MCHIP Lesotho: Voluntary Medical Male Circumcision (VMMC) FY13 APR

Overview

Throughout this program year (FY13) the MCHIP VMMC program continued to build on past achievements and the strong support from the Ministry of Health’s (MOH) in order to expand and rapidly scale-up VMMC services in Lesotho. The Lesotho MOH’s approach to VMMC service delivery and scale up is to expand integration of services to all hospitals in the country by the end of year 2 of the national strategic plan. To achieve this, the MOH requested MCHIP to assist in implementing a nationwide integrated VMMC program.

MCHIP provided in-depth technical support to the MOH, expanded VMMC services and conducted localized demand creation and mobilization. As a result, the Lesotho VMMC national program this year has developed standard operating procedures (SOPs) for service provision, tools for data collection and other guidance documents. Also through MCHIP, the country MC Technical Working Group (TWG) met quarterly throughout the year to provide technical support to the MOH. The MC TWG includes representatives of various VMMC stakeholders and coordinates the scale up of the VMMC program in Lesotho. MCHIP provided support through seconded staff to the MOH for the MOH VMMC Coordinator as well as a the Global Fund (GF) Coordinator to support the MOH to effectively implement their GF-funded activities.

MCHIP strengthened VMMC service provision at facilities that began providing services in MCHIP PY4 (FY12) and continued to expand VMMC services integration to additional facilities within the October 2012 – September 2013 period. Ten VMMC sites (integrated within district hospitals) are operational and providing services twice a week (except Motebang Hospital, which has daily service). MCHIP also entered into rental agreements with private clinics in Maseru in order to provide services in Maseru as no district hospitals are present. Three private VMMC sites are operational (two are permanent sites; one is temporary). In addition to routine services, MCHIP supported the implementation of several intensified service delivery (ISD) periods, where VMMC services are provided daily at district hospitals for a specified period of time.

From October 2012 to September 2013, MCHIP conducted 32,865 MCs in Lesotho. Since MCHIP started providing services in February 2012, 39,825 MCs have been conducted in Lesotho with MCHIP’s direct support. This table represents more than 95% of the total national target that was set at 41,355 and is to be achieved at the end of calendar year 2 (a combination of years 1 and 2); the country is on track to meet this national target.

Table 1. Progress towards national targets YEAR TARGET ACHIEVED TARGET (Jhpiego) “Difference” (as of end-Sept) FY 12 PEPFAR COP 5000 6960 +1960 2012 STRATEGIC PLAN 3886 9599 +5713 FY 13 PEPFAR COP 31,000 32,865 (106%) +1865 2013 STRATEGIC PLAN 37,469 30,226(81%) -7243 (note this is as of end-Sept so 3 months remaining still)

As seen in other countries, VMMC demand is seasonal and most potential clients are reluctant to seek services during the hot season (November–February in Lesotho). Figure 1 shows the progression of VMMC scale up per month since October 2012.

Figure 1. Progress of total MC conducted per month.

The increase in number of MC conducted during the months of May and June correspond to the opening of facilities in Maseru offering daily services as well as the organization of a national ISD in June- July. During this national ISD, 12,143 MCs were conducted nationwide representing more than 35% the total target achieved for the entire year. This continues to indicate that the winter holiday remains an important opportunity to increase coverage of services. This is likely due in part to this being the traditionally high circumcising time of year as well as school holidays. Early infant male circumcision (EIMC) services were introduced in Lesotho. An assessment of sites was conducted, and services introduced in two selected facilities, Mafeteng and Scott Hospitals.

Sixty percent (60%) of clients who received services were in the age group 10-19; when extended to the age of 24, this proportion represents 80% of total clients. The VMMC program is offering services to an age group with a relatively low HIV positive rate as per the DHS 2009 data. This DHS data suggest that the HIV positive rate is as follows in these particular age groups: 15-19: 2.9% HIV positive; 20-24 (5.9%); 25-29 (18%); 30-34 (40%); 35-39 (35%). During the past program year, 26,653 (81%) MC clients were tested for HIV, among which 1,656 were HIV positive.

The adverse events (AE) rate was reported at 0.5%. The number of males circumcised within the reporting period who return at least once for post-operative follow-up care (routine or emergent) within 14 days of surgery was reported at 30,075.

In order to perform these activities, MCHIP continued to procure MC kits and other equipment and supplies, while the MOH provides the pharmaceuticals necessary for MC services. MCHIP also procured couches, lamps, diathermy machines, and separation screens to enhance the capacity of the VMMC sites to respond to the high number of clients.

Training new providers has been a key component of MCHIP support to VMMC scale up and local ownership of service delivery. Trainings were organized as 10 day courses for the VMMC standardization of skills as per the WHO-UNAIDS-Jhpiego package. Trainings also included onsite trainings for additional staff at VMMC sites as well as orientation of nurses at health centers prior to their involvement of booking clients and ensuring post-surgery follow up visits. During this year, a total of 139 providers were trained including 26 doctors, 93 nurses and 20 counselors. These providers are competent to offer services for VMMC. 59 nurses from the public health centers were also oriented on VMMC and help in the booking of clients and performing post-surgery visits. Quality assurance activities continued to be implemented regularly at all sites. Supervision and quality assessment visits were conducted at all sites. In addition, MCHIP conducted various demand creation activities during the year. These activities include development and production of Information, Education, and Communication (IEC) materials, local mobilization through schools and associations, and orientation of journalists on VMMC issues.

Data reported in this APR are collected directly from VMMC sites. Each site maintains a surgical register of total clients who have received MC. This constitutes the principal source of information for completing monthly reports that are developed by the MOH with MCHIP support. These monthly reports are transmitted from the facilities to the MOH where they are compiled at the M&E unit of the Disease Control Directorate. For data quality assurance purposes, MCHIP conducts monthly data quality checks in its supported sites before final reporting in quarterly, semi-annual and annual reports. These checks consist of reconciling monthly totals with the physical total number of client intake forms. A spot verification of 10% of total client intake forms is conducted to ascertain extensiveness and accuracy to which forms are completed. MCHIP has also conducted a routine data quality assessment (RDQA) in four sites. The result of the RDQA shows that data were accurate to 98% for the indicator, Number of male circumcised as part of MC minimum Package, 96% for Number of males circumcised within the reporting period who returned at least once for postoperative follow up care and 98.5% for Number of clients circumcised who experienced one or more moderate or severe adverse events.

1. Program Results/Technical information

Objective 1: Support and strengthen Lesotho MOH capacity to scale up VMMC services Building human resources: During this past program year, MCHIP hired a Master Trainer/ Quality Assurance doctor; four (4) VMMC doctors; eighteen (18) VMMC nurses, and four (4) counselors to provide VMMC services under direct MCHIP supervision. In addition, MCHIP hired a Communication Officer to work on demand creation activities. The Communication Officer has the responsibility to liaise with District Health Management Teams (DHMTs) and implement locally tailored demand creation activities in order to match supply and demand. Over the last program year, MCHIP has also hired several consultants and temporary providers to support increased demand for services during specific periods or to second doctors at hospitals.

Provide technical assistance to MOH: The MCHIP Technical Director continues to work with and mentor the VMMC focal point in MOH, as well as directly support the development of VMMC related policy, monitoring and guideline materials in the MOH.

Development and implementation of joint work plan/ activities in collaboration with other MC partners/stakeholders: MCHIP has implemented several partnerships with other organizations in order to build synergies for better service provision. These partnerships include: • MCHIP/Jhpiego and UNICEF: A joint work plan was successfully developed and implemented, which focused on communication activities for MC and HIV prevention; examining the health center level role in VMMC service provision and conduct of an EIMC assessment. Through UNICEF funding, activities on communication for VMMC were focused on developing two job aids for counselors to use during group education and individual counseling sessions. The content of the job aide includes general information on HIV, other prevention strategies and information on gender based violence. The component of the health center role in VMMC examined how to increase the involvement of the health center in VMMC activities at the district level. Health centers were orientated to book and follow up clients in post-operation so that clients did not have to make the long journey to the district hospital. EIMC activities were designed to assess readiness and capacity of two selected hospitals to introduce EIMC services. Reports from the EIMC assessment and the health center involvement were disseminated with relevant stakeholders. • MCHIP/ Jhpiego private clinic collaboration: MCHIP negotiated with three private clinics to initiate free VMMC services for Maseru (Carewell Clinic, APEX clinic and Willies clinic); Maseru lacks a district hospital. MCHIP pays rental fees to these clinics as part of this collaboration. • Annual stakeholder meeting: In collaboration with the MOH, UNICEF, WHO and other partners, MCHIP supported the first annual stakeholder meeting on VMMC in February 2013. This meeting focused on informing partners and other stakeholders on the achievement of 10,000 MCs conducted in Lesotho since the VMMC program’s service delivery start in February 2012. Key stakeholders from USAID regional office and WHO regional office attended the meeting. Key recommendations were that the integrated approach should continue to be the primary model for service delivery while outreach activities and ISDs will be organized. Demand creation activities at the local level were also to be considered especially at sites where demand had decreased. • During this reporting period, a partnership was forged with the Apparel Lesotho Alliance to Fight AIDS (ALAFA). Together MCHIP and ALAFA are working to reach factory workers in Maseru with information about VMMC and to support MC service uptake. With the majority of factory workers being women, MCHIP has an opportunity to reach an influential audience, as well as any men who are working in the factories. During this past program year, ALAFA and MCHIP identified a pilot factory, conducted a site visit and assessment clinic; VMMC services for factory workers will being in early FY14. • A partnership between MCHIP and PSI was initiated in 2012 and MCHIP has continued to foster the relationship. During the program year, Jhpiego agreed with PSI to incorporate VMMC information in PSI’s New Start HIV testing outreach materials. Additionally, a referral tool was developed for New Start to refer its clients to any of the VMMC facilities throughout Lesotho. MCHIP incorporated PSI’s VMMC site for military personnel into IEC material distribution. PSI counselors were also trained on MC and reproductive health counseling. • MCHIP has partnered with the United States Peace Corps to provide resources and educational information regarding VMMC services in Lesotho. MCHIP has attended multiple Peace Corps workshops to distribute IEC materials and answer questions about VMMC in Lesotho. MCHIP also hosts a Peace Corps volunteer at Jhpiego Lesotho. This volunteer works with Jhpiego staff on a number of projects including program enhancement, and IEC development. • A partnership with Letseng Diamond mines was developed in which MCHIP provided human resources and MC kits to offer VMMC services to clients at the Letseng mines. The mine provided pharmaceuticals and infrastructure for service to be offered to its clients. Two counselors were sent prior to service delivery to inform and sensitize workers on VMMC. Following this, a team of MOH providers (one (1) doctor and four (4) nurses) supported by MCHIP traveled to the site and provided services over two days (18- 19 March 2013), during which 41 clients were circumcised on site. As part of the package of services, MCHIP included a screening tool for TB. A report is available. • Jhpiego and Lesotho Planned Parenthood Association (LPPA) have previously worked together and during this reporting period MCHIP began to fund LPPA to expand its VMMC services at the LPPA male clinic in Lesotho’s capital of Maseru. Through the partnership which began in June 2013, LPPA will provide VMMC services for men at a reduced cost, and produce IEC materials for services. Under the agreement MCHIP will also provide training and support to LPPA through May 2014. • During this reporting period, MCHIP also developed partnerships with local organizations. One such organization, Siyakhona, capacitates local young adults to train them to be film makers films based on community identified needs and challenges to create short films that are shown to local communities to raise awareness. Another, the Lesotho Evangelical Church (LEC), has committed to incorporating VMMC into its HIV prevention messaging.

M&E, data collection and analysis, data quality assurance: MCHIP continues to strengthen its M&E unit as well as to support the MOH in its role in providing VMMC national strategic information. A booking register was developed in order for all sites to manage and assess the demand for services in their sites. MCHIP is also engaging with VP Health System, an IT firm supporting the MOH in establishing a national Electronic Medical Records system for technical support in finalizing the MOH’s development of a national MC database which can be linked to other VMMC services. The objective of the collaboration is to create a VMMC central database that will file and store data (client level information) securely on a MOH server and will be accessible for further analysis. This will also represent an opportunity for potential future linkages with other health services such as ART treatment. As MC will be integrated in the HMIS system, recording individual data for each client attending VMMC services is an opportunity to have all client individual information stored in the central data base and therefore easily retrieved at future encounter with the health system.

To date, VMMC data are reported from the site to central level directly. Data is collected and captured by data clerks on site who generate reports, making three copies that they submit to the DHMT, Disease Control Directorate and Jhpiego office. Quarterly reports are shared with TWG; the same report is then presented to all sites. The chart below represents data flow for VMMC services.

VMMC PROGRAM DATA FLOW

VMMC National technical working group Dissemination to all partners through quarterly meetings: WHO, UNAIDS, other technical groups (prevention), USAID, implementing partners…

Senior management Disease Control Directorate: (HIV prevention officer, HIV program manager, Director Disease Control…) Data analysis PEPFAR Data use

MoH M&E unit Intensive VMMC program USAID/ VMMC district data is compiled in one database collaboration MCHIP (Jhpiego) (monthly) by HIV prevention M&E officer between MOH VMMC data compilation Data analysis and USAID/ VMMC data analysis and Data reporting to senior management MCHIP on data reporting to relevant audience harmonization

Data verification: M&E officers and prevention manager in MOH

MC SITES: district hospitals, Outreaches:

VMMC daily data collection (doctors, nurses, counsellors) DHMT Monthly reports compilation (daily compilation during intense service delivery) Data are collected from hospitals to Data is reported with support of USAID/ MCHIP (regular visit to be compiled in DHMT report (this is VMMC sites by data officer, hospital counsellors) not yet fully implemented in all Type of data reported monthly: district when it comes number of MC done). However, VMMC/ HTC • Number of MC performed data are compiled as part of • Number of MC client tested (these data follow hospital HTC hospital HTC data data reporting flow)

• MC Adverse events • MC follow up visit Program Evaluation and Operational Research: MCHIP has produced one scientific abstract that was submitted and accepted for poster presentation to the International AIDS Society (IAS) conference. The abstract was entitled: “Initiation of voluntary medical male circumcision (VMMC) at one hospital in Lesotho increases new HIV diagnoses and uptake of ART among men” and was a review that explored best practices in strengthening linkages between VMMC services and HIC care and treatment. This abstract was expanded in an article and submitted as part of a VMMC series by the journal, PLOS ONE. In that review VMMC clients identified as HIV infected were traced after 6 months to ascertain whether: 1) they made it to the referral HIV center; 2) they had a CD4 count done; and 3) were followed up for treatment and care. The contribution of VMMC services to HIV care and treatment was assessed by comparing the proportion of HIV infected males referred from VMMC services with those from other hospital services. It was found that 72 men coming for VMMC services tested positive for HIV between March and September 2012. 45 (62.5%) of these men received an immediate CD4 count; 40 (89%) men were eligible for treatment based on national guidelines and were initiated on ART. All VMMC clients who tested positive for HIV, who received a CD4 count on the testing day, and who qualified for ART, were successfully initiated on ART. Providing VMMC services in a district hospital offering the continuum of care was then considered as an opportunity to increase diagnoses and treatment uptake among men, but required an investment in follow-up and communication between VMMC and ART clinics. Suggestions were made to invest in PIMA CD4 devices at integrated VMMC clinics to increase male enrolment in treatment.

MCHIP also conducted operational research exploring reasons for clients to get circumcised. This research was entitled “A Study of the Views of Voluntary Medical Male Circumcision Clients in Lesotho”. The research, referred to as the Lesotho VMMC Client Views Study, was conducted at four VMMC sites from May 22 to July 1, 2013, using a cross-sectional study and mixed methods research to explore clients’ motivations for seeking medical circumcision. A total of 161 survey respondents participated in interviewer-administered questionnaires and 35 men, drawn from a convenient sample of clients seeking medical male circumcision services, participated in four moderator-guided focus group discussions. Results from this study suggest that men seeking VMMC perceived multiple positive health benefits from circumcision, such as disease prevention against HIV and sexually transmitted infections, and improved penile hygiene. Other perceived benefits included increased sexual pleasure as well as cultural recognition and increased status for circumcised males. The vast majority of survey respondents and focus group participants also reported high levels of perceived approval from influential people in their lives, including peers/friends, girlfriends/wives, and family members; acceptance of circumcision from the wider community; and endorsement from experts, such as health care providers and the MOH.

Despite participants’ sense of support and perceived positive benefits from circumcision, the study also identified barriers to male circumcision. The most commonly identified barriers included fear of pain, adverse events, and HIV testing. Access challenges due to cost of travel and time were reported, as well as concerns related to service delivery, including discomfort with receiving VMMC services with younger or older clients and being circumcised by female health staff. The Client Views Study provided important insights into the motivations of clients seeking VMMC services. Key recommendations elaborated on include the need for: 1) Addressing barriers—including transportation costs and concerns over perceived pain, adverse events, HIV testing, and client age— so that they do not deter program progress; 2) Continuing the MOH’s role in providing authoritative information on the benefits of male circumcision; 3) Expanding information on the benefits of VMMC to traditional leaders in the community as their influence might be very pertinent in the context of increasing clients’ interests; 4) Finding champions of VMMC who can talk about their experience, because study participants cited peer influence and credible communication as major influences on their decision to seek VMMC; and 5) Furthering research to explore other salient topics related to male circumcision service uptake because this Client Views Survey targeted the clients already seeking VMMC.

Objective 2: Gradually scale up facility based VMMC and EIMC services in selected hospitals and health facilities Assessment and upgrade of new sites: Ten (10) potential sites were assessed during the past program year (Motebang, Mamohau, Maluti, Seboche, Mohales’Hoek, Quthing hospitals, Mokhotlong, Paray, St. James, Tebellong, Machabeng) and five (5) of these new sites were upgraded and are providing VMMC services (Motebang, Mamohau, Mohales’Hoek, Quthing and Mokhotlong). Hospital management in Maluti is still not willing to initiate free VMMC services and Seboche does not yet have adequate space. Paray, St. James, Tebellong and Machebeng will begin VMMC services in early the first quarter of the next program year. MCHIP has procured couches, lamps, diathermy machines, and separation screens for the upgraded VMMC sites.

Orientation of staff at district level: The orientation of health center and district-level staff was piloted at Leribe, in order to involve health centers and other stakeholders at the district level in the creation of demand for VMMC services and to explore other potential partnerships and service delivery models. Two three-day orientation workshops were organized in Leribe District to provide nurses at health centers, who were involved from the beginning as part of the stakeholder meeting, with the required skills to ensure follow up of MC clients who are circumcised at the district hospital. This collaboration proved to be a success, with additional orientation trainings conducted in Mafeteng, Mohales ‘hoek, Quthing and Butha Buthe districts.

Provision of services: Figure 2 below shows the total number of MCs by age group.

Figure 2. Number of MCs conducted by age group

Clients aged between 15-24 represents 59% of total clients circumcised. A total of 26,653 (81%) circumcised clients had an HIV test result. 24,997 were found HIV negative; 1656 clients were found to be HIV positive (6%). While considering MC clients’ HIV status in two age groups - less than 15 and 15 and above - HIV status represents respectively 1.3% and 6.0%.

Figure 3. HIV status among MC clients

128 100% 1528 90% 80% 70% pos 60% 5074 19923 neg 50% 40% 30% 20% 10% less than 15 above 15

A total of 35,472 follow up visits were reported. This figure includes a total of 22,474 first visits (conducted at 48 hours post- surgery) and 12,988 second visits conducted at day 7. During FY13, 138 AEs were reported, all of which were identified at the follow up visits and successfully treated.

Intensified Service Delivery (ISD): Several ISDs where conducted at different sites during between October 2012 and September 2013. A national ISD where all hospitals were providing daily MC services was organized from the 17 June to the July 31. The table below shows all the ISDs that were conducted during the reporting period.

Table 2. ISDs conducted during the reporting period Date Duration ISD location December 2012 3 weeks 7 sites April 2013 2 weeks 9 sites May 2013 1 week Mafeteng June-July 6 weeks All sites

August 2 weeks Mafeteng and Berea

The ISD that was conducted from the 26 November to the 16 December 2012 saw a low demand for services (less than 10 per day) when compared with the previous ISD that was conducted in June- July of the same year. Possible reasons were the seasonality factor and the fact that students were sitting for exams. Students represent an important percentage of clients seeking for services. Additionally, a two weeks ISD was organized during Easter break. This time, demand was high, peaking at 50 clients a day around Easter week end. The National ISD conducted June 17 to July 31, 2013 was a major success, with 12,143 clients circumcised during the six week period. On average there were 300 men circumcised per day nationally. Sixty-eight percent (68%) of the clients circumcised were between the ages of 10-19. This high percentage of youth circumcised may be attributed to the youths’ ability to access services during winter holiday (school break). Prior to the ISD, intensified mobilization focused on schools, specifically in Maseru; this may have also contributed to the high percentage of youth circumcised. Additionally this national ISD showed great success of the Jhpiego operated sites, with the four Jhpiego sites (Motebang, Carewell, Willies, Apex) accounting for more than half of the national ISD total.

Supervision visits: Regular supervision visits are conducted to support VMMC sites. Issues that were identified during supervision visits mainly included: Registers not filled properly; clients booking not undertaken properly; unexpected high demand during a specific period (such as “high season”, which strained resources); and unavailability of doctors at VMMC sites. For each of the issue identified, MCHIP supervisors meet with teams at the VMMC site and agreed next steps.

EIMC services: With the excellent take-off of the adult VMMC program in the country and increasing demand for the VMMC particularly for the younger boys, a decision was made to pilot the initiation of Early Infant Male Circumcision (EIMC) as a strategy to institutionalize medical circumcision, and reduce the need for adult circumcision in the future. Meetings were held with the MOH Family Health Division, and a task force was created, comprising of Head Family Health Division, SRH, IMCI and, Disease Control Prevention Manager and Jhpiego. Two sites were selected for introduction of EIMC - Mafeteng Government and Scott Hospitals; a feasibility assessment for both sites was done in March and April 2013.

The assessment report noted that both hospitals assessed presented some location(s) where services could be accommodated. These locations would require improvements to the infrastructure to ensure services would be provided in a safe manner. Additionally, staff at the hospitals expressed interest in the introduction of EIMC services in their respective facilities and a willingness to be trained.

Additional EIMC activities included: the training of three Jhpiego staff members on EIMC skills in Tanzania; conduct of a stakeholders meeting to launch EIMC services; the development of draft IEC materials;

QA for VMMC services: As part on-going support to the MOH, MCHIP developed SOPs to guide health workers in the provision of safe MC services. A pin-up poster that reminds the providers of the steps in performing MC was designed and supplied to all sites for pinning up in the operating rooms. A job aide for use during group education was also designed and is already in use. A guidance document in form of a book that comprises checklists for use at different steps of the service package was also drafted and is in final stages of editing for distribution to the providers. Additionally, to help improve the reporting of adverse events, a pin-up poster was designed to remind providers on the steps to be followed when a client circumcised at the facility reports with an adverse event.

An orientation of the MCHIP site leaders (nurses and doctors) as well as the office staff on Quality Assurance of VMMC services was held. Additionally, towards the end of the fiscal year, the team undertook an external assessment to all the sites. The areas assessed included: management systems, supplies, equipment and environment, registration, group education and IEC, individual counseling and HIV testing, MC surgical procedure, Monitoring and Evaluation, and Infection prevention. Table 3 describes results from this assessment. Work on the suggested actions has started and the sites will be re-assessed in the first half of the following fiscal year

Table 3. Results from QA assessment Areas of strong performance Areas needing improvement • Excellent facility cleanliness and maintenance; • Incomplete documentation in client records, pre- Availability of stationary, forms and registers; operative and post-operative vitals, findings at Excellent team work among staff members; follow up visits; • Waste management conducted according to • Availability of AE registers in each site; standards in most sites; and • No patients’ rights policy/documents displayed in • Male circumcision procedure performed the facilities’ insufficient male and female proficiently by all providers with minimal condoms; complications • Proper hand hygiene procedures were not appropriately practiced at all times; • Lack of an inventory for supplies and medicine; and • No internal QA assessments conducted by sites team leaders. Suggested actions to be taken to address the gaps identified included: • Develop a standardized supplies / equipment inventory or card; • Quality assurance assessment tools to be distributed to the sites beforehand and team leaders trained to conduct internal QA assessments; • Providers trained on the newly developed AE reporting standard operating procedure; • Guidelines to be developed for management of emergencies; • 48 hours client follow-up to be re-emphasized and referrals to other sites for their follow-up documented in clients record at VMMC site; • Encourage providers to use the job aids more; and • Clarification of national policies.

Objective 3: Increase demand for VMMC services (including EIMC) in Lesotho IEC material development and dissemination: IEC materials were developed in collaboration with the health education unit in the MOH, including the development of the Rola Katiba (take your hat off) brand. IEC materials developed include the following: Male brochures; Female brochures; four posters targeting different key groups (taxi drivers, couples, young women, general); Stickers with locations of VMMC sites; and a Post-operative care booklet. IEC materials were distributed at clinics during sessions on VMMC education. Materials were also shared with partner organizations and associations who have shown interest for VMMC activities. Community mobilizers also distributed IEC materials throughout Lesotho.

MCHIP VMMC communications strategy: The Communication Officer with the help of a consultant developed an internal communications strategy to support demand creation activities by providing guidance with actions to be taken in order to reach anticipated goals.

Community Mobilizers: Five community mobilizers who were hired as consultants in early June to support in preparation for the ISD to raise awareness of VMMC services at district level. Community Mobilizers aimed to: 1)Increase demand and promote uptake of VMMC around the sites by making young and older men aware of the ISD (17th June- 31st July); 2) Provide communities with correct information about VMMC to enable them to make informed decisions about HIV prevention; 3) Meet with health service providers in different facilities to create and implement VMMC mobilization plans; and 4) Establish relations with other organizations and associations in order to mobilize and work together where possible. The Community Mobilizers were orientated on VMMC and trained on how to answer questions relating to VMMC. Mobilizers were equipped with IEC materials to disseminate to communities, and discussed topics including: explanation of VMMC, benefits of VMMC, post-op care basics/check-up appointments, VMMC as one HIV prevention method and the importance of ABCs, and VMMC service provision locations.

Mobilization and Demand Creation: The initial community mobilization efforts focused on schools. Mobilizers visited different primary, high schools and tertiaries schools before the institutions closed for the winter holidays. Next, mobilizers approached community leaders to organize gatherings in villages to inform the adult community. Relationships were also established and maintained with different non-governmental organizations and ministerial departments to collaborate mobilization efforts. Mobilizers travelled throughout eight of the 10 districts, excluding Qacha’s Nek and Thaba- Tseka, where services were not offered through the MOH/MCHIP partnership during FY13. Mobilizers presented to both males and females in different forums including work places.

Mobilization was successful in bringing clients to the sites for VMMC services. Some areas, such as Butha-Buthe experienced an increase in older clients due to intensified mobilization, due in part to coordination with a district Member of Parliament, focusing on community gatherings geared towards older men and women. Facilities in the districts of Berea and Mafeteng which had low number of clients also experienced high demand due to mobilization that was done in areas close to facilities and around rural areas.

Mobilizers served as a resource for the communities and were able to dispel myths and misconceptions, presented by some older men and some women in rural areas. This mobilization effort also worked to identify both community-based and national organizations that could potentially work alongside MOH/MCHIP to increase awareness and education about VMMC and VMMC services nationwide. The Communications Officers and the MOH together visited local radio stations as an outreach activity to inform listeners about VMMC. They engaged in live programs to explain what VMMC is, the benefits and where the services are provided. Since the piloting of EIMC services in two facilities in September, mobilization has been done by health providers in gatherings. This was done mainly in Mafeteng through gatherings organized by area chiefs. Nurses were also oriented to EIMC and were capacitated to include presentations on EIMC in ANC education sessions for pregnant mothers and parents at the selected hospitals when they come for services.

Orientation of journalists on VMMC issues: With VMMC services becoming more widely available and community mobilization underway to increase education and demand for VMMC services, male circumcision was becoming more widely known and articles had appeared in local papers about VMMC. Due to the cultural sensitivity of male circumcision and the common confusion in regard to traditional initiation in Sesotho (the local language – one Sesotho word is traditionally used for both actual circumcision and initiation); MCHIP initiated a journalism focused health training with a consultant. The goal was also to inform journalists of the proper terminologies used for VMMC and share different perspectives and expectations from the MOH, MCHIP and donors. The training equipped and empowered the journalist with skills to write and report factual and well researched articles on health issues. Attendees were from audio, visual and print media: Ultimate Radio station; Lesotho News Agency; Radio Lesotho; Weekender newspaper; Informative newspaper; Kereke ea Evangeli Lesotho Radio Station; Business Edge Newspaper; Department of Physics and Electronics Radio Station- National University of Lesotho; Photo journalist- Limkokwing University of Creative Technology; Achiever Magazine- BAM Media; and Siyakhona Media Studio at Kick4Life.

2. Training activities scheduled/conducted Standardization of skills training for VMMC providers: Three 10-day MC trainings were organized during this program year. Trainings were organized to initiate VMMC services in the four (4) additional hospitals (Motebang, Mamohau, Mohales’Hoe’k and Quthing). The other trainings were organized to initiate VMMC services in Mokhotlong hospital, and additional providers from other hospitals. The 3rd training was for staff of Lesotho Planned Parenthood Association. The MC trainings were organized according to the standard package developed by WHO, UNAIDS and Jhpiego. The first week of the trainings focused on theory and classroom practice, while during the second week participants provided services under supervision in their actual hospitals. Assessments were conducted using pre and midcourse questionnaires for the knowledge and checklists for the skills and attitudes. A total of 23 doctors, 77 nurses and 18 counselors participated in these 10 day trainings.

Orientation for public health center nurses: To aid with the booking of clients and follow-up of circumcised clients at the public health clinics close to their communities, nurses working in the clinics were trained in the screening of clients, post-operative review of circumcised men as well as the recognition and management of complications. These trainings were held in Leribe district, Mafeteng district , Mohales ‘hoek district, Butha Buthe district and Paballong HIV/AIDS health center in Berea district; a total of 63 nurses from public health clinics and 4 counselors were oriented.

Onsite trainings of health care workers: To increase the numbers of trained providers in sites where VMMC is already being offered, MCHIP conducted training within the hospitals where more providers were needed. This need arose because in some of the sites the providers that were trained at the start of services left those facilities. Two onsite trainings were held in the year for St. Joseph’s Mohales ‘hoek, and Mafeteng hospitals; a total of 3 doctors, 16 nurses and 2 counselors were trained.

TOT: A Training Skills Course was organized for MCHIP Lesotho, Jhpiego South Africa and MOH providers who were identified as “champions” for training other providers. Four (4) Doctors and nine (9) Nurses were trained (September 2 - 6 2013).

Early Infant male circumcision trainings: A team of three (3) MCHIP staff attended a training on Early Infant Male Circumcision (EIMC) in Tanzania from April 22 - 26, 2013. The training was organized by the Jhpiego Tanzania office. Subsequently, the first in-country EIMC training was conducted for providers from Mafeteng and Scott hospitals as well as providers working for MCHIP (September 9 - 20, 2013). Two doctors and eleven nurses were trained.

3. List of documents produced Program area Reports EIMC Feasibility Facility Assessment in Preparation of Introduction of Early Infant Male Circumcision assessment (EIMC) Services at 2 Hospitals in Lesotho: Mafeteng and Scott Hospitals, May 2013 Services Strengthening Adolescent and Young Adult Health Service Delivery in Lesotho, May 2013 Gender Addressing Gender Issues and Integrating Gender Activities into the MCHIP Voluntary Medical Male Circumcision Project in Lesotho, Literature Review, June 2013 Program Abstract: Initiation of voluntary medical male circumcision (VMMC) at one hospital in Lesotho Evaluation increases new HIV diagnoses and uptake of ART among men QA Status report on the quality of VMMC services at MC sites in Lesotho Research Client Views Report Coordination Four TWG meeting minute reports Program Supervision reports Training Training report for VMMC Standardization of skills for Motebang and Mamohau hospital providers (12th to 23rd November, 2012) Training Training report for standardization of skills for Mohaleshoek and Quthing hospitals, March, 2013 Training Training report for the orientation of public health center nurses in Leribe district on VMMC, March 2013 Training Training report for VMMC standardization of skills for Mokhotlong hospital providers, April, 2013 Training Trip report: Onsite- training for VMMC standardization of skills training at St Joseph hospital (15- 26 April) Training Trip report: Onsite- training for VMMC standardization of skills training at Mafeteng hospital (21- 31 May 2013) Training Trip report for MCHIP staff attending training on STATA / Epi-Info in Ethiopia, April,2013 Training Trip report: MCHIP staff report of training on EIMC in Iringa Regional Hospital Tanzania

Training Training skills course for VMMC/ EIMC trainers ; September, 2013 Training EIMC Training for providers of JHPIEGO Lesotho, Mafeteng and Scott hospitals

4. Program Challenges

Service provision: The shortage of human resources for health is still a big challenge in most of the government sites. Many times the doctor that is assigned to the MC clinic is also required to perform all the other duties he’s responsible for in the other departments, and this becomes impractical during the high demand seasons.

Demand creation: Because of the topography of the country, it has been a challenge to reach some of the areas - this is mainly because mobilizers use public transport to move around. Some community leaders and other individuals were resistant because they compared traditional circumcision with VMMC. Some men preferred to talk to male mobilizers as compared to females- they become rude and unruly while others preferred the opposite. Basotho consider VMMC as a seasonal procedure- to be done in winter only- this lowers the demand during the summer seasons.

Procurement and supplies: MCHIP Lesotho continues to procure MC kits (at times in collaboration with SCMS) for all clients as well as a certain quantity of supplies. The MOH has shown ownership in purchasing supplies and pharmaceuticals.

Transportation reimbursement: The program has observed that the distance to the district hospital where VMMC services are provided is often far for the surrounding population, and the return visits for follow up represent an extra cost for clients. The project has addressed this situation by expanding follow-up to health centers for closer proximity to clients and providing transportation reimbursement of client booked at the health center level to be circumcised at the district hospital.