NyanzaUpdate 01 December 2009 Quarterly provincial newsletter on the Voluntary Medical Male Circumcision Programme

Nyanza leads in Voluntary Male Circumcision: Partnerships Medical Male Circumcision Evidence-Based HIV Towards Eliminating HIV/ Efforts...... 2 Prevention...... 3 AIDS...... 3

Nyanza Mobilises for Rapid Results ’s Programme a Model for Africa

ust a year after its launch in November 2008, Kenya’s voluntary Jmedical male circumcision (VMMC) programme has become a model for other African countries that are beginning to roll out the provision of male circumcision for HIV prevention.

Health officials and programme managers from Botswana, Swaziland, Tanzania and Mozambique, who toured various VMMC sites in in mid-October, remarked on how innovative Kenya’s programme was and said they were impressed by the strong community support it enjoys.

Provincial Commissioner Francis Mutie speaks at the opening of the Rapid Results The tours were part of a learning visit to Initiative in . Kenya sponsored by the World Health Organization (WHO) and other donors. n 9 November provincial health Nyanza, which has the lowest rate of male It was the first in a series of planned officials and their partners circumcision in the country and a high visits to encourage health officials Olaunched an ambitious effort HIV prevalence rate. from various African countries to share to accelerate the provision of voluntary experiences in the implementation of medical male circumcision (VMMC) for If Nyanza meets this goal, an estimated male circumcision for HIV prevention. HIV prevention and meet the rising demand 900,000 HIV infections could be prevented, for this service in Nyanza Province. among men and women, over the next 20 Lessons from Nyanza years. This Rapid Results Initiative will increase Dr. Bennet Fimbo, head of the access to VMMC by mobilising qualified “The sooner we provide comprehensive Information and Communication Unit health care providers to offer the service VMMC services to men who wish to of the National AIDS Control Council at government health facilities, mission become circumcised, the more HIV in Tanzania, said he was impressed hospitals and selected mobile sites from 9 infections we will prevent,” Mutie with the progress made by the Kenyan November to 20 December. By doing so, explained. “That is why we are redoubling programme and particularly by its they hope to circumcise about 30,000 men. our efforts to make VMMC available efficient use of limited space. through the Rapid Results Initiative.” Speaking at the launch of the initiative, Dr. Fimbo also noted the strong Provincial Commissioner Mr. Francis VMMC will be offered in government community support for the programme Mutie praised the accomplishments of health facilities and mission hospitals and in Nyanza, despite the predominance the VMMC programme in Nyanza, which at selected mobile sites, such as schools, of non-circumcising communities in the has trained more than 700 health workers throughout Nyanza. All VMMC services region. More than 40,000 men were and circumcised about 40,000 men in are offered free of charge, under the safest circumcised in Nyanza during the first the past year. “We are proud that Nyanza conditions, as part of a comprehensive year of the programme. has taken the lead not only in Kenya but package of HIV prevention services. in sub-Saharan Africa in implementing Seventy percent of Tanzanian men are VMMC for HIV prevention,” he said. The initiative is coordinated by the circumcised for traditional, religious Provincial Task Force on Male Circumcision or medical reasons, Dr. Fimbo said. Nevertheless, Mutie added, more needs to for HIV Prevention, which is made up of Unfortunately, the country lacks the be done. The goal of the national VMMC representatives of the provincial health resources to expand access to medical programme is to provide circumcision to ministries and all of the development male circumcision for HIV prevention. 80 percent of uncircumcised men in Kenya organisations working with government to (about 1.1 million men) by 2013. About expand access to VMMC in Nyanza. half of those men are expected to be from Continued on page 2

1 Kenya’s Programme a Nyanza Leads in Voluntary Medical Model for Africa Continued from page 1 Male Circumcision Efforts Dr. Thabo Phologolo, the chief health officer in Botswana, attributes Kenya’s that positive gains have been made. progress to the strong partnerships These advances have been made he observed among the government, possible through the joint efforts development partners and other of the government, development stakeholders. partners, political and local leaders, elders, the media, health care pro- “The project is localised, and I am happy viders and many community mem- to see that it’s the local nongovernmental bers dedicated to fighting HIV/AIDS. organisations (NGOs) that are the chief implementers of the project,” he said. It is not possible to mention every individual who has contributed im- Botswana is a traditionally non-circumcising mensely to this programme. Howev- society, and less than 20 percent of the male er, I would like to acknowledge the population is circumcised. Increasing the Dr. Jackson Kioko Prime Minister of Kenya, the Right male circumcision rate will be a challenge Honourable Raila Odinga, and the due to the limited supply of health care n 2003, Kenya declared total war Nyanza members of Parliament, who providers, Dr. Phologolo reported, but his against HIV/AIDS. Since then, dedicated their time to understand trip to Kenya has given him some ideas we have focused on strategies the link between male circumcision I and HIV protection and showed about how to expand access to male to increase awareness of how circumcision for HIV prevention. individuals can protect themselves leadership by recommending male from HIV, to change behaviour and circumcision to the community. After witnessing how Kenyan providers to help people living with HIV have are using limited space and resources to quality lives. More effort is still needed. The provide the service, Dr. Phologolo hopes sooner we can provide male to implement these lessons in his country. The behaviour change message is circumcision services to men who captured in the acronym ABC— want to be circumcised, the more Jessica Greene, the technical services Abstinence, Being faithful, and HIV infections we shall prevent. By director for Population Services correct and consistent Condom use. the end of 2013, we aim to provide International in Swaziland, said that HIV testing and counselling is also services to over 80 percent of the Kenya’s experience offered many lessons part of this package of prevention uncircumcised men in Nyanza. for the Swazi male circumcision project, measures, to help couples know which began just three months before the their HIV status and adopt safer These men will be offered not just learning visit. behaviours. male circumcision, but a compre- hensive package of HIV prevention “The concept of nurses and clinical More recently, voluntary medical services, because male circumcision officers offering the circumcision service male circumcision has joined these does not offer complete protection is a lesson worth taking home,” she said. proven HIV prevention methods as against HIV infection. It reduces— another important weapon against but does not eliminate—a man’s Dr. Luke Nkisi of the Bill & Melinda HIV. chances of becoming infected. Gates Foundation, which is one of the Therefore, male circumcision must sponsors of the exchange, said that The Government of Kenya adopted be used with other HIV prevention the foundation and the other sponsors this new strategy and launched the strategies: abstinence, being faithful, plan to bring VMMC implementers voluntary medical male circumcision and correct and consistent use of together annually through learning programme one year ago. Nyanza condoms. visits and regional meetings. “We are Province has been given the I am sure that with these efforts, working together with other donor opportunity to lead not just Kenya, we are steadily working towards agencies to avoid duplication of efforts in but the whole of sub-Saharan Africa, achieving an HIV-free society. programmes,” he said. in implementing this important new intervention against HIV. Dr. Jackson Kioko, Provincial Director of Public Health and As we reflect on the first year of this Sanitation programme, I can confidently say

VMMC in Nyanza: Programme Highlights

More than 50,000 men have been More than 700 health workers have circumcised. been trained to offer safe VMMC 1 3 services. Voluntary medical male circumcision (VMMC) services can be accessed at A provincial task force coordinates Jessica Greene, Swaziland, (left) and Dr. May more than 124 health centres across the implementation of VMMC in Bukuku, Tanzania, (right) were two of the visitors 2 11 districts. 4 Nyanza. from four African countries who observed every aspect of Kenya’s male circumcision programme. 2 3 Male Circumcision: Evidence-Based Partnerships Towards HIV Prevention Eliminating HIV/AIDS Aphia II Nyanza ust one year ago, the Government of APHIA II Nyanza is a consortium comprised of Kenya officially launched voluntary AED- Academy of Educational Development, medical male circumcision (VMMC) as J CHAK - Christian Health Association of Kenya, an additional strategy for preventing HIV. EngenderHealth, PATH - Program for Appropriate Since then, more than 40,000 men have Technology in Health and IDCCS - Inter Diocesan been medically circumcised at 124 private Christian Community Service The project works and public health facilities across Nyanza, with the ministries of public health and sanitation the first province to implement the VMMC and medical services to promote the adoption of programme. healthier behaviours among Nyanza residents. Under the government’s programme, Through integrated communication, advocacy and male circumcision is offered as part Voluntary male circumcision is performed mobilisation activities, APHIA II, supports voluntary of a comprehensive package of HIV by well trained health care providers medical male circumcision in 10 sites in Nyando, prevention services that promotes the as part of Kenya’s evidence-based HIV Rachuonyo, Rongo and districts. They use of VMMC along with other effective prevention programme. work together with EngenderHealth/MCC who measures against the virus, such as conduct operations research. abstaining from sex, being faithful to one uninfected partner, and correct and male circumcision if a high percentage Catholic Medical Mission Board consistent use of condoms. of its population is uncircumcised and if (CMMB) HIV is widespread and its transmission This programme is founded on is predominantly heterosexual. The most The Catholic Medical Mission Board, a leading US- groundbreaking research conducted in affected countries are in southern Africa based Catholic charity focused exclusively on global Kisumu by the Universities of , and, to a lesser extent, eastern Africa. healthcare, has implemented VMMC in Nyanza Illinois and Manitoba (UNIM) Project since June 2008 in collaboration with faith-based and by other scientists working in Rakai, WHO also recommends that male circum- hospitals. Uganda, and Orange Farm, South cision should be part of a comprehensive Africa. The three clinical trials among HIV risk-reduction programme that includes The CMMB supports the provision of VMMC uncircumcised HIV negative men at these HIV prevention education, HIV counselling services by supplying surgical equipment and sites showed that getting circumcised and testing, provision of condoms and pro- instruments, training service providers, and dramatically reduces men’s chances of motion of correct and consistent condom providing technical assistance and supportive becoming infected with HIV. use, and diagnosis and treatment of other supervision. sexually transmitted infections. In fact, these studies found that male Its partners are faith- based hospitals in Karungu, circumcision reduced the risk of a man It is important to note that male Migori, Tabaka, Asumbi, Kendu Bay, Nyabondo, contracting HIV by at least 60 percent. circumcision does not offer complete Kisumu, Chiga, Maseno, Lwak (Asembo) and Improved hygiene and lower chances protection against HIV infection and Nyangoma. of suffering from penile cancer were should not replace promotion of safer additional benefits. sexual practices, such as: delaying the In addition to providing the comprehensive HIV onset of sexual relations, abstaining from prevention package with VMMC, the CMMB also takes Male circumcision is also expected to sex, reducing penetrative sex, having fewer a family-centred approach, offering the girl siblings benefit women by reducing their exposure partners, knowing one’s HIV status and that of its VMMC clients HIV counselling and testing, to HIV infection as well as their risk of of one’s partner, and using male or female reproductive health education and information on HIV/ contracting other sexually transmitted condoms correctly and consistently. AIDS. infections and cervical cancer. EngenderHealth The WHO recommendations are clear on The release of the results of the clinical the safety of voluntary male circumcision, EngenderHealth is a core partner in the Male trials is considered a milestone in HIV indicating that circumcision should be Circumcision Consortium (MCC), with extensive prevention research, marking the first provided by trained personnel in a safe and experience in reproductive health and HIV/AIDS major breakthrough since the finding hygienic manner, with medical follow-up services for both men and women. in 1999 that the antiretroviral drug to prevent and treat complications. nevirapine can be used to prevent mother- The organisation’s specific role in VMMC to-child transmission of HIV. “After circumcision, men must abstain implementation in Nyanza Province is conducting from sexual relations for at least six operations research through the sites supported by Based on the scientific evidence, the World weeks after surgery, to ensure that their APHIA II Nyanza for HIV interventions in Homa Bay, Health Organization (WHO) recommends wounds have healed,” states the WHO Rongo, Rachuonyo and Nyando districts. that a country implement free or low-cost recommendations. Continued on page 4

District health management teams and Community members and VMMC services are guided by key development partners have formed community leaders have provided documents from the National Task 5 steering committees to coordinate 7 ideas and support for VMMC 8 Force on Male Circumcision: national district-level activities. through stakeholder meetings and guidelines for VMMC in Kenya, consultations. a strategic plan, service delivery Several models of outreach have been guidelines, a communication plan, and developed and refined to expand a monitoring and evaluation plan. 6 access to VMCC. 2 3 Partnerships Continued from page 3 This work builds on EngenderHealth’s solid with the Nyanza Reproductive Health experience in operations research on the Society, are partners in the consortium which introduction of new technologies and its is funded by a grant to FHI from the Bill & core expertise in introducing and supporting Melinda Gates Foundation. the rollout and scale-up of new surgical MCC supports the development and reproductive health services. implementation of a national male circumcision EngenderHealth is also incorporating strategy. It is also expanding the male male circumcision into the wide range of circumcision research and training centre in approaches, tools and curricula that it has Kisumu to train more providers in VMMC. The Tuungane Youth Centre theatre group performs a developed for men’s reproductive health. male circumcision sensitization drama. MCC research is underway to assess the FACES impact of VMMC on HIV transmission and Family AIDS Care and Education Services risk behaviours, to monitor clinical outcomes, (FACES), the Kenya Medical Research and to identify the best ways to deliver Institute (KEMRI) and Research Centre VMMC services in different settings. Training Programme (RCTP) supports the provision of male circumcision for HIV In Nyanza, the MCC supports the offices prevention, along with provider-initiated HIV of the provincial directors of public health counselling and testing, at public health and sanitation and of medical services, who facilities and through mobile outreach services. coordinate provision of male circumcision services. Currently FACES offers these services Providers perform male circumcisions during outreach at three sites in Migori District and two The MCC works within the framework of conducted at a school. sites in Rongo District. FACES is a non- the National Guidance for Voluntary Male governmental organisation that provides Circumcision in Kenya. It supports activities treatment, care and support to people in Kisumu East, Kisumu West, Nyando, living with HIV and their families, conducts Homa Bay, Rachuonyo and Rongo districts. research on HIV, and offers HIV prevention and family planning services. Marie Stopes Kenya Marie Stopes International is using its Impact Research and existing infrastructure of family planning Development Organisation clinics, to provide male circumcision Impact Research and Development services in both urban and rural Nyanza. Organisation (Impact-RDO) provides The organisation works in Kisumu East, A march through Kisumu streets helped publicise the programme oversight and administers Kisumu West, Nyando, and Bondo launch of the Rapid Results Initiative. funding for the Nyanza Reproductive Health districts. Marie Stopes has developed and Society (NRHS), which is charged with tested a new outreach model to provide male the responsibility of implementing VMMC circumcision services in Nyanza. services in Nyanza. Nyanza Reproductive Health IMPACT-RDO provides this support as the Society prime partner in the Male Sexual Health Program (MSHPP) of the US Centers for The Nyanza Reproductive Health Society Disease Control. Under the MSHPP, the (NRHS) has been instrumental in the NRHS delivers services and builds the expansion of male circumcision services in capacity of government and mission health Kenya by building on its experience with the randomised controlled trial (RCT) of VMMC in Prime Minister Raila Odinga’s endorsement of male facilities to provide VMMC by training staff and circumcision for HIV prevention at a September 2008 providing equipment and supplies in the target Kisumu, its close relationships with provincial stakeholders’ meeting was a pivotal moment for the districts. and national Ministry of Health agencies, and programme. the capacity at the Universities of Nairobi, Impact-RDO also provides VMMC services Illinois and Manitoba (UNIM) clinic. All photos by Silas Achar/Family Health International at four Tuungane youth centres in Suba, Siaya, Nyando, Kisumu East, Rarieda, Bondo The NRHS’ role in the VMMC programme Memorable Quote and Kisumu West districts. Its community in Nyanza is to build the capacity of service monitors in Suba district have followed up providers and to deliver safe, voluntary “As Africans, we believe that ‘mwacha mila ni 1000 post-VMMC clients. medical male circumcision services for HIV mtumwa’ (he who deserts his culture is a slave), prevention. but I must declare that culture has no bearing on Male Circumcision Consortium the subject we are deliberating on today. In this age, whether to circumcise or not should be an (MCC) In addition to its training activities, the NRHS has 16 mobile VMMC teams that directly individual rather than a communal choice. What I The Male Circumcision Consortium (MCC) provide comprehensive male circumcision highly recommend is that individuals be allowed aims to reduce the number of new HIV service in smaller health facilities and within to make choices in practices that have health infections in Kenya and save lives by communities. By the end of October 2009, consequences.” improving and expanding the provision of these mobile teams, in collaboration with the safe, voluntary male circumcision services. Ministry of Health staff trained and supported — Prime Minister of the Republic of Kenya by NRHS, had performed over 30,000 Raila Amollo Odinga during the Second Stakeholders’ Meeting on Voluntary Medical Family Health International, EngenderHealth circumcisions. Male Circumcision for HIV Prevention at the Tom and University of Illinois at Chicago, working Mboya Labour College on 22 September 2008

The Nyanza Update is a quarterly newsletter published by the Nyanza Provincial Task Force on Male Circumcision. Correspondence sent to: Provincial Director of Public Health and Sanitation, P.O. Box 721-40100 Kisumu. Secretary, Nyanza Provincial Task Force on Male Circumcision, P.O. Box 1764-40100 Kisumu. Tel. 057 2020802