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

by: 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 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

Objectives n To describe the school campaign

n To demonstrate the role of school
strategy of mobilization for SMC campaigns as a means of reaching adolescents with male circumcision services in Botswana

Activity Time and SMC Numbers in Study Year

Proportion of time by activity type
1,200

Number of MCs by activity type

27% 73%

5,650

Methods n A retrospective analysis of routine

School campaign period Regular services period

MCs done in school campaign period MCs done in regular service period

n Compared the number of clients who

received SMC services during the school campaign periods to the total number circumcised in the period studied of the clients accessing the services

program data from four district SMC teams from May 2012 through July 2013

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.

Botswana

n Assessed age category and HIV status

Background n Scaling up SMC to reach 80% of adult

HIV Status of School Campaign Clients n 100% tested for HIV and received their
results; 0.83% tested positive for HIV.
0.83%
HIV-Negative HIV-Positive

*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

and newborn males in Botswana by 2015 would avert > 33,000 adult HIV infections and save US$ 248 million between 2009 and 2025*.

Operational Roles at District Level within the PEPFAR Partnership

Training and Clinical Services

99.17%

n Generally low uptake among older men

targeted in public places, homes and work places. Achieved 32% of national target in 2012.
Demand Creation

Coordination HIV Testing and Counseling

DHMT

Results n By the report date, the four district

n Common barriers:
healing

n Time off work (loss of income) during n The 6-week required abstinence postsurgery

Activity Cycle in Study Year

Preparations
(Planning meetings, target setting, logistics, advocacy, sensitization of teachers, parents, and students, bookings)

n Four school campaigns each lasting

teams supported by Jhpiego had cumulatively done 10,883 SMCs in the ~16 months since inception. 36 weeks took place during the study period of June 2012 to July 2013, in which 6,850 clients were circumcised. circumcised during the 18 weeks of the four school campaigns, equivalent to only 27% of the duration analyzed in the study.

n Lack of belief in male circumcision n Fear of pain

n Of these, 5,650 (82.5%) were

n School campaigns are nationwide

Post-Campaign Period
(Services targeting general community)

Service Delivery
(HIV testing and counseling, MC procedures, daily reporting, post-op follow-ups)

n Presently these campaigns generate

activities aimed at reaching schoolgoing adolescents with SMC during the school holidays. most of the circumcisions done in the country program.

Post-Campaign Evaluations
(Team evaluations, district evaluation, national evaluation)

Lessons for Field Implementation n Start preparations early in the school

n Use available student/parent/teacher n Secure a focal contact teacher in each n Provide for advance HIV testing and
499

term.

Background: Botswana SMC Program Milestones

Male circumcision strategy drafted Facility assessments Short-term communication strategy Model for Optimizing Volume and Efficiency MOVE Strategy Re-scoping MOVE Project Long-term communication strategy Start of implementation Expansion of outreach PrePex Device study

Service Delivery Statistics by Month

2,000
1,915 1,585

forums, including PTA meetings, effectively.

Number circumcised

1,500
1,150

1,074

1,060 796

school, preferably the guidance and counseling teacher.

Acceptability study

1,000

500

411

502 320 328 369 243 266 390

2004

2006

2008

2010

2012

2013

Ma

y-1

n The national-level planning team n MOH took charge of national-level n District Health Management Teams
coordination. (DHMTs) led district activities supported by NGO partners. lessons from prior campaigns that were used to improve planning and implementation in each subsequent campaign. comprised MOH, donors and implementing partners.

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3 3 3 3 12 ov-12 ec-12 n-13 b-13 ar-13 r-1 y-1 un-1 l-1 a J Ju Fe Ap N D M Ja M

Month

Number of School Campaign Clients in Study Year, by Age n More clients were reached in each
subsequent school campaign.
2,994 3,000 2,612 1019 age group All ages 2,000 1,484 1,500 1,152 849 967 1,220 1,222

n Provide SMC group education 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. counseling of the students ahead of time during school visits to shorten the duration of waiting time at the clinic on the procedure date. students to the services.

n Move services to the students, or

n Post-campaign evaluations generated

2,500

n Start services on free days preceding

actual school closure (if any) before students disperse an opportunity for peer motivation.

1,000

Coverage of Jhpiego-Supported Teams n Four SMC provider teams in four health

n Four to five day outreach visits are
districts, supporting seven districts conducted within and beyond the four base health districts

500

Conclusions n The school campaign strategy was

Nov/Dec 12 Mar/Apr 13 Jun/Jul 13

Jun/Jul 12

efficient in reaching high numbers of young, HIV-negative adolescents aged 1019 years in a relatively short time:

n Current program experiences indicate

SMC service staff address a group of students ahead of a school campaign.

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

A doctor is at a makeshift camp to deliver SMC services in an outreach.

Selebi Phikwe

opportunity to efficiently mobilize and reach adolescents, who have lower HIV prevalence, with SMC.

Mahalapye

Molepolole

Gaborone

Outreach Base location

School campaign clients primarily ranged in age from 1019 years.

This work has been supported by the Presidents 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.