1. Male Circumcision in Namibia Frieda Katuta National Prevention Coordinator Namibian Ministry of Health and Social Services

2. Population: ~ 2 million 2008 prevalence among pregnant women (15-49) 17.8% 2008 adult (15-49) prevalence estimate modeled at 15.3% (generalized epidemic) 204,000 PLWHA in 2008 HIV in Namibia

3. 21% Males Circumcised in Namibia Varies widely by region Percent of men who report being circumcised, Namibia DHS 06-07 Although the association isn’t perfect, some regions w/ highest MC prevalence (Kunene & Omaheke, >50%) also contain the ANC sites w/ lowest HIV prevalence (Opuwo & Gobabis, 8%)

4. 5-Step MC Situational Assessment Completed in 2009 1. Desk review of available MC data and mapping of facilities 2. Qualitative research on MC acceptability • Key informant interviews • Focus group discussions 3. Facility readiness survey 4. Costing and impact analysis of rolling out MC • Stakeholders meeting – to share results and develop draft policy and draft action plan

5. Implementation Status • MC Task Force functioning since 2007 • 3 Pilot Sites operational since Sept 2009 • 350 MC procedures have been carried as of June 1st, 2010 • ~90% have been tested for HIV • 83 individuals trained in 4 trainings since 2009

6. Policy & Regulation • MC Policy has been drafted • 3rd version resubmitted for government approval (June 2010) • Action plan (i.e., Implementation Strategy) drafted, will be revised based on policy approval • MC targets included in new National HIV Strategic Framework (2010-2016)

7. Communications • Communication Strategy Developed • Comprehensive MC Booklet for Clients • General MC Information leaflet for General Public • Poster • Comprehensive MC “information kits” for Policymakers, healthcare and media workers • Champions visit from Southern African Leaders advocated for MC in Namibia • Various newspaper articles on MC • Demand creation not started to date

8. Challenges Continue in “Pilot” phase--no national roll out MC only in government integrated sites Policy approval process Inadequate human resources to support MC Delays in task shifting/ task sharing guidance from Health Professional Council No electronic M&E system and general M&E needs to be strengthened and scaled-up (e.g., Inadequate supervisory visits) Support and interaction between MoHSS and traditional circumcisers delayed Primarily PEPFAR-funded No neonatal circumcision to date

9. Human Resource Challenges and Solutions National MC Coordinator position filled Jan 2010 Dedicated doctor/nurse teams hired for 3 pilot sites June 2010 Negotiating with Nursing and Health Professional Council for task sharing and task shifting guidelines for MC Collaborating with WHO to participate in the volunteer doctor program

10. Lessons Learned • Importance of a systematic evidence-based situational assessment provided support and influenced political will • Coordinate with VCT from onset • Communications material essential for health care workers and general public • Costing data assisted with GRN support • Policy approval can delay the implementation process • Need adequate human resources

11. Key Next Steps for 2010-2011 Circumcise!!! Dedicated teams in place in 3 sites Expand beyond pilot sites Pilot WHO volunteer program Expand frequency of training to support aggressive country-wide roll out Initiate demand creation and proactive communication Consider MC in sites in addition to public health facilities Enhance relationship with traditional circumcisers Adapt efficiency models (e.g.,MOVE, etc.)