Integrating Upscaled Male Circumcision With Existing HIV Prevention Programs in Zimbabwe

In line with MDG 6, Zimbabwe has set a goal of circumcising 1.2 million men by 2015 to reduce HIV infection. A decentralized circumcision scheme offered by the Ministry of Health and Child Welfare in conjunction with Population Services International (PSI), an NGO, and other development partners. Over 40 000 men have undergone circumcision as HIV testing and counseling since 2009.

Challenge
The Male Circumcision Programme faced the following challenges: 1) A health worker strike that began in November 2008 shut down public health services for several months. The loss of qualified nurses and doctors who left to work in other countries made it even more difficult to deliver the service. 2) Only very small pockets of the Zimbabwean population practice circumcision [as a cultural rite]. People needed to be educated on the benefits, so a nationwide campaign to sell male circumcision was launched. 3)There is a shortage of Health Workers. When the programme started there only eight doctors and 18 nurses, now there are about 40 doctors and 160 nurses involved in the programme. The ideal is to have at least a doctor and eight nurses at a health centre in each of Zimbabwe's 62 rural districts councils and 30 urban councils

Approach
• There is top leadership involvement. The Minister of Health and Child Welfare is actively involved in the programme.

• A male circumcision Trainer of Trainers workshop was held in April 2009 and the provision of services was launched in the same month.

•There are five mobile clinics used by the nurses and doctors to cover the whole country on a periodic basis.

• Traditionally circumcising communities have also been supportive although their concern was that they should still be able to carry on with their traditional practices, which include various rites of passage without interference. Consenus building workshops were carried out.

• The plan focuses on prioritization of targeted activities to the most-at-risk-populations with the greatest potential impact for preventing new HIV infections. It also enables a corresponding prioritization regarding national resource allocation. Overall, the project’s focus is on prevention within the broader context of the government’s national plan for combating the epidemic

•The key to working with Zimbabwean communities is a balance of respect for and acceptance of cultural and religious practices, with the realities of HIV transmission and its impact on communities in Zimbabwe. Traditional leaders recognize the benefits of medical MC and the HIV education that came with it. And government, PSI and partners are willing to meet the needs of the communities while maintaining the high standards of safe, medical MC and providing a comprehensive package of MC services, including HIV testing and counseling.
The solid partnerships that were built mean continued collaboration in the future and will provide important lessons for the benefits of male circumcision beyond Zimbabwe.

Results

Outputs

30 000 Males circumcised, tested for HIV and counseled

Outcomes

• There is behavioural change and attitude to circumciscion among males
• 52% of rural males interviewed ready to be circumcised
• Circumcised males smarter and less likely to indulge in unsafe sex, e.g. use of condoms and not having casual sex when drunk



Partners

Ministry of Health and Child Welfare - Policy implementation and overall coordinator
Population Services International- Chief implementer
Ministry of Education, Art, Sports and Culture- Policy coordination and client identification
National AIDS Council
UNFPA
UNICEF
Zimbabwe National Family Planning Council
Community-based organizations

Donors

The Global Fund To Fight AIDS, Tuberculosis and Malaria
British Department for International Development (DFID)
World Health Organization
Government of the United States (USAID)
UNICEF
The Royal Netherlands Embassy

Lessons learned

• MC Communications should include clear messaging on benefits of MC as an additional HIV prevention intervention for HIV ne gative men, for “primary” prevention.
•Recruitment of HIV negative men through existing HTC facilities in Zimbabwe means that high proportions of MC clients are of known HIV status and low numbers of HIV-positive men are being circum¬cised.
• Close links between HTC and MC service providers, direct book¬ing for the procedure and telephone reminders ensured that HTC clients who had opted for MC at the HTC site actually received the service.
• Routine offer of testing to clients who presented for MC with un¬known HIV status resulted in high uptake of HTC among men un¬dergoing MC.
• Intensive counselling on the possible adverse health impact on cli¬ents who test HIV positive and adequate referral to HIV related care and treatment services ensured that the number of HIV positive cli¬ents opting to be circumcised was kept to a minimum.


Rwakurumbira Munyaradzi is a Deputy Director in the Modernisation Department, Office of the President and Cabinet