03 December 2010 Provincial newsletter on the Voluntary Medical Male Circumcision Programme

Reaching more men to prevent Sharing tasks helps Partners in VMMC for HIV HIV infection...... 2 programme meet demand.....3 prevention...... 3 News briefs...... 4

Male circumcision clients surged in August

But these young teens are not the programme’s main audience, because most of them are not yet sexually active. The primary goal is to reach sexually active, HIV-negative men ages 15 to 49, because circumcising them is likely to have the greatest impact on Kenya’s HIV/ AIDS epidemic.

To promote VMMC services among those who are hardest to reach—men older than 25—the programme used satisfied clients as ambassadors to explain to their peers the benefits of the services. It also offered evening and weekend hours, to make it easier for working men to access VMMC services. Data on the results of these efforts are not yet available, because they are still being collected from the sites. Moses Kidi explains to a potential client the benefits of voluntary medical male Since the inception of the VMMC circumcision. Sensitisation workshops like this one with boda boda operators in Kisumu programme in November 2008, the encourage men to seek VMMC services. Photo by Beatrice Oyugi government and its development partners n effort to encourage more men to take As they did during last year’s RRI, have reached about 175,000 men and Aadvantage of the male circumcision government officials adopted several boys with circumcision services across services offered free of charge in Nyanza measures to make VMMC services more 170 health centres in Nyanza Province. Province reached 19,342 men and boys in accessible. The ministries of health However, more still needs to be done. the month of August—more than four times enlisted staff members who were on The programme aims to circumcise about the monthly average. leave to help provide VMMC services 860,000 men nationwide by the end of and deployed more outreach and mobile 2013, including at least 426,500 men in Before August, an average of 4,125 clients teams to bring the services closer to Nyanza Province. per month were circumcised and received communities. Some health facilities that related HIV prevention services this do not routinely provide VMMC formed Strategies like the ones used to accelerate year through the government’s voluntary their own teams of trained providers to uptake of VMMC services in Nyanza in medical male circumcision (VMMC) offer the services. August will help the programme achieve program in Nyanza. its goal of reaching about 80 percent of At the same time, the programme uncircumcised men ages 15 to 49. Doing The government and its partners were able promoted VMMC services. Mobilisers so would prevent an estimated 900,000 to more than quadruple the number of worked with voluntary counselling and HIV infections among men and women clients for the month by employing strategies testing services to reach young men, and over 20 years. and lessons learned from the Rapid Results sensitisation meetings were held with Initiative (RRI) of November–December head teachers from primary and secondary The partners who collaborated with the 2009, when more than 37,000 men and schools to encourage them to inform MOH during the August initiative were boys were circumcised over 30 days. their students about the benefits of male the Nyanza Reproductive Health Society, circumcision. IMPACT Research and Development Like the 2009 RRI, this effort to accelerate Organization, Family AIDS Care and uptake of VMMC services was conducted VMMC services have proved most popular Education Services, the Catholic Medical during the school holidays, when the among younger men and boys. During the Mission Board, and the AIDS Population programme has seen an increase in the 2009 RRI, for example, about 45 percent and Health Integrated Assistance (APHIA) number of clients seeking VMMC services. of clients were younger than 16. II Nyanza Project.

1 the communities. We are thus making Reaching more men to prevent every effort to take the services as close to the people as possible, through greater HIV infection emphasis on outreach and mobile services. We are also encouraging more welcome you to this issue of our involvement of health workers at every I newsletter. level, through task shifting and task sharing with our partners (see page 3). As we commence the second quarter of this year, I am convinced that we are on We have also noted that many VMMC the right path in our HIV prevention efforts clients are younger than 15 years old. in Nyanza Province. Circumcising the young men in this age group, before most of them are sexually Voluntary medical male circumcision active, will help prevent HIV in this (VMMC) has been proven to be an generation in the long term. effective intervention against HIV. But it is not offered alone. It is part of a But it is the men who are already sexually comprehensive package that includes Dr. Jackson Kioko active–the 15 to 49 year–olds–who important health education, HIV are most at risk of acquiring and then counselling and testing, the provision of We continue to deliver high-quality services transmitting HIV infection. That is why we condoms, and screening and treatment for to many men across the 12 districts where are redoubling our efforts to reach the men sexually transmitted infections. the programme is being implemented. in this age group through their peers and However, we have noted that a large by offering services at more convenient The speed at which VMMC has taken off number of men are still unreached. times and locations. in Nyanza is encouraging. This momentum can be attributed to good coordination One reason why we have been unable From 2009 to 2013, the government’s amongst the government, partners, and to reach even more men is the distance strategy is to provide VMMC services to as many other stakeholders of goodwill. between the service delivery centres and many 15- to 49-year-old men as possible, in order to reduce new HIV infections and achieve a significant impact on the epidemic. In Nyanza alone, we have already circumcised more than 175,000 men. By 2013, we aim to reach 426,500 men.

I am hopeful that we can achieve this goal through such initiatives as the successful efforts to encourage accelerated uptake of VMMC service in August (see page 1) and last year’s Rapid Results Initiative (RRI). This month we will begin another RRI that will build on the lessons of the first initiative.

Let me reiterate that the overall goal of this programme is to safeguard our community by preventing as many HIV infections as possible. As we strive to take the services closer to the people and to reach those most at risk, I urge the men of Nyanza to take advantage of this opportunity.

Clients wait for services at a mobile site where tents have been erected to serve as Dr. Jackson Kioko, Provincial Director of counselling, waiting, and recovery rooms. Photo by Michael Stalker/FHI Public Health and Sanitation VMMC in Nyanza: Programme Highlights

More than 175,000 men have been circumcised in Nyanza More than 1,124 health care providers have been trained 1 Province since November 2008. 4 to offer safe male circumcision services. Voluntary medical male circumcision (VMMC) can be accessed in more than 170 health centres and at selected VMMC is offered as a comprehensive package with 2 outreach sites in 11 districts in Nyanza. other HIV prevention services: counselling about 5 HIV prevention, diagnosis and treatment of sexually Nyanza’s experience was used as the model for expansion transmitted infections, and HIV counselling and testing. of VMMC services to Nairobi and Teso districts. 3 A provincial task force coordinates the implementation of the VMMC programme in Nyanza, while male 2 6 circumcision steering committees coordinate the programme at the district level.

2 3 Sharing tasks helps programme VMMC Partners meet demand for VMMC The following members of the Nyanza Provincial Task Force (PTF) on Male Circumcision are partners in the national nnovation is an important ingredient in the voluntary medical male circumcision Isuccessful implementation of the Kenyan (VMMC) programme, which is funded voluntary medical male circumcision (VMMC) by the Government of Kenya, the U.S. programme. A key innovation has been the President’s Emergency Plan for AIDS training of nurses to perform the routine Relief (PEPFAR), the United States Agency surgical procedure. for International Development (USAID), and the Bill & Melinda Gates Foundation. Government officials decided to allow Additional partners who collaborate with the nurses to receive such training to address Nyanza task force as part of their support the critical shortage of medical officers to the national programme include the and clinical officers available to perform Communication for Change (C-Change) male circumcision. Since the government Project, which is implemented by the announced this strategic decision in June 2009, Academy for Educational Development, the 389 nurses have been trained in Nyanza, Teso, United Nations Children’s Fund, and PSI. and Nairobi provinces. APHIA II Nyanza The nurses account for 35 percent of the A surgeon and an assistant prepare to perform 1,124 trained health care providers who a male circumcision procedure at Homa Bay The AIDS Population and Health Integrated are helping the VMMC programme meet District Hospital. Photo by Beatrice Oyugi Assistance (APHIA) II Project in Nyanza the growing demand for male circumcision. introduced mobile male circumcision clinics Since the programme’s inception in Nyanza “Drivers are able to help in the preparation in April 2010 to improve the provision of in November 2008, more than 175,000 men of packs, cleaning, and mobilisation,” said voluntary medical male circumcision and have been circumcised and have received the Llewellyn. “The counsellors assist with take the services to the people. The project comprehensive package of HIV prevention preparation of packs after counselling duties works with members of the district male services offered along with VMMC. are completed, and nurses are able to provide circumcision steering committees to plan, surgeries.” organise, and coordinate mobile services. Allowing nurses to perform male circumcision The venues for mobile clinics vary, from is an example of task shifting. The World Llewellyn adds that task shifting and task dispensaries to schools and churches. Health Organization defines task shifting as the sharing have proved cost-effective. That’s APHIA II Nyanza takes a week to mobilise rational redistribution of tasks among a team of because these strategies make it possible men in each community and then follows health care workers. to reach more clients with VMMC services, up with four days of service delivery. Due explains George Odingo, a research officer to shortages of health care staff, the project Task shifting and task sharing—the sharing for EngenderHealth/Male Circumcision pools trained providers from different health of tasks among different cadres of health Consortium. He notes that most dispensaries in facilities to avoid disruption of routine health workers—are being encouraged the world over Kenya are headed by nurses. service delivery at those facilities. as efficient and cost-effective ways of providing health care services. In Kenya, the ministries Despite these advantages, task shifting and task APHIA II also supports VMMC service of health and their development partners are sharing pose challenges. Some team members provision at public health facilities using these strategies in the implementation of are reluctant to take on more tasks, while in Nyando, Rongo, Homa Bay, and the VMMC programme. others feel uncomfortable relinquishing some Rachuonyo districts. tasks. NRHS staff members are in frequent Catholic Medical Mission Board Emma Llewellyn, project director of the male communication with the members of these circumcision programme of the Nyanza teams, to boost morale and foster a shared The Catholic Medical Mission Board Reproductive Health Society (NRHS), describes sense of responsibility for meeting project (CMMB) supports the provision of VMMC how task sharing and task shifting work in the goals. services in faith-based hospitals in field when an NRHS team arrives at a health Karungu, Migori, Tabaka, Asumbi, Kendu facility or at a school or dispensary that will Task shifting and task sharing featured Bay, Nyabondo, Kisumu, Chiga, Maseno, serve as a temporary site for mobile VMMC prominently in discussions during the Lwak (Asembo), and Nyangoma. services International AIDS Conference in Vienna, In addition to supporting these facilities

Austria, in July, where Bill Gates encouraged through the provision of surgical equipment, “When a team reaches a site and there conference participants to use more cost- training of health care providers, and are no clients, all of the team members effective methods of service delivery. general technical assistance, CMMB do mobilisation to help in the boosting of has a unique, family-centred approach numbers,” she explained. “Even as we advocate for more funding, we that involves parents and adolescents. can do more to get the most benefit from Adolescent girls are offered voluntary HIV The teams consist of a surgeon (usually a each dollar of funding and every ounce of counselling and testing (VCT), reproductive clinical officer or medical officer, but sometimes effort,” Gates said in a keynote speech on 19 health education, and information about a nurse), a surgical assistant who is a nurse, a July. “If we push for a new focus on efficiency HIV/AIDS, while their male peers are counsellor, a hygiene officer (who ensures that in both treatment and prevention—and we offered mentorship on reproductive health the equipment, supplies, and theatre are clean continue to innovate to create new tools—we and life skills, information about HIV/AIDS, and safe for use), and a driver. To maintain the can drive down the number of infections and the comprehensive VMMC package, quality of services, NRHS trains each member dramatically and start writing the story of the which includes VCT. The parents of these of its teams to perform a variety of tasks, such end of AIDS.” adolescents are also offered VCT and as mobilising clients and preparing packs of information about HIV/AIDS. VMMC instruments and supplies. Continued on page 4 2 3 Partners in VMMC for HIV prevention Continued from page 3 news briefs FACES The MCC is composed of FHI, Harvard team visits the VMMC Programme EngenderHealth, and the University Family AIDS Care and Education of Illinois at Chicago, working with the A team from the Global Health Delivery Project Services (FACES) supports the provision Nyanza Reproductive Health Society to (GHDP), an affiliate of Harvard University, was in Kenya of male circumcision for HIV prevention, support the Government of Kenya and in October to learn about its voluntary medical male along with provider-initiated HIV other local partners to implement the circumcision (VMMC) programme. Kenya’s programme counselling and testing, at public health national male circumcision strategy. It is among six health projects in the world that the GHDP facilities and through mobile outreach has supported expansion of the male is preparing case studies about, to highlight the lessons services. Its focus for the next five circumcision research and training centre learned in designing, coordinating, and implementing years, as of 1 July 2010, is on providing in Kisumu to train more providers in biomedical interventions. comprehensive HIV services at the 12 VMMC. district and subdistrict hospitals in Migori, Nyatike, Suba, Kisumu East, and Rongo. The MCC also supports the coordination of the National Task Force on Male Each facility will have a team of four staff Circumcision. In Nyanza, it supports the (a clinical officer, nurse, counselor, and offices of the provincial directors of public hygiene officer) trained to provide VMMC health and sanitation and of medical services. Ministries of health staff will also services, who coordinate the Nyanza be trained in VMMC service provision, so provincial task force. And at the district that they can rotate with the VMMC staff level, it supports steering committees on in providing male circumcision. male circumcisions in six core districts: A nongovernmental organisation, FACES Kisumu East, Kisumu West, Nyando, is a collaboration between the Kenya Homa Bay, Rachuonyo, and Rongo. Medical Research Institute and the MCC research is under way to assess University of California at San Francisco. the impact of VMMC on HIV transmission The Lang’ata district commissioner visits a mobile Impact Research and and risk behaviours, to monitor clinical VMMC theatre. Photo courtesy of IRDO Development Organization outcomes, and to identify the best ways to deliver VMMC services in different Impact Research and Development settings. VMMC expansion to Nairobi builds on Nyanza Organization (IRDO), with funding from lessons the President’s Emergency Plan for AIDS Nyanza Reproductive Health Relief (PEPFAR) through the Centers for Society VMMC services are now available free of charge in Disease Control and Prevention (CDC), Nairobi’s Lang’ata District. The ministries of health are The Nyanza Reproductive Health Society collaborating with Impact Research and Development is currently providing VMMC services (NRHS) has been instrumental in the in six districts: Nyando, Kisumu East, Organization to offer the services, which are currently expansion of male circumcision services available at Lang’ata Health Center, Ushirika Medical Suba, Migori, Rongo, and Lang’ata in Kenya by building on its experience (Nairobi). It also offers VMMC services at Clinic, and the AMREF health facility in Laini Saba. with the randomised controlled trials of Nairobi is the second province after Nyanza to offer four Tuungane youth centres, which are male circumcision in Kisumu, its close located in Suba, Nyando, Kisumu East, free VMMC as part of a comprehensive package of HIV relationships with the provincial and prevention services. and Bondo districts. national ministries of health, and the capacity of the Universities of Nairobi, The strategies that IRDO is using to reach Workshops aim to enhance media capacity more clients in these regions include Illinois, and Manitoba (UNIM) clinic. The Nyanza Provincial Task Force on Male static delivery, where clients go to the The NRHS’s role in the VMMC Circumcision, in conjunction with FHI/Male service provision centre closest to them programme in Nyanza is to build the Circumcision Consortium, held training workshops for VMMC services, and mobile delivery, capacity of service providers and to for journalists, radio presenters, and representatives where teams of health care providers visit deliver safe VMMC services for HIV of the district health management teams (DHMTs) in and provide the services at different sites prevention. NRHS has teams of trainers September to promote accurate coverage of the VMMC in the communities. who train health care workers in VMMC programme. The workshop for DHMT representatives, service provision at its UNIM clinic and In addition, IRDO provides training held on 15 September, provided training on conveying other health facilities. NRHS has trained to build the capacity of staff from information about the VMMC programme to the media. the ministries of health, helping the more than 1,100 service providers in government enlarge its pool of skilled Nyanza, Teso, and Nairobi, and in the personnel ready to provide VMMC as armed forces. Video appeals to football fans the demand for this essential service In addition to its training activities, the A three-part video series about VMMC developed continues to grow. NRHS has 19 mobile VMMC teams that during the World Cup season is now being shown at Male Circumcision Consortium directly provide comprehensive male various video show halls around Nyanza. Created by (MCC) circumcision services in smaller health the Communication for Change (C-Change) Project, the facilities and within communities. By series uses soccer as an analogy to educate men about The Male Circumcision Consortium the end of August 2010, these mobile VMMC services. It is one of the products developed by (MCC) aims to reduce the number of new teams, in collaboration with the ministries C- Change and PSI in collaboration with the provincial HIV infections in Kenya and save lives by of health staff trained and supported by and national task forces on male circumcision. improving and expanding the provision NRHS, had performed more than 80,000 Other products include posters, leaflets, dialogue of safe, voluntary male circumcision circumcisions. cards, and flip charts, as well as materials for specific services. constituencies, such as faith leaders, employers, and community leaders.

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. Tel.: 057 2023176/2020105 [email protected]; Secretary, Nyanza Provincial Task Force on Male Circumcision, P.O. Box 1764-40100 Kisumu. Tel. 057 2020802. [email protected].