No Circ, No Sex: Women withhold sex, sending men to get circumcised first

It’s been documented that women generally have better health service seeking behaviors than men. It’s therefore not surprising that a new study by Jhpiego and the Ministry of Health and Social Welfare on the role of women in uptake of VMMC in the Njombe and Tabora regions of Tanzania has revealed that women there are playing a significant role in influencing males in uptake of voluntary medical male circumcision (VMMC) for HIV prevention.

In this study, whose results have recently been published in PLoS One, participants reported that mothers and female partners influence boys’ and men’s decisions to seek VMMC. The women use both direct and indirect means to achieve this – from persuasive discussions, pressuring friends, sons, siblings or partners to denying partners sex.

This study confirms what’s been known but has not been adequately documented. As such, many programs in the different VMMC priority countries can take advantage of the influence that women have on the males in their lives to find ways to meaningfully engage them so as to help scale up roll out of services. Also, messaging on benefits of VMMC to women should be part of these conversations to ensure that women and men know that while VMMC is an intervention for men, its benefits go to women as well, at the individual and community levels.

For additional background about the benefits VMMC can have for women’s health as well as ways women can advocate and support the implementation of this HIV prevention method, check out Making Male Circumcision Work for Women, which AVAC and partners published in 2010.

New PrEP Educational Videos from APCOM

Having recently held a regional dialogue focusing on the roll out of PrEP, PrEPARING ASIA: A new direction for HIV prevention among MSM in Asia, APCOM has released a number of short educational videos regarding PrEP. The videos are designed to give people a greater understanding of PrEP from the experience of users, community advocates and experts.

Four videos have been released in the series. with a selection of interview highlights from:

  • Dr Chris Beyrer, President of International AIDS Society
  • Dr Nittaya Phanuphak, Chief of Prevention at Thai Red Cross AIDS Research Centre
  • Midnight Poonkasetwattana, Executive Director of APCOM

The videos also feature the experience of three PrEP users from Indonesia, the Philippines and Canada.

You can watch the videos now by clicking here.

Truvada as PrEP: A new HIV prevention option on the table for Zimbabwe?

Zimbabwean advocate Paul Sixpence’s opinion piece, Truvada as PrEP: A new HIV prevention option on the table for Zimbabwe? was published in The Zimbabwe Chronicle. Given scientific evidence that PrEP works, he calls for PrEP rollout for young women, sex workers and serodiscordant couples in Zimbabwe. Paul’s work centers on the use of media as an advocacy tool to push for policy support around new HIV prevention science.

Recent policy pronouncements by the World Health Organisation (WHO) recommending national public health systems to incorporate Truvada as Pre-Exposure Prophylaxis (PrEP) into their prevention interventions present a new revolution in the fight against new HIV infections. The WHO guidelines came on the background of overwhelming science that proves that Truvada as PrEP works when taken correctly as presented at two major global HIV and AIDS conferences namely the 2015 Conference on Retroviruses and Opportunistic Infections (CROI) and the International AIDS Society (IAS) 2015.

In light of scientific evidence that proves that PrEP works and considering the burden of HIV and AIDS to Zimbabwe’s socio-economic development, this instalment advocates for PrEP roll-out for young women, sex workers and sero-discordant couples in Zimbabwe.

What is PrEP?

Pre-exposure prophylaxis is the use of antiretroviral medications (ARVs) to reduce the risk of HIV infection in people who are HIV negative. Truvada is an ARV that has been approved in Zimbabwe for treatment purposes. In a nutshell, PrEP is the taking of preventive drugs to prevent primary infection prior to engaging in a potential risky sexual encounter that can possible expose one to HIV infection. In other words, it is akin to taking anti-malaria tablets prior to getting into a malaria zone.

Evidence that proves that PrEP works

This article is based on the TDF2 and Partners PrEP clinical trials. TDF2 was conducted in Botswana among young heterosexual couples and Partners PrEP was conducted among sero-discordant couples in Kenya and Uganda. Both clinical trials exhibited efficacy rates of over 80 percent.

PrEP efficacy and feasibility case studies presented in this piece have been deliberately chosen because they were conducted in Africa and in resource constrained settings relatively similar to those obtaining in Zimbabwe. There are other clinical trials that have been conducted in France, Britain, Brazil and the United States of America, among diverse sets of population and they all indicate that PrEP works.

Taking note of all these positive and inspiring findings in the field of HIV biomedical interventions, the president of the International AIDS Society and Chair of IAS 2015, Chris Beyrer had this to say:

“The science on PrEP is overwhelming and its conclusions are clear: PrEP works when taken. Access to PrEP is now a public health and human rights imperative. The studies presented here [at IAS 2015] provide the most detailed data to date on PrEP implementation successes and challenges, underscoring that the intervention is feasible and effective in the real world. We hope these studies launch the beginning of a new PrEP era.”

Current global trends in adopting PrEP

PrEP was licensed for treatment purposes in the United States of America in July 2012. Applications for regulatory approval have been filed in Australia, Brazil, Canada, South Africa and Thailand.

Is PrEP for Zimbabwe?

PrEP is not for everyone but for specific populations at high risk of infection. Among those who are in need of PrEP in Zimbabwe are key populations, namely, young women, sero-discordant couples and sex workers.

Presenting oral evidence to the Parliament of Zimbabwe Thematic Committee on HIV and AIDS in July 2015, National AIDS Council (Nac) Chief Operations Officer, told the Committee that his organisation was worried about the increasing rates of new infections among girls and young women between the ages of 15 and 24 years.

He noted that about 80,000 young girls and women were living with HIV as compared to 36,000 of their male counterparts. These statistics speak of an urgent need to offer young women with a wide range of HIV prevention options.

According to the Centre for Sexual Health and HIV/ AIDS Research (Ceshhar) out of 52,214 sex workers almost 11,000 (20 percent) are living with HIV. These figures speak of an urgent need to provide sex workers with new and effective solutions in preventing primary HIV infection in addition to messages on correct and consistent use of condoms and behaviour change.

The way forward

There is an urgent need for collaborative engagement between policy makers in relevant State institutions, HIV and AIDS researchers and civil society actors to analyse the science that proves that PrEP works with the local context in mind, work on regulatory approval, develop guidelines and roll-out PrEP to those at high risk of HIV infection and who need it.

From November 29 to December 4, 2015, Zimbabwe will host the International Conference on AIDS and STIs in Africa (ICASA).

In light of the encouraging PrEP efficacy and feasibility results, ICASA 2015, should serve as a marketplace of ideas and exchange of knowledge on how to mobilise resources for PrEP roll-out, enhancing the capacity of public health systems to integrate PrEP into their existing comprehensive HIV treatment and prevention packages and ways of raising awareness among people of the existence of this new HIV prevention option.

Paul Sixpence is an HIV prevention and treatment advocate and 2015 AVAC fellow. He can be contacted at:

Clearinghouse Quarterly Research Digest

The Clearinghouse on Male Circumcision has announced a new feature to their site – Clearinghouse’s Quarterly Research Digest. The digest provides links to full text of articles that are open access. The Clearinghouse is a global resource center designed to expand access to information and resources on voluntary medical male circumcision for HIV prevention. It is a collaboration between FHI 360, WHO, UNAIDS and AVAC. Details on this digest are available in the Clearinghouse’s announcement at this link, and you may click here to sign up for periodic updates from the Clearinghouse.

Pre-exposure Prophylaxis in Kenya, Can it be Real?

Kenyan advocate Carolyn Njoroge published an opinion piece, Pre-exposure Prophylaxis in Kenya, Can it be Real?, calling for immediate action on PrEP as an HIV prevention option for individuals at high risk of HIV infection. An openly HIV positive activist and sex worker herself, Carolyn lauds the Kenyan government for including PrEP in its roadmap to an HIV-free Kenya by 2030 but challenges them, and other governments, to talk less and act more.

This is a timely piece given that just last week, on September 30, WHO issued an “Early Release Guideline” on when to start antiretroviral therapy and on pre-exposure prophylaxis (PrEP) for HIV. Carolyn is a 2015 AVAC Fellow advocating for the roll out of PrEP that would empower and protect sex workers, and other key populations. She is hosted by the Kenya Sex Worker Alliance (KESWA). Read more about her advocacy activities here.

Interview with an Advocate: Fearless leader of Uganda’s Voluntary Medical Male Circumcision (VMMC) Program speaks of momentum, motivation and maintaining success

Uganda has made tremendous progress in its VMMC (also known as Safe Male Circumcision or SMC in Uganda) scale-up over the past two years, with over 1.7 million men were circumcised in 2013 and 2014 alone. A cumulative total of 2.1 million circumcisions have been done in Uganda since 2008 according to WHO’s recent Progress Brief. As Coordinator of the National Safe Male Circumcision, Dr. Barbara Nanteza has led the Uganda program during this critical period of scale-up. Dr. Nanteza talked to the coordinators of the VMMC Truth-tellers Initiative about leadership, collaboration with the Ministry of Health and implementing partners, the unmet need for sustainable funding, best practices and loving her work.

Truth-tellers (TT): What is your role as the head of the National Safe Male Circumcision (SMC) program in Uganda?

Dr. Barbara Nanteza (BN): My roles are really many and broad. I’m responsible for management of the program – in other words providing coordination, leadership, and ensuring that the program has the infrastructure, logistics and supplies to keep it running smoothly. I’m also responsible for maintaining standards of the program on a range of issues including policy, capacity building, training, supervision and quality improvement. As head of the program, I also mobilize resources and lead its strategic planning.

TT: What was the program’s biggest challenge when you took over in 2012, and what’s the biggest challenge today?

BN: Much as Uganda spearheaded the clinical trials in 2005, the country didn’t take on safe male circumcision immediately. It wasn’t until 2010 that some SMC work started. The US President’s Emergency Plan for AIDS Relief (PEPFAR) had already started funding the program directly through the implementing partners (IPs), but the entire management system was down. It took a lot of courage and effort to streamline both management and maintaining the standards given that IPs had been given a lot of money by PEPFAR. It’s rather ironic that our biggest challenge today is funding.

Unfortunately, the funding challenges are coming at the back of three years of our biggest scale-up. Demand for SMC services is very high at the moment. Last year our target was one million circumcised, but we had funding for 750,000. We ended the year with 878,109 males circumcised. Our target for 2015 is still one million, but I have funding for only 330,000 procedures. That’s a huge funding gap, which without a doubt, will slow down the program.

TT: Some issues came up around tetanus and SMC in Uganda last year; can you tell me about them? [Editor’s note: In 2014, nine cases of tetanus were reported across multiple country national VMMC programs—six resulted in death. Consequently, WHO and partners assessed tetanus risk associated with VMMC and different circumcision methods. To minimize tetanus risk, WHO now advises a dual approach of clean care (emphasis on clean wound care and standard surgical protocols for sterility) and tetanus vaccine interventions. For more information go to WHO Informal Consultation on Tetanus and VMMC.]

BN: In 2014, we faced another unforeseen challenge – tetanus. There were reported cases of tetanus among five males [in Uganda] who had undergone circumcision [with either surgical or device methods]. The reality is that the SMC program helped Uganda realize that as a country we have high background tetanus. The SMC program should be strengthened to help save many Ugandans from this immunizable disease. Through the SMC program we can reach many Ugandans, both men and women. If funds are available, we can make the SMC program become proud of vaccinating Ugandans against tetanus, which has a mortality of more than 56 percent.

TT: The program has made tremendous progress since you took over—from about 80,000 circumcisions in 2011 to a cumulative total of 2.1 million by 2014—about 80 per cent of which were accomplished in 2013–14. What are your plans to maintain this pace of scale-up or even surpass it?

BN: I attribute the achievements to hard work and focus. A few individuals and institutions stand out – including those at PEPFAR, the Ministry of Health (MoH), the AIDS Control Program, the National SMC task force, the implementing partners and many others.

The plan to maintain this scale-up is very simple—we need stable funding. We have proven that we have the desire and ability to get the results. We can even surpass the targets if every stakeholder can play their role.

TT: How did your approach change from when you first took over the program?

BN: Management has been very instrumental to this. I made sure that all IPs operated under MoH guidance. This was very difficult in the beginning but with time most IPs have realized that they offer services to Ugandans and it’s MoH that is answerable to their health.

My approach is straight and candid. I never want anyone to use me as an excuse for his/her failure. I focus on the ultimate goal of averting HIV infections through the SMC program.

TT: If another program manager in another country wanted to achieve what you’re achieving in Uganda, what would you advise he/she to do?

BN: I have always wanted to share Uganda’s best practices but have never had an opportunity. Though I can talk till the cows come home, I’ll give a few pieces of advice:

  • Love your work: We should love our work even in the absence of money. Since childhood I have liked to make a difference in another person’s life so when I was given this job (initially I started as a volunteer) I was very happy. Today, my accomplishments speak volumes. I know my daughter will be happy to know that I did something for my country when the opportunity came.
  • Be in control: MoH leadership is key. Through my years at the MoH, it has been tough simply because it’s the IPs with the money. This puts MoH officers in a very tricky situation. But when you know your role, everything else doesn’t count. I have been able to tell IPs to follow MoH even though they have lots of money. Those who didn’t follow can tell you that I have had to communicate to them in a way many have not liked, but in the end, I’m sure the IPs are also enjoying our success.
  • Data: All mangers should ensure that they have and control data for their programs. That way they are able to analyze and make informed decisions to improve their programs.
  • Research: Nothing beats scientific evidence. I really like to do research or implementation science. This improves programs and helps formulate better policies.
  • Results dissemination: I always want to share what I do with others such that we can learn from each other. This can be through meetings, workshops, and conferences, though as MoH we always have limited resources to do all this.

TT: You’re a vocal advocate for the program yourself, what’s your message to your own government? And funders? And other advocates like you?

BN: First, I would like to thank the government for the support and guidance they offer to the program though I am requesting that they allocate more funds to the SMC program since it’s an important piece of combination prevention.

To the funders – if they want value for their money, I can assure them that Uganda is currently the country that can give the much-needed results in a very short time. My only caution though would be for them to respect the MoH, and let the MoH take leadership.

To my fellow advocates – they should keep the fire burning. Despite the challenges we face, no condition is permanent and all good things are worth fighting for. Every infection is worth our sweat!