reaching adolescents with safe male circumcision services: school campaigns in botswana
TRANSCRIPT
Reaching Adolescents with Safe Male Circumcision Services: School Campaigns in Botswanaby: Ronald Wandira1, Conrad Ntsuape2, Adrian Musiige1, Kenanao Motlhoiwa1, Galina Stolarsky1, Amon Marwiro1, Kelly Curran3,4, Tracey Shissler3, Koziba Mookodi1, Segomotso Gaamangwe1 and Tigistu Adamu Ashengo3,4
affiliate: 1Jhpiego, an affiliate of Johns Hopkins University/Botswana; 2Ministry of Health (MOH), Botswana; 3Jhpiego, an affiliate of Johns Hopkins University/USA; 4Johns Hopkins Bloomberg School of Public Health
Background: The Safe Male Circumcision (SMC) and HIV SituationnHigh HIV prevalence (17.6%)#
nHigh HIV incidence (2.9%)# nLow circumcision prevalence (11.5%)#Botswana AIDS Indicator Survey (BAIS III) 2008; http://www.gov.bw Global/NACA%20Ministry/wana/BAIS%20III_Stats%20Press.pdf
Botswana
BackgroundnScaling up SMC to reach 80% of adult
and newborn males in Botswana by 2015 would avert > 33,000 adult HIV infections and save US$ 248 million between 2009 and 2025*.
*USAID/Health Policy initiative: The Potential Cost and Impact of Expanding Male Circumcision in Botswana; http://www.aidstar-one.com/sites/default/files/resources/external/health_policy_initiative/Botswana103009.pdf
nGenerally low uptake among older men targeted in public places, homes and work places. Achieved 32% of national target in 2012.
nCommon barriers: nTime off work (loss of income) during
healingnThe 6-week required abstinence post-
surgerynLack of “belief” in male circumcisionnFear of pain
nSchool campaigns are nationwide activities aimed at reaching school-going adolescents with SMC during the school holidays.
nPresently these campaigns generate most of the circumcisions done in the country program.
Background: Botswana SMC Program Milestones
2004 2006 2008 2010 2012 2013
Acce
ptab
ility
stud
y
Mal
e ci
rcum
cisi
on s
trate
gy d
rafte
d
Faci
lity
asse
ssm
ents
Shor
t-ter
m c
omm
unic
atio
n st
rate
gy
Star
t of i
mpl
emen
tatio
n
Expa
nsio
n of
out
reac
h
Mod
el fo
r Opt
imiz
ing
Volu
me
and
Effic
ienc
y —
MO
VE S
trate
gy
PreP
ex™
Dev
ice
stud
y
Re-s
copi
ng M
OVE →
Pro
ject
Long
-term
com
mun
icat
ion
stra
tegy
Base locationOutreach
Gaborone
Molepolole
Mahalapye
Selebi Phikwe
Activity Time and SMC Numbers in Study YearProportion of time by activity type Number of MCs by activity type
27%
73%
School campaign periodRegular services period
5,650
1,200
MCs done in schoolcampaign period
MCs done in regularservice period
A large proportion of MC numbers in the study year came from a much shorter fraction of work time devoted to school campaigns over the year.
HIV Status of School Campaign Clientsn100% tested for HIV and received their
results; 0.83% tested positive for HIV.
99.17%
0.83%
HIV-Negative
HIV-Positive
ResultsnBy the report date, the four district
teams supported by Jhpiego had cumulatively done 10,883 SMCs in the ~16 months since inception.
nFour school campaigns each lasting 3–6 weeks took place during the study period of June 2012 to July 2013, in which 6,850 clients were circumcised.
nOf these, 5,650 (82.5%) were circumcised during the 18 weeks of the four school campaigns, equivalent to only 27% of the duration analyzed in the study.
Lessons for Field ImplementationnStart preparations early in the school
term.nUse available “student/parent/teacher”
forums, including PTA meetings, effectively.
nSecure a “focal contact teacher” in each school, preferably the guidance and counseling teacher.
nProvide for advance HIV testing and counseling and parental consent by reaching out, during PTA meetings or home visits, to the parents of students who express interest in undergoing SMC.
nProvide SMC group education and counseling of the students ahead of time during school visits to shorten the duration of waiting time at the clinic on the procedure date.
nMove services to the students, or students to the services.
nStart services on free days preceding actual school closure (if any) before students disperse – an opportunity for peer motivation.
ConclusionsnThe school campaign strategy was
efficient in reaching high numbers of young, HIV-negative adolescents aged 10–19 years in a relatively short time:nCurrent program experiences indicate
that it would have been more difficult to reach these adolescents later as older, more sexually active, and working men.
nSchool campaigns are a crucial opportunity to efficiently mobilize and reach adolescents, who have lower HIV prevalence, with SMC.
ObjectivesnTo describe the school campaign
strategy of mobilization for SMC nTo demonstrate the role of school
campaigns as a means of reaching adolescents with male circumcision services in Botswana
MethodsnA retrospective analysis of routine
program data from four district SMC teams from May 2012 through July 2013
nCompared the number of clients who received SMC services during the school campaign periods to the total number circumcised in the period studied
nAssessed age category and HIV status of the clients accessing the services
Operational Roles at District Level within the PEPFAR Partnership
This work has been supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the Cooperative Agreement Number 5U2GPS001822-04 from the U.S. Centers for Disease Control and Prevention (CDC). The opinions expressed herein are those of the authors and do not necessarily reflect the views of PEPFAR, CDC or the United States Government.
SMC service staff address a group of students ahead of a school campaign.
A doctor is at a makeshift camp to deliver SMC services in an outreach.
School campaign clients primarily ranged in age from 10–19 years.
Training and Clinical Services
DHMT
Demand Creation HIV Testing and Counseling
Coordination
Activity Cycle in Study YearPreparations
(Planning meetings, target setting, logistics, advocacy, sensitization of teachers, parents,
and students, bookings)
Service Delivery
(HIV testing and counseling, MC procedures, daily reporting,
post-op follow-ups)
Post-Campaign Evaluations
(Team evaluations, district evaluation, national evaluation)
Post-Campaign Period
(Services targeting general community)
0
500
1,000
1,500
2,000
May-1June-12
Jul-12Aug-12
Sep-12Oct-12
Nov-12Dec-12
Jan-13Feb-13
Mar-13Apr-13
May-13Jun-13
Jul-13
411320
1,150
328243
369
1,074
502
266
390
1,060
796
499
1,585
1,915
Num
ber c
ircum
cise
d
Month
Number of School Campaign Clients in Study Year, by AgenMore clients were reached in each
subsequent school campaign.
0
500
1,000
1,500
2,000
2,500
3,000
10−19 age group
All ages
849
1,152967
1,220 1,222
1,484
2,612
2,994
Jun/Jul‘12
Nov/Dec‘12
Mar/Apr‘13
Jun/Jul‘13
Service Delivery Statistics by Month
nThe national-level planning team comprised MOH, donors and implementing partners.
nMOH took charge of national-level coordination.
nDistrict Health Management Teams (DHMTs) led district activities supported by NGO partners.
nPost-campaign evaluations generated lessons from prior campaigns that were used to improve planning and implementation in each subsequent campaign.
Coverage of Jhpiego-Supported TeamsnFour SMC provider teams in four health
districts, supporting seven districtsnFour– to five– day outreach visits are
conducted within and beyond the four base health districts