Three clinical trials have shown that male circumcision (MC) reduces female to male HIV transmission by approximately 60%. Modeling suggests that scaling up MC to 80% coverage of men 15 to 49 over the next five years would avert over 4 million new HIV infections in 14 countries in southern and eastern Africa. That would require 29 million circumcisions. The shortage of skilled health professionals in high prevalence countries has posed a major challenge to achieving that goal.
The health professional shortage is both absolute and related to utilization. WHO estimates that sub-Saharan Africa has 25% of the world’s disease burden, but only 3% of the world’s health workforce. In addition, many health care workers in the region are unemployed and others are recently retired.
Jhpiego takes a multi-pronged approach to address this shortage, from improved clinical technique and better logistics to task sharing and task shifting. In Kenya and Swaziland, Jhpiego-supported task shifting has had a great impact. Jhpiego has helped train and empower nurses to perform MC procedures in an effort to intensify HIV prevention programs. With the involvement of nurses, Kenya was able to circumcise 268,000 men in just 2.5 years. In Swaziland, a short term MC campaign supplemented the small nursing workforce with volunteer physicians from other countries. Every volunteer takes an assessment and undergoes training to ensure standardization of critical skills.
By expanding the health workforce through task shifting, Jhpiego is improving locally-sustainable prevention efforts and strengthening the skills of nurses in Southern and East Africa.
There is an age old story about a man walking along a river who sees someone being pulled along by the current and calling for help. As he reaches for a vine to toss to the person, he sees more people coming downstream. As he continues to try to rescue those struggling in the river, he asks a friend to go upstream and see what he can do to prevent people from falling in.
Since voluntary medical male circumcision (MC) has been proven to reduce female to male HIV transmission by approximately 60% or more, the world of HIV prevention is driving major national level campaigns to deliver MC to adolescents and adults. Studies show that this short term ‘downstream’ approach is essential to avert many future infections and reduce the overall prevalence of the disease.
However, in the long term, the attention will shift ‘up stream’ with programs in early infant male circumcision. Jhpiego is preparing for that future now. Dr. Tigistu Adamu, HIV/AIDS Technical Advisor for Jhpiego, helped produce the global learning resources package for early infant male circumcision with the World Health Organization (WHO). The package includes dynamic audio-visual materials, inexpensive anatomic models, and training manuals for the trainer and participant.
Early infant male circumcision is cheaper, easier, and less risky than adolescent and adult MC. Infant patients heal faster, have even lower rate of complications than the already low rate in adults, and avoid the adult risks associated with sexual activity before healing. Programs for early infant male circumcision cost less because there is little need for post-procedure counseling, devices are more affordable and accessible, and programs can be integrated with existing maternal health services.
Tonight, Dr. Adamu will share more about this intervention as he joins four other impressive speakers from UNAIDS, WHO and the Kenyan Ministry of Health at a satellite session during the IAS conference in Rome. (More at http://www.jhpiego.org/en/content/events.)
Going to Rome for the IAS conference? Don’t miss the Jhpiego event on Sunday, just before the opening reception. Stop by our event for inspiring speakers and lovely refreshments before joining in the grand opening.
The Cutting Edge: What’s New in Male Circumcision?
Sunday 17 July 2011; 17:00-19:00; Mini Room 1
For more than 35 years, Jhpiego has pioneered innovative, low-cost, lifesaving solutions for today’s global health concerns, including the prevention of HIV/AIDS. One of the most effective tools that exists today is voluntary medical male circumcision (VMMC).
Compelling evidence indicates that VMMC can reduce the risk of female-to-male transmission of HIV by approximately 60%. VMMC provides a greater protective benefit than any potential vaccine studied to date. Modeling suggests that rapid scale up of VMMC to 80% of adult males in East and Southern Africa would avert more than 3 million new infections and save 416.5 billion in care and treatment costs by 2025. Further, there is evidence that female partners of circumcised men have lower rates of cervical cancer and certain sexually transmitted infections.
Join Jhpiego and its partners from WHO, UNAIDS and the Kenya Ministry of Health for conversation and refreshments.
Cate Hankins, UNAIDS; 2007-2011: State of the VMMC Scale-up
Tigistu Adamu, Jhpiego; Start at the Beginning: Early Infant Male Circumcision
Tim Farley, World Health Organization; Adult MC Device Update and WHO Approval Process for Medical Devices
Peter Cherutich, National AIDS and Sexually Transmitted Infections Control Programme (Kenya); 250,000 Circumcisions in 2.5 Years
Hally Mahler, Jhpiego; Matching Supply with Demand for VMMC
By Melody McCoy
Maputo, Mozambique – The community health workers grab their signature blue backpacks, hoist them over their shoulders and head down the dirt roads of Mumemo. The things they carry will make a difference in the health of families in this southern African country that has one of the highest HIV prevalence rates on the continent.
Walking six to 10 miles a day, Rosalina Antonio Tamela carries 15 pounds of supplies and forms in her back pack, everything she needs to share information about prevalent health issues and to test a villager for HIV, provide counseling and a referral for treatment. She consults a color-coded map to find the day’s clients—green indicates homes of families where all members have been tested, yellow pinpoints homes where a few have been tested and red signals a refusal to test. But Tamela is not deterred by the number of red houses on her map. She lost her parents and all of her siblings to HIV/AIDS, and she doesn’t want anyone else to suffer. Volunteers like Tamela say, “We must test all—we must make sure that ALL who need services receive them.”
With help from Jhpiego, Mozambique has expanded community-based HIV counseling and testing services throughout the country, reaching provinces where people have limited access to essential health services and facilities. In a country of 20 million, less than 25 percent of adults are aware of their HIV status. Jhpiego worked with the Ministry of Health to develop a national HIV prevention and treatment plan with the goal of providing HIV counseling and testing services to all citizens and helping link them to health facilities. In 2007, Jhpiego developed a pilot program to use community volunteers to counsel and test Mozambicans in their homes and villages.
The pilot was so successful—its testing rate is less expensive and accurate—that it is being replicated through a collaboration with nonprofit organizations and other partners. Since the program began and expanded to 10 provinces, 441,134 Mozambicans have been counseled and tested for HIV, with 192,500 from October 2010 to March 2011, a considerable increase. That’s impressive progress in a country where 11.5 percent of adults and 13.5 percent of pregnant women are living with HIV.
In Mumemo, a Franciscan nun, Sr. Susana Custodio, has been a big supporter of the Home and Community Counseling and Testing for Health initiative (CCT). She knows firsthand the need for such a program—the orphanage she runs is populated by children whose parents have died from HIV/AIDS. The first act of prevention is to get tested, and the community volunteer program brings testing to a family’s doorstep.
The volunteers learned the essentials of health counseling including HIV testing from Jhpiego health professionals who helped design the program. Communities were studied and mapped to identify families who need services. Volunteers—who routinely work long hours and in all weather—carry backpacks that contain HIV rapid testing equipment, supplies, forms, condoms, other HIV-prevention materials and rain gear. Some carry the packs on their head, if their children accompany them on their route.
On any given day, a volunteer will visit five to 15 houses and test about 15 people. On Thursdays in Mumemo, the 10 volunteers, who receive a small monthly stipend, focus on houses with yellow and red codes and check on HIV-positive clients to ensure they are taking their medicines. In conjunction with the Ministry of Health’s emphasis on an integrated health systems approach, the volunteers assess clients for a variety of health concerns—for example, tuberculosis, malaria and hypertension—and make referrals, if necessary.
When a household refuses testing, community workers focus on counseling and testing neighbors. Once surrounding neighbors have been tested, a worker will return to the “red house” and approach the family again about following the good example of nearby residents. Program staff report that, in most cases, members of that family will reconsider participating in testing.
This mission “has put something in our hearts,” says Judite Cardoso, a Jhpiego CCT program coordinator.
Adds Tamela: “We put ourselves in their place. If we can’t help, our hearts are not free.”
On one recent Saturday, counselor tester Alfredo is sitting under a leafy green tree, his equipment and supplies laid out on a tray. A young mother named Sabina arrives with her 12-year-old son Frederico and her new baby. The mother tells Alfredo that her son is old enough to decide if he wants to be tested. He says he does. The boy is curious and nervous. With a prick of the 12-year-old’s finger, the volunteer begins the test. The mother sits nearby, quietly nursing her baby.
The boy’s test is negative and everyone is relieved. Frederico is asked to leave so his mother can receive her test results in private. The news is heartening—Sabina also is negative. Alfredo counsels her on ways to prevent contracting HIV and advises her to seek care for her high blood pressure. As the two are talking, a neighbor wanders by. The man asks the health worker to please visit his family so they can be tested, a request befitting the program’s motto: “Never leave anyone behind.”
By Lopa Basu
Cotonou, Benin — At the Mon Etoile maternity clinic, owner and midwife Flora Abalot Azondekon has learned that quality assurance is good for business. After adapting lessons learned in a Jhpiego-supported program, Madame Flora saw an increase in new clients at her private clinic.
“To make us competitive, Jhpiego taught us approaches in performance improvement to provide quality care to our clients,” explains Madame Flora, who opened the private maternity clinic in 1980 in Benin’s capital of 760,000.
Madame Flora first began working with Jhpiego in 2008 as part of the IMPACT program, an initiative in Benin funded by the U.S. Agency for International Development and designed to strengthen maternal health care services in HIV/AIDS counseling and testing, prevention of mother-to-child transmission of HIV, family planning and reproductive health and to increase demand for these services. Starting with two pilot sites in Glazoue and Kalale, the Benin IMPACT program has expanded to 12 public health centers and more than 50 private clinics affiliated with the ProFam network run by partner Population Service International.
As part of the IMPACT program, Jhpiego, which started its first project in Benin in 1998, worked with health providers to adopt an integrated health services approach to delivering care and to apply the Jhpiego-developed Standards-Based Management and Recognition (SBM-R) process to strengthen health systems and improve services. Through her collaboration with Jhpiego, Madame Flora and her staff were able to set premium health care standards at her facility and build capacity among employees to reinforce and strengthen the quality of care for mothers.
Pregnant with her first child, Olivia Tunde, 25, visited Mon Etoile after seeing a local television program highlighting the quality of care and well-trained staff. “I chose the services at this hospital for my first pregnancy and am very happy here because I am treated well. The medical interview and physical examination were well done,” said Mrs. Tunde.
Through the IMPACT program, more than 360 physicians, midwives and nurses in public health centers have received training in an integrated approach to reproductive health. As a result, more than 9,000 clients were counseled and tested for sexually transmitted infections, 7,483 women participated in focused antenatal care (with a majority receiving services for prevention of mother-to-child transmission of HIV) and 1,600 accessed family planning services.
In addition, 137 private health providers received training in integrating HIV-related services with reproductive health care.
For the past five years, Jhpiego’s Benin technical advisor, Dr. Mathurin Lougbegnon, has successfully integrated reproductive health services and HIV prevention programs using Jhpiego’s SBM-R approach with the goal of strengthening health systems. “The reproductive health (RH) and HIV/AIDS services are strongly integrated in Benin and Jhpiego is working on that approach,” he said. “Now we’re doing an extension of that integrated approach. We are working in 12 public health facilities and 7 of them are offering the integrated services of RH and HIV/AIDS . . . I can ensure you that all Benin residents get the HIV care and services that they need.”
By giving health care providers like Madame Flora a means to develop and implement their own self-improvement program, SBM-R strengthens current local best practices in maternal health care. This accountability-based strategy provides incentives for employees to maintain compliance with performance measures and allows for a more standardized approach to health care delivery.
A graduate from the National Medical-Social Institute of Benin, which trains midwives, nurses and social workers, Madame Flora decided that instead of taking the traditional route in her profession by working in the public sector, she would open a private maternity hospital. This entrepreneur’s experience with Jhpiego’s pioneering quality assurance program shows how private sector clinics and hospitals can gain a competitive edge by improving their health care services.
Benin is among eight countries—including India, Kenya, Philippines and Tunisia—in which Jhpiego has helped private hospitals, clinics and providers expand and improve health care services. In Benin, private businesses account for about 35 percent of the West African nation’s medical services.
Laura Yekame, 34, is another satisfied customer of Madame Flora’s Mon Etoile clinic. She chose to deliver at Mon Etoile after suffering three previous miscarriages. Diagnosed with malaria, she was placed on an intravenous drip in order to protect her baby and felt reassured that she was in good hands. “My friends advised me to come here for better care,” said Mrs. Yekame. “Indeed, as soon as I entered the clinic, I noticed that the reception is better than in other clinics I’ve attended.”
By Bright Orji and Enobong Ndekhedehe
When word went out for volunteers to help prevent malaria in her home state of Akwa Ibom in Nigeria, Uduak Imo Bob responded to the call. How could she not? For years, she worked as a traditional birth attendant for a church group, delivering babies in the community of Atiamkpat in southeasternNigeria. She had witnessed firsthand the devastating effects of malaria on pregnant women. Death was not uncommon in the women she knew who had acquired the mosquito-borne disease. She, too, had become ill with the fevers and headaches—but survived.
The malaria in pregnancy program introduced by Jhpiego and funded by ExxonMobil offered Uduak a chance to keep others safe. She signed up with 38 other women to serve as a CDD (community-directed distributor) in the villages surrounding the Atiamkpat Clinic, providing malaria prevention services and treatment.
Her neighbors knew they could count on her. “Uduak has been resourceful in the past and always committed in whatever assignment given to her,” one community leader commented about the 47-year-old mother of six.
With Jhpiego’s support, Uduak learned the skills and protocols to deliver malaria in pregnancy services to women, including distributing insecticide-treated bed nets and administering intermittent preventive treatment of malaria in pregnancy (IPTp). She is part of a frontline network of volunteers and health care providers who deliver services from home to health facility in the Onna local government area and help direct community malaria-fighting projects. Uduak and her CDD colleagues have provided malaria prevention and treatment services to 12,106 pregnant women.
Uduak showed such exceptional skills and promise during her training that colleagues chose her to be the chief volunteer coordinator. “Uduak is responsible and one who respects other people’s opinion,” said one co-worker.
In this role, she supervises and coordinates the other women volunteers and ensures their antimalarial drug stocks are adequate and their community registers are updated for accurate service provision.
Uduak understands the threat that malaria poses to Nigerian women and families—malaria causes the deaths of 4,500 pregnant women a year and accounts for one in four cases of anemia in pregnancy. Malaria also causes low birth weight in one in 10 Nigerian infants. On her own initiative, Uduak decided to organize and mobilize traditional birth attendants in her community, persuading them to send their clients for prenatal or antenatal care (ANC), where pregnant women receive malaria prevention services. The nursing officer at the Atiamkpat Clinic and the traditional ruler in the community supported her in this life-sustaining effort.
Without any financial reward or personal gain, Uduak carries out her duties responsibly and enthusiastically. As she explains: “The life and survival of pregnant women is my concern and much more important than money. There is an inner joy in providing quality community service, and this motivates me.”
As part of her work, Uduak delivers health talks to women in her church and offers group counseling sessions on malaria to pregnant women in her community. And she is not shy in her efforts to convince women to protect themselves from malaria. Consider her outreach to one woman who received an insecticide-treated bed net:
“Without Uduak I would not have started using the net,” said the woman who participated in the ExxonMobil-funded program. “Her consistency and persistence in reminding me to use the net prompted and encouraged me to do so.”
The work of Uduak and her fellow community volunteers is improving health services in other important ways. Before the ExxonMobil-funded program began, pregnant women were not patronizing the Atiamkpat health facility and its clinics. Women complained that they couldn’t count on staff being on duty when they visited a facility—there are about six clinics in the district. Uduak and her colleagues met with the health providers and got their commitment to staff the facilities. This coincided with Jhpiego’s training of health staff to improve the quality of ANC and malaria control services they provided.
Now women are coming to the facility to receive ANC. The number of clients has increased from just two pregnant women in the three months preceding the discussions with health staff, to 50 pregnant women in the first three months of staff reporting to the facility. And now women also give birth at the health center. As a result of efforts made by Uduak and her group of CDDs, on average 43% more pregnant women in the Atiamkpat Clinic catchment area are receiving the required two doses of IPTp as compared to pregnant women in three other local government clinics/catchment areas.
Uduak has been a role model to her fellow volunteers and a source of support.
“We would have stopped this work since we are not paid, but Uduak has continued to encourage and motivate us,” said one colleague.
The pregnant women Uduak serves also recognize her contributions. “Uduak is selfless and committed to helping people. Her life is a testimony and a challenge to us,” said one program beneficiary.
By Tsigué Pleah and Megan Harris
Ouagadougou, Burkina Faso – As a physician, Jean Lankoande has a hard time telling a patient that she has cervical cancer. At that stage, he says, he can offer a woman little hope. He knows that early detection is the key to treating this preventable disease. But rather than be overcome by his sense of frustration, Dr. Lankoande has channeled his energy into championing cervical cancer prevention programs for women across the West African nation of Burkina Faso.
Dr. Lankoande, 58, has been collaborating with Jhpiego as a trainer and consultant and working toward greater access to cervical cancer screening since 2008, when he attended a training course in Malawi on Jhpiego’s pioneering, single visit approach to screening and treatment. This screening method uses visual inspection of the cervix after it has been swabbed with vinegar to detect precancerous cells. If precancerous cells are identified, the provider offers treatment with cryotherapy—a freezing technique that destroys potentially lethal cells—in the same visit. The single visit approach ensures that women receive their screening results and treatment on the same day, thus reducing loss to follow-up.
According to a World Health Organization survey of cancer in Burkina Faso, an estimated 921 women are diagnosed with cervical cancer every year and 724 women die from the disease. Of all the deaths from cancer among women in Burkina Faso aged 15–44, cervical cancer is the highest, at 13.7 deaths per 100,000.
Jhpiego, in partnership with the Ministry of Health, has been working to strengthen health systems and build capacity in maternal and newborn health in Burkina Faso since 1995. A demonstration project on improving basic and comprehensive emergency obstetric and newborn care in health centers and hospitals was so successful that it led to the founding of a regional, comprehensive emergency obstetric and neonatal care center at Bobo-Dioulasso, which serves to build the capacity of midwives and doctors.
Jhpiego’s work in Burkina has since expanded to include projects for the prevention of mother-to-child transmission of HIV, prevention and treatment of malaria in pregnancy, and a cervical cancer prevention initiative funded by the Izumi Foundation. The two-year cervical cancer prevention project, in partnership with the Midwifery Association of Burkina, seeks to expand access to cervical cancer screening by strengthening the skills of midwives and nurses to successfully perform the single visit approach and reach many more women. The project is under way at two university teaching hospitals in Burkina where 512 women have been screened between September and February of this year.
Most women in countries like Burkina Faso don’t have access to Pap tests, the routine way women are screened for cervical cancer in the developed world. With 80 percent of deaths from cervical cancer occurring in the developing world, Dr. Lankoande says he can’t emphasize enough the relevance and importance of the single visit approach in Burkina.
“This is the best method to boost our activity around managing precancerous cervical lesions,’’ said Dr. Lankoande, who has served as master trainer and consultant for Jhpiego in Guinea and Haiti. “There are
only four pathologists [in the country]. The single visit approach is the way to go and I’m convinced it can serve the population in Burkina Faso.”
An enthusiastic supporter of cervical cancer screening, Dr. Lankoande is a well-respected resource on maternal health issues and policies in Burkina, said Dr. André Yolland Ky, Country Director of Jhpiego’s Burkina Office. “A real advocate!”
As the chief of obstetrics and gynecology at Yalgado Ouedraogo Teaching Hospital, Dr. Lankoande began an early screening program there with Jhpiego’s support. On his own initiative, he did the same at two regional hospitals in Fada and Ouahigouya with donated equipment from a French nongovernmental organization and persuaded hospital administrators to commit to maintaining use of the cryotherapy machines.
During his visits to the cervical cancer screening centers, Dr. Lankoande says he feels keenly his mission to heal. “There are women who come in with very advanced cases [of cervical cancer], which unfortunately are seen very frequently during screening—cases of women without hope,” said the doctor. “There is a sentiment of loss, a sentiment of frustration and really that is what motivates me and reinforces my decision [to promote cervical cancer prevention efforts].”
The Ministry of Health has been supportive in helping provide these services to women in Burkina Faso, he said, but the need is great. He cited the example of a regional meeting of fellow obstetricians and gynecologists who volunteered to host a cervical cancer screening. “A lot of women came,” he said, “but we could only handle 800. There is a huge demand for the service.” Dr. Lankoande said he has sought additional help from international organizations to supply cryotherapy machines at facilities that lack them so more women can be screened and treated in the same visit.
Dr. Lankoande is heartened by the fact that midwives in Burkina Faso have begun providing cervical cancer screening of patients, increasing the capacity to deliver these services to women. “They are doing the screening. They are doing the cryotherapy. It is a huge addition. In the past, cervical cancer was taken care of by physicians. Now there is a huge commitment to take care of the women by the midwives,” he says.
That shift should make it easier for more women to receive such services once screening units are in place and a national cervical cancer prevention program established. As of 2009, the World Health Organization estimated that there were 10 physicians per 100,000 people, compared to 13 midwives per 100,000 people.
The benefits of early screening, diagnosis and treatment of cervical cancer prevention have been seen time and again. According to research studies, countries that have developed and implemented high-quality cancer prevention programs with high participation rates have seen their incidence of cervical cancer decrease by 70 to 90 percent.