This document summarizes a presentation on the progress of male circumcision programs in 13 African countries. It provides an overview of global recommendations and UN support actions. It then reviews each country's situation analysis, policy development, training activities, and service delivery. Key challenges discussed include human resource constraints, political buy-in, funding, and involving traditional providers. Facilitating factors highlighted are increasing political commitment, tools and guidelines, funding support, and country peer learning.

1. 5th SAHARA Conference
Dr Sibongile Dludlu
UNAIDS RST/ESA
Male circumcision Country Updates
Johannesburg, South Africa
01 December 2009

2. Outline
• Review key elements for country MC
Programming
• Give an analysis of country
implementation
• Outline some challenges and constraints
• Consider facilitating factors

3. Global Recommendations
• Countries with high prevalence (>15%), generalized
heterosexual HIV epidemics and low rates of MC
should consider urgently scaling up access to MC
services
• 13 countries identified: Botswana, Kenya, Lesotho,
Malawi, Mozambique, Namibia, Rwanda, South Africa,
Swaziland, Tanzania, Uganda, Zambia and Zimbabwe
• Consider ethics, communication,
culture, health systems,
funding, gender,
comprehensive prevention
strategies

4. UN Support Actions
UN Agencies have a joint work plan:
The goal of the UN partners joint work plan on
male circumcision is to assist countries to
make evidence-based policy and programme
decisions to improve the availability,
accessibility and safety of male circumcision
and reproductive health services as an integral
component of comprehensive HIV prevention
strategies

5. UN Support Actions
The objectives are to:
1. Set global norms and standards
2. Provide technical support to countries
3. Conduct high level advocacy and develop global
communication strategies and messages
4. Coordinate the setting of global research
priorities, and develop systems for monitoring
and evaluation of male circumcision services

6. UN Tools and Guidelines to Support
Implementation
The UN partners are working
together to develop resources to
support programme scale up:
• Information/Advocacy
documents
• Guidance documents
• Tools
• Reports
• The Male Circumcision
Clearing House

7. Developed by the World Health Organization (WHO),
the
Joint United Nations Programme on HIV/AIDS
(UNAIDS), the AIDS Vaccine Advocacy Coalition
(AVAC), and
Family Health International (FHI)

8. Operational Guidance
Key elements for operationalizing MC services
1. Leadership and 6. Quality assurance and
partnership improvement
2. Situation analysis 7. Human resource
development
3. Advocacy
8. Commodity security
4. Enabling policy and 9. Social change
regulatory environment communication
5. Strategy and 10. Monitoring and
operational plan evaluation

9. Two years later……
How far have countries moved …???

10. Situation Analysis
• A situation analysis is to determine attitudes, beliefs,
practices and socio cultural aspects of MC, policy
and regulatory framework, health system readiness
• Some countries have done comprehensive SA –
Botswana, Lesotho, Namibia, Uganda, Zambia,
Zimbabwe
• Others rapid assessment - Swaziland (Key informants,
Facility readiness), Rwanda (facility readiness)
• Some still in progress – Malawi, Tanzania

11. Policy
Notable differences in approach:
• Botswana no separate policy but
strategy with policy elements
• Kenya policy guidelines
• Lesotho, Namibia, Swaziland, Uganda and Zimbabwe,
dedicated policies (drafts completed)
• Zambia – Information note to Cabinet – not policy

12. Strategy
• Country strategies developed that include:
– Objectives, target population, numbers of men to be
reached, costs, service delivery strategies, resource
mobilization, monitoring and evaluation
• Decision Makers' Programme Planning Tool to
determine cost, impact, pace of scale up
• Most countries have 'catch-up' strategies to reach
adult men – Botswana, Kenya, Swaziland, Zimbabwe,
Zambia
• But longer term neonatal circumcision also being
considered in Botswana, Swaziland, Zambia

13. Progress in other Key Elements
• Quality Assurance being implemented in
Kenya, and Swaziland using WHO Guide and
Toolkit
• Regional and country trainings in almost all
countries
• Communication strategies under development
in Kenya, Namibia, Swaziland – UN Toolkit
under development
• M&E Indicators gradually being introduced
into HMIS – Botswana, Kenya

14. Progress on Male Circumcision
Tanzania, Malawi
Situation analysis, pilot Kenya: national guidance &
service sites strategy, situation analysis,
guidelines, training, Quality
Rwanda advocacy Assurance guide, expanded service
campaign, situation delivery, communication & advocacy
assessment under development, M&E, research
underway, services in
military Uganda
Situation analysis, policy
Lesotho: advocacy, development, Comms draft
situation analysis, policy
development, draft Zambia: Situation analysis,
strategy & comms trainings, strategy &
Implementation plan, service
Namibia: delivery
Champions visit, Botswana: Situation analysis,
advocacy, DMPPT,draft DMPPT, strategy, training, M&E,
policy, strategy, training communications and QA
and QA planned,
communications plan Swaziland
Situation analysis, policy, strategy &
Implementation plan, leg/regulatory
assessment, trainings, QA, M&E
draft, comms draft

15. Snapshot of country progress
Policy Service
Leadership I II Situation & Trainin Training Quality delivery
analy Reg g I II Assu M & E
Botswana
Kenya
Lesotho
Malawi
Mozambique
Namibia
Rwanda
South
Africa
Swaziland
Tanzania
Uganda
Zambia
Zimbabwe

16. Service Delivery
How many circumcisions have been done?

17. Service Delivery
• Kenya - Cumulatively 40,000 MC’s done
by October 2009
• Zimbabwe - 4 sites, 1818 men
circumcised as of June 2009
• UTH Zambia – 2500 in 6-month
Adverse event rates remain low <3%

18. Challenges and
Constraints
• Human resource constraints
- For country programming at national level, staff already
overloaded
- For service delivery – lack of personnel, staff mobility
• Political support – it has been a process to get
political buy-in in some countries, also delays due to
elections, set backs with change of government
• Funding – countries not clear on what funds are
available and how to access

19. Challenges and
Constraints
• Traditional providers – almost all countries have them
but no clear guidance on how to involve them
• Communication – partial protection, issues of risk
compensation, how to develop strategies and tools
• HIV positive men – how service delivery sites will
handle without stigma and discrimination
• Implications for women – how to involve women in
service delivery, monitor and evaluate for adverse
societal effects

20. Facilitating Factors
• Level of political commitment now in almost all
countries
• Country Champions
• Leadership and coordination
- Of the UN, with WHO leading joint UN team
- UN coordination with other partners
- MoH leadership and collaboration with NACs
- National multi-stakeholder MC Task Forces and
focal persons
- Countries with well coordinated TF making more
rapid progress
- Replication at provincial level

21. Facilitating Factors
• Engagement of key stakeholders in countries with
extensive consultations – with traditional providers,
women, young people
• Availability of tools and guidelines and increasing
technical support
• Funding support - PEPFAR, Gates, GFATM
• Subtle country peer pressure through experiences
sharing
• Innovative models to improve the efficiency of
services

22. Acknowledgements
•Country Male Circumcision Task Forces
•UN Male Circumcision Working Group,
Geneva
•UN Inter Agency Working Group (IATT)
•Implementing partners supporting MC roll
out in countries