reaching adolescents with safe male circumcision services: school campaigns in botswana

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Reaching Adolescents with Safe Male Circumcision Services: School Campaigns in Botswana by: Ronald Wandira 1 , Conrad Ntsuape 2 , Adrian Musiige 1 , Kenanao Motlhoiwa 1 , Galina Stolarsky 1 , Amon Marwiro 1 , Kelly Curran 3,4 , Tracey Shissler 3 , Koziba Mookodi 1 , Segomotso Gaamangwe 1 and Tigistu Adamu Ashengo 3,4 affiliate: 1 Jhpiego, an affiliate of Johns Hopkins University/Botswana; 2 Ministry of Health (MOH), Botswana; 3 Jhpiego, an affiliate of Johns Hopkins University/USA; 4 Johns Hopkins Bloomberg School of Public Health Background: The Safe Male Circumcision (SMC) and HIV Situation n High HIV prevalence (17.6%) # n High HIV incidence (2.9%) # n Low 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 Background n Scaling 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 n Generally low uptake among older men targeted in public places, homes and work places. Achieved 32% of national target in 2012. n Common barriers: n Time off work (loss of income) during healing n The 6-week required abstinence post- surgery n Lack of “belief” in male circumcision n Fear of pain n School campaigns are nationwide activities aimed at reaching school- going adolescents with SMC during the school holidays. n Presently these campaigns generate most of the circumcisions done in the country program. Background: Botswana SMC Program Milestones 2004 2006 2008 2010 2012 2013 Acceptability study Male circumcision strategy drafted Facility assessments Short-term communication strategy Start of implementation Expansion of outreach Model for Optimizing Volume and Efficiency — MOVE Strategy PrePex Device study Re-scoping MOVE Project Long-term communication strategy Base location Outreach Gaborone Molepolole Mahalapye Selebi Phikwe Activity Time and SMC Numbers in Study Year Proportion of time by activity type Number of MCs by activity type 27% 73% School campaign period Regular services period 5,650 1,200 MCs done in school campaign period MCs done in regular service 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 Clients n 100% tested for HIV and received their results; 0.83% tested positive for HIV. 99.17% 0.83% HIV-Negative HIV-Positive Results n By the report date, the four district teams supported by Jhpiego had cumulatively done 10,883 SMCs in the ~16 months since inception. n Four 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. n Of 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 Implementation n Start preparations early in the school term. n Use available “student/parent/teacher” forums, including PTA meetings, effectively. n Secure a “focal contact teacher” in each school, preferably the guidance and counseling teacher. n Provide 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. n Provide 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. n Move services to the students, or students to the services. n Start services on free days preceding actual school closure (if any) before students disperse – an opportunity for peer motivation. Conclusions n The school campaign strategy was efficient in reaching high numbers of young, HIV-negative adolescents aged 10–19 years in a relatively short time: n Current program experiences indicate that it would have been more difficult to reach these adolescents later as older, more sexually active, and working men. n School campaigns are a crucial opportunity to efficiently mobilize and reach adolescents, who have lower HIV prevalence, with SMC. Objectives n To describe the school campaign strategy of mobilization for SMC n To demonstrate the role of school campaigns as a means of reaching adolescents with male circumcision services in Botswana Methods n A retrospective analysis of routine program data from four district SMC teams from May 2012 through July 2013 n Compared the number of clients who received SMC services during the school campaign periods to the total number circumcised in the period studied n Assessed 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 Year Preparations (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-1 June-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 411 320 1,150 328 243 369 1,074 502 266 390 1,060 796 499 1,585 1,915 Number circumcised Month Number of School Campaign Clients in Study Year, by Age n More 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 1,152 967 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 n The national-level planning team comprised MOH, donors and implementing partners. n MOH took charge of national-level coordination. n District Health Management Teams (DHMTs) led district activities supported by NGO partners. n Post-campaign evaluations generated lessons from prior campaigns that were used to improve planning and implementation in each subsequent campaign. Coverage of Jhpiego-Supported Teams n Four SMC provider teams in four health districts, supporting seven districts n Four– to five– day outreach visits are conducted within and beyond the four base health districts

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Page 1: Reaching Adolescents with Safe Male Circumcision Services: School Campaigns in Botswana

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