesting parents or guardians to sign consent form when client are accompanied minors • Standard surgical method, use of electrocautery and definition of adverse events • One site – uses a ONE recording format that has most of the information that need to be completed for one client. This approach of having one standardized recording format that has provisions for recording demographics of the client, counseling and testing, consent, history and physical examination, surgical procedure note, post procedure follow up, adverse events recording and management, referral notes will help reduce paper work, reduce the chance of missing pages from client files and provides opportunity to have all documents in one record rather than multiple pages

Challenges • Completeness of records need to be 100% for all necessary information – – – – • • Date of surgery History and physical examination Type of service providers Type of surgical methods Intro Op adverse events Use of diathermy Post op follow up Adverse events There are no standardized client record forms, HTC forms, consent forms, referrals, adverse event reporting and management forms and post operative care forms. The absence of comprehensive monitoring and evaluation system for VMMC is pushing partners to develop their own system and tools. This makes standardized reporting and experience sharing a challenge. In addition, the presence of multiple recording formats that are not properly introduced to service providers caused the quality of the records to be low. The monitoring information isn’t changed into electronic formats as expected, but everything is done manually. This proves to be cumbersome and affects the completeness as well as quality of data and reports.

Issues • Standards recording and reporting tools for the national VMMC program are not available. • Client files kept outside MMC clinics. • Counseling and testing – Incomplete records in most sites – Mandatory testing in some sites • Consent Form – – Missing consent signed forms in the client record in most sites At least one MMC site had no consent form signed on client records No records of parents or guardians consent for minors in the client records Consent form for testing missing in client records in most sites • No provincial or national adverse events management system in place – Monitoring of adverse events – Management of adverse events

Recommendations • • One monitoring and evaluation system for the VMMC program in RSA is critical to effectively monitor progress, assure safety and plan for expansion. Recording and reporting can and should be computerized and data should be accessible for NDOH for decision making real time Standardized recording and reporting tools needs to be developed as part of the monitoring system Consensus amongst partners and donors on one monitoring system, orientation and training of providers on standardized tools are important considerations for the VMMC programs in RSA supported BY PEPFAR Clients records need to be kept on site HIV Counseling and Testing is not mandatory Consent Forms need to be signed and kept in clients file and parents should consent for minors , consent need to be signed for testing and the surgery Date of Surgery, history and physical examination – • • Need to be carefully recorded in ALL clients files Even though type of providers, use of electrocautery and surgical methods are standard, need to be reported in client file Adverse event – National or provincial adverse event monitoring and management system need to be design and implemented

Findings • Generally sites visited provide the minimum package of services: – HIV testing and counseling, – Risk reduction counseling, – Screening and treatment of STIs. • Only few sites refer clients for STI services outside VMMC. • Clinics Linkage to care and treatment is also implemented in different facilities at different levels. • VMMC clinics provide little or no information to women and partners about the services. • No couple counseling services are provided

Best Practices • Discovery’- clients who test positive and CD 4 count below 350 are ‘escorted’ to care and treatment clinics to be enrolled. • Such active linkage between MC and other services need to be strengthened

Challenges • Follow up of clients after referral, according to most of the sites, has proved challenging. – There is no mechanism to confirm if clients actually accessed services at the receiving end of the referrals. – Especially referrals to care and treatment are not receiving feedbacks about clients. • In addition, the VMMC service has little to offer to women in the form of access to information, opportunity to access couple counseling and testing and risk reduction. – Although a couple of sites reported efforts to educate women, in general there is a lack of IEC materials that targets women and families. – Also providers are not trained to provide couples counseling in the VMMC clinic.

Issues • Clinics make decisions to circumcise clients who test positive and have a CD 4 count of >200 and < 350. – While this cut off for CD 4 along with clinical assessment works well in all the clinics clients who, according the national guidelines, need to be enrolled for care and treatment as a priority are lost in favor of performing circumcision. – The linkage to care and treatment after circumcision is weaker than the linkage before circumcision. clinics need to prioritize enrollment to care and treatment over circumcision.

Recommendations • Active referral system need to be design and implemented to track clients referred to other services mainly care and treatment. – Possible utilization of dedicated personnel (case manager, peer educator, expert client) to provide active referral and linkage – A recording and reporting mechanism to track and document where clients went, when they accessed services. – A simple SMS system to provide and or exchange feedbacks between referring and receiving clinics can be helpful.

Findings • No standard composition of the site staff • Most sites have staffs working 5 days a week but with variation of time per day • Physicians time is variable from part time to full time • Some of the staffs do not provide MC counseling. They were not trained

Best Practices • Very motivated, hard working and competent staff. • The site has enough number of nurses dedicated for MC. • A good number of counselors who are dedicated for all types of counseling.

Challenges • Each site have different composition of teams: MOVE team • Some sites have no dedicated physician(s) for MC clinic. • Some clinic does not open full time • Some of the staffs do not offer counseling because they were not trained • Most of the site have no data manager

Recommendations • Each site need to have a standard composition of the MC team and each MC site need to have a dedicated physicians – The ration of physician – nurse recommended in the WHO MOVE document is 1 physician for 4 fixe nurses and 1 mobile nurse for 4 clients/surgical bed – Clinic should maximize use of staff time and facility space by having either one or two surgical team • All the staffs working at the clinic need to be trained on risk reduction counseling • Each site should have a data clerk or data manager who will be responsible for data management, record keeping and reporting.

Findings • Most of the standards are met. • Mixture of Lignocaine and Marcaine is used for Local anesthesia. Standard dose is used for all clients • One artery forceps broke during procedure. • The MOVE model used by all facilities

Best Practices • • • MOVE model is applied. Good surgical procedure. Sterile techniques are followed Attention to the client throughout of the procedure. The surgical bays are very well arranged and all the necessary equipments and the waste bins are located at the surgical bay. This is very efficient way to minimize contamination and maintain high level of waste management.

Challenges (1) • Using the standard dose for Local anesthesia instead of weight based dosage. • No marking of the intended point of incision is done prior to the placement of forceps by some providers • The recommended vertical mattresses for 3, 9 and 12 o’ clock positions are not applied by some providers • Duration of surgery is not recorded. No clock in the surgical bay in most sites • Waste bins are very far from the surgical bays in some sites, this led the nurse to run from the surgical bay to the disposing area whenever he touches unsterile surrounding environment.

Challenges (2) • The recovery room for the clients is not clearly defined. This may lead to not providing proper post op recovery services which includes the 30 minutes observation with taking the vitals. • Diathermy’s inactive rod is handled by the client during the electrocautery. • Screening of the client is done in the surgical theatre and is brief in some sites • Hand cleaning is not standard for surgical procedure. • Only ring blocking is done while administering local anesthesia • No segregation of medical wastes at the point of origin.

Challenges (3) • Post op written instructions are not given to all clients. • Partially applied surgical techniques, such as picking up needles with fingers instead of pick up forceps. • Task sharing is not practiced in some sites. Surgeon does all steps of the procedure from injecting anesthesia to final stitches. Nurses bandage the penis.

Recommendations (1) • Weight based dosage should be used to every client. This means that every client‘s weight should be taken during the pre op examination. • Marking is recommended in WHO manual, so it is also recommended that the intended incision line is marked prior to placement of forceps. This reduces the chance of cutting too much of the foreskin. • Waste bins should be kept in every surgical bay to minimize unnecessary movements and risk of contamination. • While the diathermy is great, the distance between the active rod and the inactive rod is very long, since the inactive rod is hand held by the client. The electric current travels long distance to complete the circuit

Recommendations (2) • The recovery room should be considered and special staff should be available at the recovery to serve clients according to WHO recommendations. • Screening of all clients needs to be done prior to clearing clients for surgical procedure. The screening should be thoroughly done and not brief. • Ring block with Dorsal Penile Nerve block is the recommended techniques for administration of local anesthesia. • It is recommended that medical wastes are segregated from the point of origin into infectious/hazardous and non infectious wastes.

Recommendations (3) • Sterile procedures and techniques should be applied throughout the procedure as it will minimize chances of causing infections • Efforts should be made to make sure that every client is given post op written instructions. • Recovery monitoring and post op care should be stressed to make sure that every client access these services. • Duration of the procedure is one of the standards for MMC (and any other surgical procedure). It is also important to provide each surgical bay with wall clock. • There is a need to implement MOVE model for efficiency and to maximize surgeon’s time. This will increase the clients’ volume. • If surgery is done under sterile techniques, there is no need for routine antibiotics as post op prophylaxis.

Best Practices (1) • Several best practices were observed, and these standards should be celebrated and continued. – Many of the clinics have strong outreach, and demand for VMMC services is strong overall. • The majority of the clinics display signage on VMMC, HIV prevention, risk reduction, etc. • Most of the clinics exhibit signage outside of the VMMC facility, and eleven of the twelve clinics display ‘Brothers for Life’ posters inside their clinics. • Most of these facilities also offered ‘Brothers for Life’ pamphlets/flyers and/or other take-away IEC materials on VMMC and HIV prevention.

Best Practices (2) • Several best practices were observed, and these standards should be celebrated and continued. – Several components of the group session and the individual pre- and post- HIV testing and counseling sessions were excellent overall. • In all group counseling sessions, counselors made clients feel comfortable, managed group dynamics effectively, and encouraged group interaction. • Most group counselors used teaching aids such as pictures and props, and the vast majority demonstrated correct usage of male condoms and offered complimentary male condoms to clients. • All group counselors observed discussed the required six weeks of abstinence following VMMC. – Lastly, all sites offering HCT services insured privacy by providing private rooms for individual HIV testing and counseling.

Challenges (1) • IEC materials – Although many clinics display signs outside of the clinic facility, most fail to mention VMMC’s effect on HIV prevention. – Many signs are not visible from the street. Therefore, clients need to enter the facility grounds to realize that VMMC services are offered on-site. – Most facilities do have some type of IEC materials, flyers and pamphlets seemed in short supply in many clinics, especially when taking supplies of all relevant local languages into account, and these materials were not always being provided to clients. – None of the sites were taking the opportunity to play video messages on VMMC, HIV prevention, and risk reduction, even though clients were frequently waiting at facilities for several hours or even the better part of the day. Not utilizing a TV fails to take advantage of a valuable messaging opportunity.

Challenges (2) • Group and individual counseling sessions – In general, most counseling sessions fail to repeat and reemphasize key HIV prevention and risk reduction messages such the importance of partner testing, the partially protective nature of VMMC, the required 6 -weeks of abstinence including abstinence from masturbation, and the importance of combining VMMC with other HIV prevention strategies in order to stay negative. – It seems that individual counselors tend to assume that clients previously receive the required messages in the group session and therefore miss out on the chance to reinforce key taking points and promote a deeper understanding. – Only a minority of group counselors discussed the need to abstain from masturbation. Those that did discuss masturbation were usually prompted due to a question from a client. Including a discussion about masturbation is critical, as clients may not understand that masturbation will delay healing.

Challenges (3) • Group and individual counseling sessions – Only a few group counselors demonstrated female condoms or offered free samples. – Many group counselors failed to explain that STI screening was a key criterion for determining eligibility for VMMC. – In certain sites, the space for group counseling is inadequate. A few clinics offer group settings in the lobby – a space that is extremely busy, with doctors, nurses, and clients going in and out. Therefore, privacy and client attention span are major concerns. Many clients were distracted by movement in the hallway, and several were even called out of initial group sessions to fill out admissions paperwork. This is troubling, because it makes it easy for individuals to miss out on certain key messages. – Clients who come late are not always offered group counseling sessions, thus they miss out completely on this experience. Given that risk reduction messages need to be repeated to have an impact on behavior, allowing a client to skip a group session is inappropriate.

Challenges (4) • Individual post-op counseling sessions – While counselors did tend to discuss general wound care, many failed to talk about potential adverse events or the warning signs requiring immediate attention. – Most post-op counselors failed to explore knowledge about HIV transmission and prevention, discuss information about HIV/AIDS, provide prevention counseling, stress the importance of partner testing, repeat that VMMC is only partially protective against HIV, or discuss a personal prevention strategy. • Counseling supervision – The VMMC and HIV counseling supervisor is frequently shared by other clinics and/or only available on select days of the week. – Additionally, several challenges with correct messaging were observed, and the lack of counseling supervision could be exacerbating this problem.

Challenges (5) • Lastly, at several clinics, clients receive counseling services on the other side of the hospital rather than at the VMMC clinic. Therefore, it is difficult to assess whether or not the quality standards are being adhered to and if the messaging if consistent and appropriate.

Recommendations (1) • Male Circumcision Promotion Efforts – The VMMC program in South Africa should adopt a National branding – Each clinic should have a sign outside which is visible from the street, not just inside of the hospital or facility, which mentions VMMC’s proven effect on HIV prevention. • IEC – Development of standard set of IEC materials needed at site level to be use by all sites – standardized videos should be produced for VMMC to ensure consistent messaging going forward. – Each clinic should increase the availability of IEC materials on VMMC, HIV prevention, and risk reduction overall and insure that each pamphlet/flyer is available in all relevant local languages. – Each clinic should add a TV and DVD player so that VMMC and/or HIV prevention messages may be broadcasted during the client waiting period.

Recommendations (2) • The partners should consider looking into MTV’s PEPFAR-sponsored ‘Shuga’ series or other pre-prepared material so as to not miss out on this valuable messaging opportunity. • More effort needs to be put into matching site-specific supply with demand. – While certain sites were booked until September and/or sending away clients on a daily basis, others will need to put far more effort into outreach to match supply with demand as their capacity for VMMC increases. • Education and Counseling Resources and Procedures – All site should use the National HTC guidelines – All counselors should incorporate more risk reduction and HIV prevention messages into group and individual sessions. These key messages should be repeated and re-enforced throughout each step of client communication. – All counselors must communicate that VMMC is only partially protective and discuss the importance of combining VMMC with other prevention strategies in order to stay negative.

Recommendations (3) • Initial VMMC Education and Counseling – All clients should participate in the full group sessions without distraction, so the space and client flow at certain sites must be re-examined. – Privacy should be insured so that the group feels comfortable to ask questions in a safe and secure environment. – Group counseling should incorporate specific VMMC teaching aids such illustrative photos and props such as dildos, demonstration vulvas, etc. – Group counselors must demonstrate correct and consistent condom use for male and female condoms. A full demo of a female condom with a demonstration vulva where possible will improve the condom presentation overall. – Group counselors must explain the 60% protective effect of VMMC, discuss that VMMC does not directly protect clients’ partners from acquiring HIV, communicate that STI screening is part of evaluation for VMMC, and clarify the importance of abstaining from all form of sexual activity, including masturbation, for six-weeks post-op.

Recommendations (4) • Individual HIV Testing and counseling need to – – – – Explore knowledge about HIV transmission and prevention, Discuss information about HIV/AIDS, Provide prevention counseling, Stress the importance of partner testing, Prepare the client mentally for his HIV test results before the test, Repeat that VMMC is only partially protective against HIV, and Discuss a personal prevention strategy with each and every client. Counselors should highly encourage, though not mandate, clients to test for HIV prior to VMMC. • Post-operative VMMC Counseling need to – Provide information on the warning signs requiring immediate attention and how to address any potential adverse events, – Re-emphasize the six-week period of abstinence including masturbation, and – Remind the client that VMMC should be combined with other strategies to prevent HIV transmission. – There should be a private room for post-operative exams and counseling sessions.

Recommendations (5) • Routine Follow-up Counselors must – discuss the partially-protective nature of VMMC and – remind clients of the required 6 -weeks of abstinence, including abstinence from masturbation • Gender Issues: – More attention needs to be put into targeting women with relevant messaging regarding VMMC and HIV prevention. – All of the information sessions, from the initial group session to the postoperative follow-up session, need to include messaging which promotes respect for women and female partner(s). – IEC materials need to target women with the benefits of VMMC and allow them to become informed in order to support and encourage male partners to pursue VMMC for HIV prevention. – A comprehensive set of IEC materials needs to be compiled to ensure that all facilities are using a comprehensive, 360 degree, standardized communications approach targeting both men and women.

4 years ½ after WHO-UNAIDS Recommendations “Neither the elegance of the science nor the strength of the effect predict the ease of implementation. " David Stanton 2009

Achieving Pace & Scale • • Community buy in and engagement of traditional leaders Political Will and Country Ownership Strategic communication Strong Leadership and Coordination from the MOH with the National and Provincial MC Task Force • Enough resources for service delivery • Technical support from partners • Capacity to change the strategy as new information become available – Task shifting to nurses – Mobility of service delivery: taking services to people has proven highly effective – Dedication of sites with campaign style: continuous service delivery more productive; mixed staffing models (public and private/NGO) – Practicality: temporary services (adult MC) – Innovation

Next Steps • Prepare site-specific reports to share with USAID Mission, Provincial DOH, partners and sites • Continue the communication for improvements and implementation of recommendations • Finalize the Site Operational Guidance and tools in annexes to be use at site level • Work with the PEPFAR SA and the NDOH to define IEC materials needed at site level and branding for the VMMC program in South Africa

Assessment Team • • • Emmanuel Njeuhmeli, USAID Washington Rebecca Fertziger, USAID Pretoria Olga Mashia, USAID Pretoria Pamala Horugavye, USAID Washington Tigistu Adamu, MCHIP HIV Team Leader Abubakari Mwini, MC Program Manager ICAP Tanzania • Partners and Site Managers

Many Thanks To • The NDOH • Provincial Department of Health in Gauteng, Mpumalanga, Free State, and KZN • District Managers • Wendy Benzerga of USAID Pretoria • PEPFAR Liaison in Gauteng, KZN, Mpumalanga and Free State • Hospital Managers • Hospital Sites MC Managers • Partners • All the dedicated staffs • Drivers