The U.S President’s Emergency Plan for AIDS Relief

1. The U.S President’s Emergency Plan for AIDS Relief PEPFAR Male Circumcision Technical Working Group

2. The U.S President’s Emergency Plan for AIDS Relief PEPFAR MALE CIRCUMCISION TECHNICAL WORKING GROUP PEPFAR MALE CIRCUMCISION PARTNER’S MEETING Commodities and Improved coordination of Male Circumcision for HIV Prevention

3. The U.S President’s Emergency Plan for AIDS Relief PEPFAR MALE CIRCUMCISION PARTNER’S MEETING Commodities and Improved coordination of Male Circumcision for HIV Prevention PEPFAR MC TWG Panel Discussion

4. The U.S President’s Emergency Plan for AIDS Relief PEPFAR MALE CIRCUMCISION PARTNER’S MEETING Commodities and Improved coordination of Male Circumcision for HIV Prevention PEPFAR MC TWG PANEL DISCUSSION INTRODUCTION OF THE MC TGW MEMBERbyNomi Fuchs-Montgomery(OGAC)

5. The U.S President’s Emergency Plan for AIDS Relief PEPFAR MALE CIRCUMCISION PARTNER’S MEETING Commodities and Improved coordination of Male Circumcision for HIV Prevention PEPFAR MC TWG PANEL DISCUSSION MC Special ConsiderationsbyJASON REED (CDC)

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7. Achieving Scale • Scope and pace of service delivery should be in line with country strategies • Targets should be defined (quantified) and meaningful • Efficient practices must be considered and implemented • Technical assistance and tools should be utilized to assess targets and performance relative to scale and modify practices for efficiency • Implementation support in two forms: • Long-term: Capacity building support for sustainable services that will remain indefinitely (i.e., neonatal MC) and may broadly benefit the health system • Short-term: focused support for immediate, high-volume MC service delivery (i.e., adult MC) that will conclude once targets are met

8. Meeting Human Resource Constraints • Reducing the time a surgeon spends on a case by half is equivalent to hiring an additional surgeon. When people are in short supply, efficiency is the most accessible HR solution • Service delivery should incorporate the sharing of clinical tasks to the maximum extent allowed • Consider all possible human resource sources (part-time, full-time, and volunteers) • Staffing and training requirements should be clearly defined (quantified) • Training must be complemented by continuous assessments of provider competency • Consider regional, national, and program-specific training options

9. Quality Assurance • Complementary dual-approach • Self-assessments (WHO Guide and Toolkit) • External quality assurance (EQA) audits (PEPFAR-supported audit teams) • WHO QA Standards and PEPFAR EQA activities are congruent • Service delivery programs should utilize both self-assessments and external assessments • PEPFAR EQA activities provided to service delivery sites can be funded by other partners, if requested • Quality also includes developing service delivery volume with the potential for impact

10. Communications • PEPFAR and WHO supporting media toolkit with partner input • All key messages required to be tailored to specific audiences, with particular sensitivity to gender • Development and tailoring of media is based upon the experiences of others (to avoid duplication of effort) • Funding for communications should be balanced/relative to funding for service delivery

11. HIV Testing Considerations • Work with VCT partners to allow systematic referral of men testing HIV-negative for MC • When providing HTC on site, PITC model is preferable to VCT model • Linkages to HIV care and treatment are essential for routine referrals of those who test HIV-positive • Request funding for HIV test kits if possible

12. Gender Considerations • Key communications messages: reduced risk of HPV/cervical cancer but no direct reduction of risk for women against HIV; circumcised HIV-positive men can transmit HIV; circumcised HIV-negative men can acquire HIV; other risk-reduction strategies necessary; MC not FGM. • Counseling of men to prevent gender- based violence, coercive sex, and risk compensation • Formative research of unintended consequences for women and men (disinhibition, sexual coercion, difficulty negotiating safer sex) and use of data to prevent and mitigate harmful consequences • Male-friendly services to promote healthy male norms integrated or linked with MC roll-out; promotion of MC through services for women (i.e., family planning and maternal and child health care)

13. Neonates and Children • Assent of the child is strongly encouraged, in addition to parental/guardian consent, in accordance with international normative guidance • MC should be deferred until the maturity level of the child allows for use of local anesthesia • MC consent for children without a guardian should be handled in a manner similar to other medical procedures in-country • Two-pronged implementation approach includes capacity building activities that may be particularly well suited to neonatal MC programs

14. Monitoring & Evaluation • PEPFAR indicators have been developed for implementation in 2010 and correspond with WHO indicators • Programs are encouraged to monitor for undesirable events and linkages to care and treatment following referral (HIV and STI)

15. Traditional Circumcisers • In areas where traditional foreskin cutting is common, programs may explore collaboration with traditional providers if possible • Delivery of HIV prevention information and education may be conducted in the traditional setting • Traditional ceremonies may allow for medical excision of the foreskin while maintaining all other aspects of the traditional ceremony • Specific uses of PEPFAR funding related to traditional circumcision are outlined in the 2009 COP Technical Considerations

16. The U.S President’s Emergency Plan for AIDS Relief PEPFAR MALE CIRCUMCISION PARTNER’S MEETING Commodities and Improved coordination of Male Circumcision for HIV Prevention PEPFAR MC TWG PANEL DISCUSSION Question and AnswerbyPEPFAR MC TWG

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18. The U.S President’s Emergency Plan for AIDS Relief PEPFAR MALE CIRCUMCISION PARTNER’S MEETING Commodities and Improved coordination of Male Circumcision for HIV Prevention PEPFAR MC TWG PANEL DISCUSSION WRAP UP/NEXT STEPbyEmmanuel Njeuhmeli (USAID)

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