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MRC/info4africa KZN Community Forum | March 2012
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MRC/info4africa KZN Community Forum | March 2012


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Miss Dhirisha Naidoo - Clinical Manager of Male Medical Circumcision Programme at McCord Hospital spoke on the primary concepts related to prevention of infectious diseases, with a focus on Male …

Miss Dhirisha Naidoo - Clinical Manager of Male Medical Circumcision Programme at McCord Hospital spoke on the primary concepts related to prevention of infectious diseases, with a focus on Male Medical Circumcision (MMC). Based on the biological plausibility and epidemiological evidence, Miss Naidoo's presentation focused on the individual and public health benefits of Medical Male Circumcision (MMC). She also outlined the comprehensive programme based at McCord Hospital, and the challenges faced by the institution.

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  • This implies that for prevention trials of new strategies, all strategies know to work must be provided to participants.
  • 28-34 % decrease in HSV2 infections32-35% decrease in penile HPV infections
  • Transcript

    • 1. Dhirisha Naidoo Peninah Thumbi
    • 2.  Prevention Concepts  The case for Medical Male Circumcision: • Biological plausibility • Epidemiologic evidence  Current HIV prevention situation • Biomedical • Behavioural  Adding MMC to the toolbox • WHO / National  National Strategic Plan (2012 -2016)  Social Mobilisation  Training  Bioethics  McCord Hospital and MMC
    • 3.  Avoid contact with the source: Behavioural change for HIV infection– abstain, use condoms, reduce number of partners, know your status etc  Reduce the infectious load in the source – Treatment of cases: e.g. HAART for PMTCT, now „Treatment for Prevention‟  Block Entry / Access to receptors in the host- Condoms, Microbicides for HIV infection, MMC  Immunization – still evasive for HIV, very effective for other diseases including eradication possibility e.g. Small pox
    • 4.  The shaft & outer foreskin- keratinized epithelium (protects against HIV infection)  Inner mucosal surface is not keratinized and is rich in Langerhans‟ cells- particularly susceptible to HIV infection  During intercourse – foreskin pulled back over the shaft of the penis exposing the whole of its inner surface and thus a large surface area where HIV transmission can take place  Longer survival of organisms in the warm moist sub-preputial space  Indirectly; by protecting against other STDs
    • 5.  1st suggestion of association as early as1986  Ecological descriptions of areas with low MC prevalence and high HIV prevalence late „80s  Systematic reviews of observational studies comparing HIV risk between circumcised and uncircumcised men in the same populations- consistent finding of lower HIV risk in circ men  Meta- analysis of 15 studies that adjusted for potential confounders – risk reduction large and significant  Evidence compelling, but causality difficult to prove using observational data
    • 6. 0 10 20 30 40 50 60 70 80 WC FS LP EC MP NC NW KZN GP 67.5 70.7 47.5 43.8 36.3 34.1 32.8 26.8 25.2 3.2 19.2 11.0 15.5 23.1 9.0 18.0 21.9 15.8 Circ HIV Data from: Shisana O; Rehle T, Simbayi LC, Parker W, Zuma K, Bhana A, Connolly C, Jooste S, Pillay V et al. (2005). South African National HIV Prevalence, HIV Incidence, Behaviour and Communication Survey, 2005. Cape Town: HSRC Press.
    • 7.  Testing the observed concept: 3 RCT of circumcision among consenting healthy adult men – Uganda, Kenya, SA initiated 2002-3  Each halted early by DSMBs due to significant reduced risk of infection in the circumcised men (2005-06) ◦ Kenya: RR 0.41 (95% CI, 0.24-0.70) ◦ Uganda: RR 0.43 (95% CI, 0.25-0.75) ◦ South Africa: RR 0.41 (95% CI, 0.24-0.69)  Compared well to observational data: ◦ RR 0.42 (95% CI, 0.34-0.54)
    • 8. Inclusion of all strategies known to work:  the provision of HIV testing and counselling services  treatment for sexually transmitted infections  the promotion of safer sex practices  the provision of male and female condoms and promotion of their correct and consistent use “When you teach people how to use condoms, give [them some] to take home, then the message that male circumcision only works together with other HIV prevention strategies is better reinforced.“ Clinical manager, Kenya  Reduction of number of sexual partners  Promotion and provision of proven biomedical HIV prevention strategies – PMTCT,PEP, MMC, Prep, Rx as they become available
    • 9.  Medical male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%  It is safe if provided by well trained health professionals in properly equipped settings  WHO/UNAIDS recommendations (March 2007)-when it hailed male circumcision as an important landmark in the history of H.I.V. prevention emphasize that it should be considered an efficacious Intervention for HIV prevention in countries and regions with heterosexual epidemics, high HIV and low male circumcision prevalence- that‟s us.  Male circumcision provides only partial protection, and therefore should be only one element of a comprehensive HIV prevention package
    • 10. Health:  A decrease in HSV2 infections  A decrease in penile HPV infections  Indirect female benefits in transmission of bacterial vaginosis, trichomoniasis & HIV  Reductions in UTIs, phimosis and balanitis
    • 11. Scaling up MMC to reach 80 % of adult and newborn males in 14 African countries(including SA) by 2015 could: Avert > 4 million adult HIV infections between 2009-2025, with 10 of the 14 countries averting more than 19 % of new HIV infections by 2025 Yield an annual cost saving of US$ 1,4 -1,8 billion after 2015, with a total net saving of US $20,2 billion between 2009 and 2025 Taken from USAID – Health Policy Initiative Sept 2009
    • 12.  UNAIDS and WHO using SA data in a heterosexual transmission model, estimate that one new HIV infection can be avoided for every 5-15 circumcisions done and this estimate takes into account possible risk compensation across the entire population (Kesinger & Millard, SAMJ NO:3 2012).  Stepping up combination prevention is more cost effective in SA than compared to other countries (US Secretary of State of State Hillary Clinton) , as cost saving in HIV prevention in high prevalence areas is estimated at between US$150 and near $900 per infection prevented over a 10 year time horizon (Hankins/UNAIDS/WHO/SACEMA 2009).  If 1000 adults circumcised in Gauteng alone, $2,4 million could potentially be saved on HIV treatment in the next 20 years (Khan, Marseile, Auvert 2006)
    • 13.  Recommended MMC in March 2007 for regions with high HIV and low MC prevalence  WHO is leading UN Agencies, UNAIDS etc, to set norms and standards, develop policy and programme guidance for safe male circumcision services and support countries to develop male circumcision policies and strategies within the context of a comprehensive HIV prevention strategy  Manual for MMC under LA  Operational guidance for scaling up male circumcision services for HIV prevention e.g MOVE method  Has become DoH Policy; SA National Guidelines for MMC under LA version 1, May 2010
    • 14.  Target of 5,7 million men between the ages of 15-49 years from 2010 – 2015  Presently +- 500 sites offering MMC (incl. High volume sites, district hospitals and community health centres)  2009 – 2011 – 140 000 men circumcised  500 000 men circumcised to date  Over 400 nurses and 150 doctors trained in MMC thus far
    • 15.  Strategic Objective 2 : Prevent new HIV,STI and TB infections  Package of combination prevention includes MMC as part of an array of prevention strategies that should be used in combination with each other.  Also mentions STRATEGIC ENABLER- COMMUNICATION
    • 16.  A Model for Optimizing Volume and Efficiency for MC (2010)  Three recommended surgical MC methods (procedure time): Forceps-guided (19 minutes 20 seconds),Dorsal slit (21 minutes 45 seconds) and Sleeve resection (27 minutes) • Recommended use of the following techniques/concepts: Hemostasis by diathermy machine, Task Sharing and/or Task Shifting, Bundling of surgical items; use pre-assembled surgical kits, Theatre layout for fast patient turnover and Client scheduling (appointments) • Staff ratios 1 physician/surgeon per 4 clients (1 surgeon per 4 surgical bays*) 4 preparation/surgical assistants (e.g., nurse assistants) per surgeon 1 anaesthesia/suture provider (e.g., surgical nurse) per surgeon 1-2 counsellors per team + 1 site manager (if high volume site) Futures Group, Preliminary cost Analysis for NDOH, March 2011
    • 17.  Staffing based on task-shifting from physicians might lead to reduction in personnel costs, especially in the High Volume model  However, this requires policy change and extra up-front training costs for surgical nurses
    • 18.  The goal of the surgical procedure is the removal of the foreskin in its entirety ; a variety of methods  Paediatric surgical methods ◦ Dorsal slit method for children ◦ The Plastibell method ◦ Mogen clamp method ◦ Gomco clamp method  Adult Surgical methods ◦ Forceps-guided method of circumcision ◦ Dorsal slit method of circumcision ◦ Sleeve resection method of circumcision ◦ Tara Klamp method -safety in question per study in Orange farm (sample size very small- more data is needed)
    • 19.  Used in KZN only  Tara Klamp, Shang Ring and Ipex still under investigation by WHO  In a statement by Dr Yogan Pillay (Deputy director General Health) “We are not going to expand the use of Tara Klamp beyond KZN, but we are likely to conduct a larger randomised control trial with the WHO to test the three devices used in circumcision, the Tara Klamp, Shang ring and Ipex, which doesn‟t need anaesthetic.”  Neither WHO or PEPFAR have indicated support for TK thus far  WHO developed a Framework for Clinical Evaluation of Devices for Adult Male Circumcision and this states that WHO and other health authorities wish to identify 1 or more devices that would make the MC procedure safer, easier and quicker, more rapid healing than current methods and or might entail less HIV risk transmission in the immediate post operative period, easily performed safely by HC providers with minimal level of training and would be cost effective compared with standard surgical methods for MC scale up ( MILLARD, SAMJ March 2012) Taken from (Kerry Cullinan 10/06/2011)
    • 20.  Primary Training in SA by CHAPS (Centre for HIV/AIDS Prevention Studies) in association with FPD (Foundation for Professional Development)  OAC (Operation Abraham Consortium)  DOH  Match ( Maternal, Adolescent and Child Health)
    • 21.  1ST type is that that needs to be strengthened between the NATIONAL and PROVINCIAL efforts to ensure that all efforts need to be coordinated and focused on achieving the goals of the NSP  2nd type of communication that is critical for the implementation is that of communication with and through the media about the NSP, its goals, principles, interventions and successes and challenges  3rd is the social and behaviour change communication which is critical to changing risk behaviours and social conditions that drive the HIV and TB epidemics. This encompasses the individual, community and social political levels and includes advocacy, media, social/community mobilisation and campaigns
    • 22.  Brothers for Life (JHHESA) Launched last month: • Campaign “Time is now” based on insights that MMC should be done in winter as is with traditional circumcision, but can be done through out the year • MMC Database that uses GPS technology to enable people to access their closest MMC site (SMS “MMC” to 43740), they will receive a return sms with prompts and receive details of their nearest MMC service provider – FREE SERVICE • HCT Database to follow the same route shortly • Will be marketed using Television ads, outdoor media campaign • 2nd sms number created for men who have been circumcised and can receive reminders about follow up visits and care post operatively
    • 23.  Soul City • Television series Siyayinqoba-Beat it, on SABC 1 Thursdays @ 13h30 • Previous Soul City series 11 aired from Oct 2011(messages of MMC) • Radio Talk shows since last year in all the provinces (MMC )  Sonke Gender Justice  Various others partners involved in social mobilisation
    • 24.  Anticipated risk compensation among circumcised men necessitates good communication and the need to get the messaging right about this intervention: ◦ highlight the partial effectiveness of male circumcision and that it will not work in isolation ◦ need to abstain from sex for 6 weeks after the procedure
    • 25.  Consent: what information do you give? • Currently available to 15- 49 year old (CDC awaiting DOH official written stance on doing younger than 15 years before requesting their partners to do so) ◦ Voluntary ◦ Condom use- Emphasize partial protection ◦ Disposal of foreskin  Does Testing have to take place before MMC? ◦ Does not have to, but it is part of the comprehensive package that is being offered for HIV prevention. Men will be encouraged to test- referring the positive ones for care and offering MMC for prevention to negative men ◦ Unintentional disclosure -
    • 27.  PEPFAR funded through CDC  Started February 2011 in McCord Hospital  Moved off site to Brickfield Road on the 18th July 2011  4 Operating Theatres  Using Move Method  Thus far we have done over 3400 circumcisions  6 moderate AE‟s and 1 severe AE  Staff have been trained by OAC and CHAPS
    • 28. We offer a Comprehensive Package of Care :  HIV Counselling and Testing  Screening for Sexually Transmitted Infections and treatment  General Health Assessment including a symptomatic TB screen  Risk Reduction Counselling  Linkage to HIV care and Treatment for HIV positive men  This is a FREE SERVICE
    • 29. About the Procedure :  It is done under Local Anaesthetic (5ml Lignocaine and 2ml Bipuvicaine)  The Forceps guided method is used  The procedure takes between 10- 20 minutes  Clients are monitored for about 45 minutes to an hour post procedure which includes Blood Pressure, Pulse and operation site  Clients are discharged with Pain Medication  Clients are required to come in for a review on Day 2, 7 and 21  Clients advised to ABSTAIN from Sexual Intercourse and Masturbation for 6 weeks  Clients educated on condom usage
    • 30.  Pain  Haemorrhage, Haematoma  Injury to/amputation of the glans  Redundant foreskin  Infection  Delayed wound healing etc.  In the context of the 3 RCTs : Kenya- 1.7%, SA 3.6%, Higher in Uganda -7.6%.  Overall the risk of moderate adverse events related to surgery was 3% and 0.2% severe AEs – all were successfully managed and resolved
    • 31.  Low patient numbers  Funders Targets  Marketing Initiatives  Workplace Forums  Partnerships with other Health Care Providers  Partnership with Local Educational Facilities
    • 32. Know Status Target Women Men HIV Positive Reduce infection in source HIV Treatment HIV Treatment STD Treatment STD Treatment Condoms Condoms HIV Negative Block entry / Avoid Contact Abstain Abstain Be faithful (Avoid multiple partners) Be faithful (Avoid multiple partners) Condoms Condoms Pre-exposure prophylaxis (e.g PMTCT) Pre-exposure prophylaxis ? Post exposure prophylaxis Post exposure prophylaxis Treatment of STIs Treatment of STIs Microbicides – in studies MMC
    • 33. Contact us : 155 Brickfield Road Overport Durban 031 2093295 Dhirisha Naidoo 031 209 3297 You can also communicate with us via Facebook (search for McCord Hospital)