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April 2012

Initiating Community-Level Medical Male Circumcision Services in South Africa and Training Their Teams (August 2010 – December 2011)



ABBREVIATIONS CBT: Competency-Based Training CDC: Centers for Disease Control and Prevention CPD: Continuing Professional Development FGT: Forceps Guided Technique JAIP: Jerusalem AIDS Project KZN: KwaZulu Natal KZNDOH: KZN Department of Health MEC Health: Provincial Minister of Health for KwaZulu Natal MMC: Medical Male Circumcision MMCT: Medical Male Circumcision Teams MOVE: Models of Optimizing the Volume & Efficiency for Male Circumcision Services NDOH: National Department of Health OAC: Operation Abraham Collaborative PEPFAR: The United States President’s Emergency Plan for AIDS Relief PPT: Power Point Presentation RCT: Randomized Controlled Trails SHESHA: Be quick; be fast in: isiZulu STMH: St Mary’s Hospital, Mariannhill, South Africa USAID: United States Agency for International Development WHO: World Health Organization 1|P a g e

S Table of Contents

ABBREVIATIONS ..................................................................................................... 1 ACKNOWLEDGMENTS ............................................................................................ 4 DONORS................................................................................................................. 4 CONTACTS ............................................................................................................. 5 INITIATING FACILITIES FOR HIGH VOLUME MMC ................................................... 6 ASIPHILE – PIONEER HIGH VOLUME VMMC CLINIC IN ETHEKWINI ........................ 7 HEEDING THE CALL OF KING GOODWILL ZWELITHINI .......................................... 10 SHESHA PROGRAM: INTERNATIONAL COLLABORATION IN VMMC TRAINING ..... 11 SHESHA ACCOMPLISHMENTS (AUGUST 2010 – DECEMBER 2011) ....................... 15 SHESHA DAY BY DAY - OAC TRAINING IN THE WHO RECOMMENDED FGT ........... 17 SHESHA CLIENT EDUCATION ................................................................................ 18 SHESHA QUALITY ASSURANCE AND SUSTAINABILITY ........................................... 20 OAC TRAINERS ARE WORLD EXPERTS IN MMC..................................................... 20 OAC TRAINING TEAMS ......................................................................................... 21 PREPARATION OF AN OAC DELEGATION .............................................................. 21 OAC SHESHA DELEGATIONS TO KZN .................................................................... 22 SUPPORTING VMMC FACILITY INITIATION IN PUBLIC SECTOR HOSPITALS ........... 30 17 MEDICAL MALE CIRCUMCISION TEAMS TRAINED ........................................... 34 2|P a g e

SHESHA ACCREDITATION ..................................................................................... 34 EDUCATING THE HEALTH COMMUNITY ON MMC................................................ 34 SUPPORT TO PEPFAR, SA: CONSULTING ON OPERATIONAL ISSUES ..................... 35 PUBLIC-PRIVATE PARTNERSHIPS (PPP) FOR MMC ................................................ 36 SUPPORT FOR GLOBAL ADVOCACY IN VMMC ...................................................... 36 ACKNOWLEDGING SUPPORTERS AND DONORS ................................................... 37 CONCLUSIONS...................................................................................................... 40 FREQUENTLY ASKED QUESTIONS ABOUT OPERATION ABRAHAM COLLABORATIVE ............................................................................................................................. 41 FURTHER INFORMATION ..................................................................................... 48

PHOTO CREDITS Amnon Gutman JAIP OAC delegations members

Copyright © 2012 by Jerusalem AIDS Project/OAC All rights reserved

Suggested Citation: Malowany M, Ross D, Dash B, Schenker I (2012). Initiating CommunityLevel Medical Male Circumcision Services in South Africa and Training Their Teams (August 2010 – December 2011). Project Report. Operation Abraham Collaborative, Jerusalem, Israel. April 2012.

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ACKNOWLEDGMENTS This report was compiled by a team from OAC and STMH headed by Dr. Maureen Malowany Ms. Britt Dash and Mr. Robin Maarman. We would like to especially thank: Ms. Yael Edri, Dr. Eitan Gross, Dr. Lilach Malatskey, Ms. Hanni Rosenberg and Dr. Moshe Westreich for their valuable input. Dr. Abdoulaye Bousso, Dr. Issa Labou and Dr. Adama Ndir provided insights to Senegalese expertise and participation in MMC. Overall guidance for the development of this report was provided by: Dr. Inon Schenker, OAC Global Health Consultant and Dr. Douglas Ross, CEO of St Mary's Hospital, Mariannhill. OAC and St Mary's Hospital would also like to take this opportunity to thank the following individuals and organizations directly involved in project implementation: PEPFAR/CDC South Africa: Dr. Jeff Klausner, Ms. Catey Laube, Dr. Maryet Mogashoa and Dr. Carlos Toledo St Mary's Hospital: Mrs. Sheena Hardiman (Development and Marketing Manager), Mr. Tony Lott (Financial Manager), Mr. Robin Maarman (Asiphile Unit Manager) Mrs. Philomena Pakade (Nursing M anager), Mr. Peter Staples (Facilities Manager) and Dr. Tainos Zingoni (Medical Manager) Operation Abraham Collaborative Members: Jerusalem AIDS Project (JAIP); Hadassah Medical Organization (HMO); Israel Center for Medical Simulation (MSR); The Edith Wolfson Medical Center (EWMC); Asaf Haroffe Medical Center (AHMC); Israeli Ambulatory Pediatric Association (IAPA); The Israeli Urological Association (IUA); Israel Association of Pediatric Surgery (IAPS),Israel Perioperative Nurses Association (IPNA). In Senegal: Ministry of Health (Dept. of HIV/AIDS) and Senegal Medical Association. There are several dozens of individuals who very actively supported us at various stages of this project with wise suggestions, research, community liaison, fundraising and goodwill. While we could not name them all here, we salute each and every one for their help in making this intervention a great success.

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DONORS The OAC-STMH program in South Africa is being supported by generous grants. We would like to acknowledge and thank the following donors for their support for this pioneering project in medical male circumcision training and health services strengthening in South Africa. With their generous contributions a significant difference in fighting AIDS is being made: PEPFAR/CDC in Pretoria, South Africa Discovery Health, Johannesburg, South Africa Victor Daitz Foundation, Durban, South Africa Jerusalem AIDS Project donors, particularly Lady Kristina and Sir Roger Moore; and (in kind) contribution of: Meltzer, Igra, Cohen Architects

CONTACTS Operation Abraham Collaborative (OAC) Jerusalem AIDS Project POB 7179, Jerusalem Israel 91072 Tel: +972 2 6797677 Fax: +972 2 6797737 Email: Website:

St. Mary's Catholic Mission Hospital 1, Hospital Road, Mariannhill KwaZulu-Natal South Africa 3605 Tel: +27 31 7171026 Fax: +27 31 7002424 Email: Website:

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INTRODUCTION Compelling evidence established male circumcision (currently called “Voluntary Medical Male Circumcision” or VMMC) as an additional intervention for HIV prevention. Three randomized clinical trials (RCTs) demonstrated a reduction of 60% in the probability of a man contracting HIV from an infected heterosexual partner1. VMMC was recommended by UNAIDS and WHO as an important intervention in the fight against AIDS in Africa. Priority countries in Sub-Saharan Africa, accepting the scientific evidence, had begun looking for effective ways to implement large scale VMMC programs2. Since November 2006 OAC teams have been engaged in the development of clinical guidelines for Medical Male Circumcision (MMC) under local anesthesia, formulation of policies on adult and neonatal MMC, consultations on facilities’ preparedness, training of providers on swift, fast and effective MMC, conducting research in this area and in developing guidelines and materials for clients’ education during and post MMC. These activities are in response to requests of African governments and organizations responsible for scaling up or rolling out VMMC services. OAC, which was conceptualized and developed by Dr. Inon Schenker, a Senior HIV/AIDS Prevention Specialist and a Global Health Consultant from Jerusalem, Israel, supports the fiveyear action framework to accelerate the scaling up of voluntary medical male circumcision as a prevention measure in Africa3. This report on our efforts in rolling out pioneer VMMC services in KZN, South Africa, highlights for both implementers and decision makers the challenges in VMMC implementation we had to face and suggests ways to overcome them.

1 3 2

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INITIATING FACILITIES FOR HIGH VOLUME MMC Facility preparedness is a core component of the OAC delivery model. OAC consulted the respective hospitals in KZN on structuring available space to allow for a good flow of clients (based on an improved MOVE model) that could assist them in meeting their target of circumcising 50 and more men a day. Based on a Gold Standard established in Asiphile, the men's health clinic pioneered by STMH, other hospitals have followed suit, establishing community-level surgical procedures clinic offering comprehensive VMMC. Examples: • • • •

McCord Hospital opened Siaphile, a community level MMC service4. Wentworth Hospital opened a designated site on the hospital premises named Thando Impilo/Ward D65. Stanger Hospital has begun planning a designated site for MMC at the community level and meanwhile rearranged a surgical facility to take up high volume MMCs6. Other public sector hospitals have made similar provisions within existing surgical theaters.

ASIPHILE – PIONEER HIGH VOLUME VMMC CLINIC IN ETHEKWINI OAC was requested to consult STMH on making the best use of an existing space to meet the WHO and PEPFAR requirements, as well as the requirements of local regulations and policies, for a community-level VMMC service offering up to 100 MMCs a day. Working closely with STMH construction team, it was site, formally serving other comprehensive high volume

management and the local possible to renovate an existing purposes, and convert it into a and high quality VMMC site.

The floor plan presented in the next page is the first draft named Asiphile (Let's Be tailor-made for the new clinic Healthy in isiZulu) and located on 17, Caversham Rd, Pinetown, KZN. The final layout was further improved, as documented on p.10 and could be easily modified when considering needs and available apace in other locations. 4 6 (p.6) 5

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The Facility Initiation part of OAC’s Technical Assistance includes consultations on: • • • • • •

Floor plan Equipment, instruments and consumables Bio hazards Clients' records (including electronic data base and booking systems) Staffing Protocols and policies

The pictures below demonstrate a process of eight weeks. On the left view Asiphile clinic space rented out by STMH in a semi-urban area near Durban before setup. On the right is the same space, fully developed and equipped as a VMMC service. May 2010

August 2010

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HEEDING THE CALL OF KING GOODWILL ZWELITHINI Building on the success of the OAC Pilot in Swaziland (2007-2008)7, OAC welcomed the invitation extended by Dr Douglas Ross, Chief Executive Officer of St Mary’s Hospital, Mariannhill, Durban, KwaZulu Natal, South Africa to assist the hospital in launching a comprehensive community level MMC service aimed at delivering safe, cost-effective and efficacious adult male circumcision to 17,000 men per annum. The decision of STMH to launch a VMMC program was in response to the campaign initiated in KZN by His Majesty King Goodwill Zwelithini, insisting that all Zulu men be circumcised and VMMC pushed by PEPFAR/CDC. Just several weeks before, OAC was selected as a 'best practice' by the South Africa National Department of Health. In fact, the Department of Health in South Africa web page boasts that8. From May 2010, OAC worked with STMH’s senior management on rolling out the MMC program, focusing specifically on: facility preparedness; competency-based hands on training, and mentoring of trainees. With a training program tailored to local needs and policies, OAC was able to build local capacities in both training and delivery of MMC. Posttraining mentoring, consultation and follow - up ensured sustainability. OAC and St Mary’s Hospital entered into a long-term collaboration, making a strategic decision to enhance capacities in VMMC in public sector hospitals in KZN, replicating the Asiphile model. For the KZN population, reducing HIV transmission demands immediate and sustainable population health interventions. OAC’s primary objective in delivering a training program intervention for KZN doctors, nurses and health providers is to ensure safe and swift circumcisions with good cosmetic results for large populations of men. The OAC team approach allows for high quality and high volume VMMC through comprehensive training to facilitate rapid scale up of VMMC service delivery.

7 8 Tried and Tested, SA NDOH, June 2010

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SHESHA PROGRAM: INTERNATIONAL COLLABORATION IN VMMC TRAINING The SHESHA (‘is Quick, Be Fast’ in isiZulu) training program was launched on August 1, 2010. Following World Health Organization guidelines, and building upon the experience of Israeli doctors and nurses, OAC created SHESHA9. The program is an example of North-South and South-South collaboration in skills’ transfer in medicine and public health. Before SHESHA could be launched, OAC sought to ensure that a dedicated MMC clinic facility would be appropriately designed for high-volume adult VMMC service delivery and on-site training. After a needs assessment, OAC evaluated the floor plan, supply chain, equipment and surgical consumables. This clinic received staff from St Mary’s Hospital. They were the first surgeons, nurses and health clinic staff to be systematically trained in VMMC in KZN. As the pioneer clinic in KZN, Asiphile became the OAC –STMH base for training of teams from public sector hospitals in the eThekwini Health District and other KZN Health Districts. Each SHESHA training program was of one-week duration with supportive supervision and mentoring of teams trained within 6-10 weeks following completion of the training program.

OAC TEAM TRAINING Doctors, nurses, clerks, and counselors work together in order to efficiently deliver highvolume, high quality MMC. OAC training teams include highly experienced surgeons, nurses and public health consultants to provide hands-on training and step-by-step guidance. OAC teams were tasked with overseeing post-roll-out mentoring, and monitoring quality assurance and digital data management. The team approach of OAC emphasizes building good working relationships among doctors, nurses and health clinic staff, augmenting their individual skills into an orchestrated effort of high volume MMC, in which every minute counts. OAC team members work with their corresponding colleagues on nurse/doctor special inputs within the MMC procedure. As administrative clerks are the entry point for all MMC clients, clerks are included in the OAC team approach. OAC developed a comprehensive client medical record keeping system to be digitized. Health education of MMC


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clients takes place through the SHESHA program and is a responsibility of every member of every team. During OAC training, doctors demonstrate VMMC through simulations conducted prior to hands-on training. Physicians are required to review and practice the Forceps Guided Technique (FGT), following WHO guidelines as the preferred method for foreskin removal; review and practice in penile block using local anesthesia; and to acquire suturing techniques relevant for adult male circumcision. Nurses are required to review and practise universal precautions; client intake, medical examination, counseling and client education. Nurses must also prepare for task-shifting. Consultation on VMMC guidelines provided essential input to the UNAIDS & WHO normative tools and clinical guidelines on MMC under local anesthesia by OAC.


Support the MMC Program of the Departments of Health

Develop and implement an MMC demonstration project of facility initiation and training of provincial MMC teams in designated districts with a view to replicating this in other sites

Ensure training of essential MMCTs for rolling out Circumcision Camps and facility-based MMC during 2010-2012

Inform the wider medical and nursing communities in South Africa on MMC benefits, procedures and normative guidelines

Consult public, NGO and private facilities on MMC preparedness following assessment

Support St Mary’s Hospital and the other public sector trained teams in rapid scale up through mentoring and quality assurance

Advise on formative and operational research

South Africa National and KZN Provincial

SHESHA MISSION: GOALS & PRINCIPLES The SHESHA Training Program was originally designed to meet the needs of KZN health professionals. The competency-based training (CBT) included: clinical practice- bedside 12 | P a g e

teaching; education, counseling, nursing and surgical skills. Participating trainees demonstrated skill competency on models first, and then on clients. OAC’s wider vision is to build upon the training experience in the Durban area of KZN to deliver appropriately –tailored programs to other hospitals in the province. In this respect, OAC facilitates capacity building throughout KZN. OAC trained health professionals provide mentoring for graduate trainees at their own hospitals and at Asiphile Clinic when possible.


Team training – to develop a new model aimed at establishing local teams capable of rolling out (immediately post-training) a high volume adult male circumcision service. Training given to comprehensive hospital teams allocated by their respective hospitals for a 5-day training course. In most cases every team included: 1-2 medical doctors, 6-8 nurses, 1-2 administrative staff. Advising medical and nursing managements is part of the training.

Facility-based training – OAC promotes the establishment of community-level surgical facilities (Procedures Room) fully designed as self-contained and self-sustained MMC centres. Thus, training is conducted at the facility where the service will be provided.

Forceps Guided Technique (FGT) - OAC has been engaged by WHO and UNAIDS in the development of the approved manual on MMC under local anaesthesia. Of the internationally recommended techniques, OAC trains local teams in KZN in the FGT, which we consider easy to teach, safe and swift and yielding good cosmetic results.

Medical Simulation- before moving to hands-on training at the operating table the OAC model offers medical simulation for the local nursing and surgical team members focusing on all five segments of the procedure: reception, intake, surgery, recovery and post-operative visits.

Electronic Clients’ records- in compliance with local regulations and policies, OAC adapts a data management system to meet facility reporting and data keeping needs. The electronic records kept under strict privacy and security protocols are backed up by hard copies produced on the spot for every client.

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Client education- OAC promotes integration of a comprehensive educational component as part of VMMC service delivery. Education of clients, community and health care workers are all part of the OAC training course.

SHESHA TRAINING SEQUENCE While the OAC teams come for a two-week period, the SHESHA program for each trainee team unfolds over a five-day period. A second SHESHA course starts on the following Monday with a new trainee team. On the Israel-Senegal side, the OAC designated team meets prior to deployment for a full day training to ensure adequate knowledge of SHESHA delivery and the contexts into which the training will take place. The preparation pre-arrival in Durban includes guidance on the culturally relevant and appropriate tasks and attitudes as well as the professional skills training that will be undertaken in KZN. On the first day, OAC trainees and Asiphile staff meet at Asiphile Clinic. OAC prepares training kits for the trainees, conducts a pretest for the intervention and clarifies any questions that arise regarding training expectations. In formal presentations the OAC team delivers overviews of the knowledge required to build an adequate resource base and introduce the trainees to the WHO/UNAIDS normative guidelines as well as to local policies. Trainees then participate in a MMC demonstration simulation session to prepare for work with clients to begin the next day. From Day 2 through Day 5, doctors perform in two task areas. The first is a pre-operative clinical examination given as required for clients and requested by nurses conducting the pre-operative screening of clients. The primary task for doctors is performing MMCs in the surgical theatre. Nurses, however, rotate on stations such that by Day 5 each trainee has had the opportunity to work in each of the following stations: (1) Reception – client records, taking biometric measurements and delivering the first formal health education information session; (2) Physical examination of a client to determine contra indications under supervision of a medical doctor; (3) Preparation of the surgical theatre; (4) Hands-on training to assist in the surgical procedures; (5) Monitoring a client post-procedure in the Recovery Station. Doctors and nurses are trained in the follow-up visits (Days 2 and 7- post operation): protocol, physical examination and clients' education. 14 | P a g e

SHESHA ACCOMPLISHMENTS (AUGUST 2010 – DECEMBER 2011) Overall, OAC has trained 86 health professionals between 2 August 2010 and 31 December 2011. This includes 19 medical doctors, 53 nurses, 11 administrative personnel, and 3 counselors. These health professionals were members of 17 MMCTs from 13 hospitals in KwaZulu Natal: • Stanger (two teams) • St Mary’s (two teams) • RK Khan • Montebello • Albert Luthuli Central (one team of • Addington nurses only) • Wentworth (two teams) • Mahatma Gandhi Memorial • Ngwelezane • CATHCA organization (one team of • McCord (two teams) nurses only) • Osindisweni (two teams) •

King George V

Described in the detailed schedule below, in most SHESHA courses, we tried to establish continuity between the staff members’ allocation for the training by their managements (often in a non-strategic, on the spot, decision) and their providing the VMMC services in their respective hospitals. The process used was twofold: team building of all staff members allocated for SHESHA training from one institution, as was already described; and a joint visit to that institution on day three of the SHESHA training. The visit of OAC and the trainees in their own institution included three elements: meeting and discussion with senior management (CEO, Nursing and Medical Managers) on how to best utilize the soon fully trained MMCT in rolling out VMMC service at that hospital; site visit to assist in allocating a most suitable (community-level or hospital-based) building for the VMMC service; and presentation to interested staff members on benefits of MMC. In most cases, this was the first time for respective hospitals in eThekwini District to discuss programmatically the launch of VMMC service. In almost all of the hospitals visited trained staff were immediately given authority and responsibility to support the hospital in rolling out VMMC. The next pages demonstrate key elements of the SHESHA course. We first present the schedule of the 5-day course and then show the implementation through a series of photographs. Visits to Addington, Stanger & Montebello Hospitals

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SHESHA TRAINING SCHEDULE OAC SHESHA Training Detailed Daily Program Monday, Day 1 09:30 10:00-12:30 12:30-13:00 13:00-16:00

Meeting at Asiphile Clinic, Tea. SHESHA official opening: Greetings – introduction of all participants, trainees, trainers and Asiphile team. Distribution of SHESHA training kits; Monitoring/evaluation pretest and OAC PPT presentations (overview, surgery, nursing). Questions and discussion. Lunch Simulation sessions 1-4. All trainees participate in the male circumcision simulation sessions conducted in: the operating theatre, the reception and recovery areas, with specific assignments for the doctors, nurses and administrative sub-groups

Tuesday, Day 2 07:30-11:45 11:45-12:30 12:30-15:30

Hands-on training in operating theatre; 5 clients; supervised participation of trainees in all stages of client process: (1 )reception/recordkeeping/intake; (2) health education; (3) physical examinations; (4) operating theatre preparation and surgical procedure; (5) recovery. Trainee nurses rotate through each station throughout the week. Lunch Hands-on training; 5 clients; supervised participation in all stages of process for each client. Medical doctors practice pre-operative screening of clients for contra indications.

Wednesday, Day 3 07:30-11:45 11:45-12:30 12:30-15:30

Visit to the trainees hospital\institution to establish continuity between trained staff and respective institution’s roll out VMMC service plans Lunch Hands-on training; 15 clients supervised participation in all stages of process for each client. Monitoring/Evaluation Debriefing – mid-course: All participants including the Asiphile Team, Training OAC Delegation, and trainees. Discussion, questions.

Thursday, Day 4 07:30-11:45

Hands-on training, 15 clients; supervised participation in all stages of process for each client.




SHESHA : hands-on training, 15 clients, supervised participation in all stages of process for each client:.

Friday, Day 5 07:30-11:45 11:45-12:30 12:30-14:00 14:00

Hands-on training, 20 clients; supervised participation in all stages of process for each client. Lunch Monitoring/Evaluation Post -Test and an evaluation of training program week completed by all trainees. Final debriefing with all participants: Asiphile team, OAC Training Delegation and Trainees. Discussion. SHESHA Graduation: Greetings; Awarding of Certificate, 'SHESHA Jump". 16 | P a g e

SHESHA DAY BY DAY - OAC TRAINING IN THE WHO RECOMMENDED FGT Day One: Presentations and Medical Simulation in MMC

Day Two: Hands-on, bedside training in MMC (learning the basics)

Day Three: Enhancing Doctor-Nurses Team work and Training the Clerk

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Day Four: Scaling-up to high volume

Day Five: Sustaining high volume and practicing follow up visit protocols; Course debriefing10

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SHESHA CLIENT EDUCATION Client education is a key component of the SHESHA program. Both doctors and nurses are expected to educate clients at each ‘station’. Hospitals are encouraged to send a reception clerk as part of the team to ensure record keeping and data recording quality and to learn how to engage clients in education on the benefits of VMMC. OAC developed an educational model of MMC clients and the communities they come from. The education of clients begins during the very first contact of the client with the clinic (often by phone), continues throughout the visits of the clients to the clinic and thereafter. Below are pictures of the various stages of OAC's clients' education model:

Pre-Operation Group & Individual counseling

Every minute counts: clients' education during the procedure makes good use of a captive audience

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SHESHA QUALITY ASSURANCE AND SUSTAINABILITY Throughout the week, trainers and trainees are encouraged to engage in collaborative conversations. Scheduled de-briefing sessions are included in the program mid-week and at the end of the training week at which time the post-test for the intervention is also distributed. A formal graduation completes the program as each trainee receives a certificate attesting to program completion.11 In addition to the new trainees, former, graduated trainees of the SHESHA program are encouraged to return to Asiphile to work with the OAC team for a one-day or half-day refresher course. OAC teams, when possible, also go to the home hospitals of trainees to support and mentor those who have completed the SHESHA program. Trainees often return to under-resourced settings restricting opportunities to practice the OAC MMC team approach. Asiphile Clinic stands out as the first dedicated MMC clinic in KZN. The OAC is very proud to have trained surgical, nursing and administrative staff for 13 other dedicated clinics in KZN. The OAC surgical team has developed technical expertise in the training and delivery of high volume, low cost, and high quality circumcisions utilizing the WHO recommended forceps guided techniques.

OAC TRAINERS ARE WORLD EXPERTS IN MMC OAC lead trainers were recruited in the early 90's to provide dozens of thousands of interested men in Israel adult VMMC service12. They were able to quickly establish a protocol for MMC under local anesthesia that yields 30-40 clients circumcised safely, swiftly and effectively by one doctor through one working day. The cadre of these surgeons, who circumcised individually 11

“Asiphile Jump” – the joy of a shared accomplishment at the end of each SHESHA course brought about a new tradition: trainers and trainees assembled for a group photo jumping high spontaneously, celebrating graduation. (See pictures on pp.23-27) 12

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between 5,000 – 9,000 clients, is the core team of OAC. Most OAC specialists are also university professors and heads of departments of surgery across the country. OAC partners from Senegal are most experienced in medical male circumcision through their service provision in Senegal, predominantly a Muslim country where health providers are responsible for male circumcision of children and adolescents. MSR – the Israeli Center for Medical Simulation, a core member of OAC, is hailed around the world as one of the best and innovative centers of its kind.

OAC TRAINING TEAMS The doctors and nurses coming from Israel and Senegal are volunteers. Most of these volunteers are also university professors and heads of departments of surgery in established universities with ample experience in training residents and medical students. The Israeli and Senegalese doctors themselves were trained in a WHO recommended FGT method for MMC which they could now introduce to South African doctors. Nurses on the OAC delegations are all members of IPNA – Israel Perioperative Nurses Association, with long years of training experience in operating room nursing. IPNA is a lead member in OAC developed training modules for nurses in MMC. Heading OAC delegations are specialists in public health. They fulfill three functions: delegation leadership and coordination, public health input, community education on VMMC benefits. In 2011 OAC has developed itself to include international team members with nationals from: USA, Canada, France, Brazil, Israel and Senegal13.

PREPARATION OF AN OAC DELEGATION The following preparatory steps were taken prior to the arrival of the OAC delegations in KZN: •


Verify and follow-up on arrangement with National and KZN Department of Health and other authorities in South Africa for the issuing of the necessary permits and temporary South African medical and nursing licenses to the OAC visiting volunteer doctors and nurses (p.8)

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Provision of the operating room at Asiphile Clinic in Durban for the period of training, and the necessary equipment and medications

Recruitment of local doctors and nurses to be trained in VMMC during the visit of the OAC teams

The following preparatory steps were taken by OAC in assembling its teams: •

Assignment of OAC medical circumcision trainers (physicians). There are two for every team.

Assignment of OAC Operating Room nursing trainers. There are two for every team.

Nomination of team leader (with public health expertise).

Training of the participating physicians, nurses and public health experts on African and Zulu culture, South Africa and its Health system and the functions of OAC in KZN to date.

Arranging the logistics of the arrival of the medical team on time for the first day of operations and for their stay.

Consulting STMH on the purchasing/allocation of instrumentation for the performance of the operation.

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OAC SHESHA DELEGATIONS TO KZN Delegation 1 Dates: 2 August – 13 August 2010

Delegation Members: Dr. Inon Schenker, Dr. Eitan Gross, Dr. Moshe Westreich, Ms. Batya Weinstein, Mr. Yasser Barakat. Core Function (SHESHA 1): This was the first OAC training delegation in KZN. They arrived in August 2010 to train St Mary’s Hospital staff assigned as core and backup MMCTs at Asiphile. Other activities: Delegation members made several presentations on the benefits of MMC to health care professionals, including students of the Mariannhill Nursing College.

Delegation 2 Dates: 25 October – 5 November 2010

Delegation Members: Dr. Inon Schenker, Dr. Zvi Shkolnik, Dr. Moshe Grunspan, Ms. Edna Lavi, Mr. Jamal Hammud. Local Medical MMC Teams Trained (SHESHA -2, SHESHA -3): RK Khan Hospital, Addington Hospital, Wentworth Hospital and Osindisweni Hospital. Other activities: Delegation members made several presentations on the benefits of VMMC to health care professionals, they visited all hospitals for meetings with their respective managements to create a synergy between SHESHA training and post-training roll out of VMMC service delivery at these hospitals.

Delegation 3 Dates: 13 December – 21 December 2010 Delegation Members: Dr. Inon Schenker, Dr. Eitan Gross, Dr. Abdoulaye Bousso, Mr. Alex Chernevsky, Mrs. Rachel Woittiz, Dr. Limore Racin. Local Medical MMC Teams Trained (SHESHA-4): Wentworth Hospital and Ngwelezane Hospital

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Other activities: This third delegation was conducted differently than the first two such that there was one week of training followed by a two day camp in collaboration with eThekwini Health District, MaTch and Wentworth Hospital. This format was suggested to pilot the possible collaboration of several providers and the eThekwini health district under one roof in an effort to develop synergy and a model for future integration of trained medical doctors and nurses in MMC for a time-limited high volume MMC site-based camp. The hospital-based camp was conducted on the weekend (Sunday-Monday). Wentworth Hospital was chosen as the pilot site for the following four reasons: 1. Wentworth's management were on board 2. Two teams from this hospital were already trained in MMC by OAC 3. Wentworth's location, being in the industrial area, is easily accessible and therefore will be able to quickly reach higher numbers 4. Wentworth has collaboration with MaTch and has the potential to be a front runner in servicing the community with mass adult medical male circumcision. Providers of VMMC in this pioneer model were: members of the host institution – Wentworth Hospital – certified by OAC and STMH in SHESHA, volunteering Asiphile staff, nurses from MaTch and OAC delegation members. The camp circumcised over 120 men in two working days. Moreover, it demonstrated that combined teams could work jointly on six beds, using the FGT in a MOVE model approach without compromising safety, infection control and respect to clients of diverse ages. OAC supplied Wentworth Hospital with printable sets of clients’ records. OAC team continued mentoring the Asiphile team and conducted quality review of Asiphile staff to ensure high volume and safe practice male circumcision. The training took place at Asiphile, St Mary's Hospital's Clinic and not at the local hospitals in order to ensure availability for the number of people partaking in the training as well as the resources. During the last day of this OAC delegation a meeting was held with ASIPHILE management and the OAC staff. The aim was to discuss issues related to the Quality Assurance Review Process and debriefing of the first three delegations.

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Delegation 4 Dates: 28 March - 8 April 2011

Delegation Members: Dr. Maureen Malowany, Dr. Moshe Grunspan, Dr. Sraya Kahanovich, Ms. Yaira Gutman, Mr. Adi Elimelech. Local Medical MMC Teams Trained (SHESHA-5, SHESHA-6): McCord Hospital (two teams), St Mary’s Hospital new team members. Other activities: Delegation head visited McCord Hospital for a site visit and discussions on adapting the VMMC service at STMH for McCord needs.

Delegation 5 Dates: 20 June - 1 July 2011

Delegation Members: Dr. Maureen Malowany, Dr. Avi Stein, Ms. Yael Edry, Mr. Jacob Grabli Local Medical MMC Teams Trained (SHESHA-7, SHESHA-8): Osindisweni Hospital and Stanger Hospital.

Delegation 6 Dates: 15 August - 26 August 2011 Delegation Members: Dr. Inon Schenker, Dr. Zvi Shkolnik, Dr. Joseph Shental, Ms. Daniella Regev, Ms. Alina Taikach. Local Medical MMC Teams Trained (SHESHA-9, SHESHA-10): Stanger Hospital, Mahatma Gandhi Hospital and CATHCA. Other activities: At the request of STMH management, the OAC developed and implemented a mini-course on Day 2 and Day 7 clinical examinations and on pre-operative contra- indications. This course was implemented in parallel to SHESHA training. 25 | P a g e

Delegation 7 Dates: 14 November- 25 November 2011 Delegation Members: Dr. Lilach Malatskey, Dr. Abdoulaye Bousso, Prof. Francis Serour, Dr. Moshe Westriech, Dr. Serge Kuadjovi, Mr. Jamal Hammud, Mr. Shady Arraf, Dr. Inon Schenker. Local Medical MMC Teams Trained (SHESHA-11): King George V Hospital, Montebello Hospital, Albert Luthuli Central Hospital. Other activities: Delegation 7 split its mission: during week one, they conducted a full training course for new hospital teams from KZN. For the first time training included task-shifting modules to allow nurses to improve capacities in performing more independent tasks during the circumcision operation. The second week was devoted to mentoring and quality assurance. OAC team members split into sub-teams moving with one nurse from Asiphile to mentor past trainees at RK Khan Hospital and Stanger Hospital and to conduct facility needs assessment and site visit at Montebello Hospital. On 25th November OAC and STMH co-organized a half day seminar titled: “Community-Level Medical Male Circumcision in KZN – New Opportunities for DOH Hospitals and International Updates”. The meeting brought together national, KZN and international speakers, who covered a range of topics outlined on the next page. Medical doctors from the 11 SHESHA courses were honored with CPD Certificates for graduating the SHESHA Program offered by OAC and STMH. University of KZN approved 34 points, Level 2 and 2 ethics points for medical doctors completing successfully the five days program. The pictures below are from that event.

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RESULTS OF THE STMH- OAC COLLABORATION PHASE ONE The following are key results of the phase one collaboration between OAC and STMH, being a pioneered program deploying international expert physicians and nursing in MMC to support roll out of comprehensive MMC service delivery in KZN, South Africa.

HIV Cases Averted by Teams Trained in KZN (Based On Nov. 2011 Data) Several scientific estimates published in peer reviewed journals suggested that one HIV infection could be prevented for every five to 15 men circumcised in settings with high levels of HIV and low rates of male circumcision14. The following table presents official data from KZN DOH on the number of MMCs performed by districts15:

Local MMCTs trained by OAC at STMH came from three districts: eThekwini, iLembe and Uthungulu. With the FGT being used for least 50% of all MMCs performed, the total MMCs performed in those districts by teams trained by OAC is estimated at: 9,099 (33% of the KZN totals). Under UNAIDS high ratios, 1,820 cases of HIV infections were averted through OAC and


UNAIDS/WHO/SACEMA Expert Group on Modeling the Impact and Cost of Male Circumcision for HIV Prevention. Male circumcision for HIV prevention in high HIV prevalence settings: What can mathematical modeling contribute to informed decision making? PLoS Med 6(9): e1000109. 15 Progress report on key health service delivery initiatives presented by KwaZulu-Natal Health MEC, Dr Sibongiseni Dhlomo at the KwaZulu-Natal Provincial Legislature (1 Sept. 2011).

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STMH’s interventions in training MMCT in KZN in less than one year. This is a very conservative estimate when looking at the reported figures from Asiphile alone.

ASIPHILE MMC DELIVERY ON TARGETS From August 2010 to December 2011 (16 months) STMH MMC Program at Asiphile became a leading high volume site form VMMC in all of KZN, with an accumulated number of 5898 circumcisions (Fig. 1). Asiphile helped avert 1,180 HIV infections during this period. Figure 1: Number of Men Circumcised at Asiphile from August 2, 2010 to December 31, 2011 7000 5600



5156 4534

5000 3908 4000


3000 2000








1000 0 Bal. c/f













The rate of adverse events is less than two percent (<2.0%), all being very mild. It is interesting (Fig. 2) to note the trends in the clinic performance over 18 months. Figure 2: Trends of Monthly VMMC performed at Asiphile (2.8.2010-29.2.2012) 700




500 400 300 200

453 353 222 296 211



372 314



298 225


2010 2011

217 130

100 0




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Asiphile is a replicable example of facility initiation with good planning, highly motivated trained staff and dedicated management, ready to meet ambitious targets set by KZN DOH and PEPFAR/CDC. Scientific papers in preparation will further inform on Asiphile success story.

SUPPORTING VMMC FACILITY INITIATION IN PUBLIC SECTOR HOSPITALS The close collaboration of STMH and OAC produced at Asiphile a Gold Standard CommunityLevel dedicated surgical clinic providing a comprehensive VMMC service. Visitors from KZN and other Provinces in South Africa toured Asiphile and discussed with us options for replicating the model. Several of the MMCTs trained at Asiphile implemented lessons learned at their own facilities, improving on the core model and delivering quickly on high volume MMC. Selected examples:

McCord Hospital â&#x20AC;&#x201C; Siaphile McCord Hospitalâ&#x20AC;&#x2122;s Male Circumcision Clinic celebrated its first year of operation on 14th February 2012. Since opening its doors 12 months ago, the clinic has circumcised over 3 250 men, averting 650 new HIV infections.

Wentworth Hospital - Thando Impilo Before establishing Ward D6 as its location for routine VMMC service, Wentworth Hospital designated an area close to its out-patient clinics for high volume MMC. In partnership with 30 | P a g e

MaTCH, a local organization, the hospital is aiming at 60 and more MMCs/d. The latest report in 2011 indicated 35 MMCs/d, which on an average yield 890 MMCs/month.

Stanger Hospital

R K Khan Hospital In serving Muslim children and some other clients, the hospital has an on-going MMC service delivery program which is low volume by definition. The staff members of R K Khan trained by OAC at STMH are only occasionally invited to support this program.

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Stanger Hospital In a strategic decision to enhance the capacity of medical and nursing staff in VMMC, Stanger Hospital sent two teams to be trained in VMMC at Asiphile. Returning to their posts team members are recruited for high volume campaigns and low volume routine MMC service provision. The ultimate goal of the hospital is to establish a community-level VMMC clinic for adults and neonates. OAC traveled to Stanger to assist in post-training mentoring and quality assurance.

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The Aurum Institute In Guateng, The Aurum Institute, in partnership with the Ekurhuleni Metropolitan Municipality and Department of Health Ekurhuleni District, opened a comprehensive Male Medical Circumcision Clinic in Tembisa. A team headed by Dr. Fazel Randera came to visit STMHâ&#x20AC;&#x2122;s Asiphile and met with OAC on site. OAC was then invited to present at Aurum Institute and visit the Winnie Mandela Male Sexual Health Clinic.

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17 MEDICAL MALE CIRCUMCISION TEAMS TRAINED OAC has trained to date 17 MMCTs from 13 hospitals in KwaZulu Natal: St Mary’s (two teams), RK Khan, Addington, Wentworth (two teams), Ngwelezane, McCord (two teams), Osindisweni (two teams), King Edward VIII (one team member), Stanger, (two teams), Montebello (one team), Inkosi Albert Luthuli Central (one team of nurses only), Mahatma Gandhi Memorial (one team member), King George V and CATHCA organization (one team of nurses only) between 2 August 2010 and 12 August 2011. These included: 86 health professionals: 19 doctors, 53 nurses, 11 administrative personnel, and 3 counselors. When reaching full capacity, with well supplied clinics and defined working conditions – these MMC service providers, working in teams, could produce at minimum 7,800 VMMCs every month. When reaching that level, they will be averting 18,720 HIV infections every year. Following mentoring, the number of VMMCs per month could be scaled up to 13,000; averting 35,000 HIV infections per year.

SHESHA ACCREDITATION Another important achievement of the OAC – STMH collaboration is the first accreditation in Africa of a CPD course in MMC for medical doctors. KwaZulu Natal University reviewed the SHESHA training program and granted participating physicians 34 Level 2 CPD points plus two ethics points. The initial accreditation (2010) was approved again in 2011, making this program the first to receive formal accreditation for medical doctors trained in MMC not only in South Africa, but in the continent. We hope to assist participating nurses obtain the same level of accreditation in 2012.

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EDUCATING THE HEALTH COMMUNITY ON MMC OAC’s mission in support of the UN, PEPFAR and the scientific community in scaling up VMMC in Africa places great emphasis on clients’ education and on community mobilization. The latter is considered a major challenge due to misconceptions, cultural norms and beliefs as well as low coverage by media. Based on its work in other countries in Africa OAC made great efforts under the current project to engage with healthcare providers and students in medicine, nursing and allied health professions and encourage them to discuss widely in their respective communities and proactively the benefits of VMMC. During the South Africa project OAC team members made 18 public presentations, including at the STMH College of Nursing.

SUPPORT TO PEPFAR, SA: CONSULTING ON OPERATIONAL ISSUES When requested by its partners in this project, OAC experts were only happy to provide input and consult PEPFAR South Africa on operational aspects of scaling up VMMC. Two aspects were considered urgent as they had impact on decisions relating to purchase of expensive instruments: Diathermy Machines and Disposable Surgical Kits. The following input was provided by Asiphile Unit Manager: “At the inception of Asiphile in August 2010, the Diathermy machines that arrived at the clinic were not of a standard that could cater for high volume MMC’s. It surfaced because the numbers of men coming for MMC after the initiation of the program grow daily. The OAC surgeons gave their input in that STMH needed a heavier duty diathermy machine. They also suggested that Asiphile continue using disposable cauterizing units and not just the tips that STMH were initially given with the machines that arrived later. OAC were also not keen on the rods that patients had to hold on. This consultation, based on the experience of OAC, tried to assist Asiphile management to make better decisions when anticipating high volume and high quality service. The looked at operational issues more holistically. While STMH could not retract from a purchase order, a meaningful change was made: plates that were suggested as a replacement to the rods were included in the purchase order from the company and indeed made a huge 35 | P a g e

difference in the turnover of clients, their comfort during the operation and the convenience for the staff. When considering the quality of MMC surgical kits: valid suggestions on the suture material, missing instruments (e.g. dissecting forceps, and 2 more artery forceps and surgical scissors), unnecessary inclusions and the quality of some of the instruments (e.g. too stiff) – were echoed to PEPFAR/CDC with the goal of assisting in decision-making on the provision of the most suitable supplies for high volume sites”.

PUBLIC-PRIVATE PARTNERSHIPS (PPP) FOR MMC OAC as a technical assistance group is dependent on donors/contractors funding for all of its operations. In the case of KZN, the OAC facilitated the inclusion of the private sector in the KZN MMC campaign. Discovery Health is the first South African private sector corporation to support MMC. Discovery Health contributed funds for the first three OAC delegations to KZN paving the way for other PPPs in VMMC.

SUPPORT FOR GLOBAL ADVOCACY IN VMMC No successful population-level intervention can be sustained without the support of community leaders and government. KZN has responded to the enormous challenges of HIV/AIDS people live with day-to-day in outstanding ways. In 2010, King Goodwill Zwelithini reversed a 200-year old Zulu custom, originally decreed by King Shaka of historical fame with the declaration that Zulu men would now be circumcised. Together with political leaders, King Zwelithini’s leadership established health as a community concern and 16 responsibility . The National and Provincial VMMC policies are now streamlined. Jerusalem AIDS Project/OAC is among the first international organizations to heed the call of His Majesty and come forward as a leading technical assistance group in practical support for the Province scale up efforts. On 18th December 2010 King Goodwill


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Zwelithini led hundreds of amabutho at the annual harvest celebration, Umkhosi Wokweshwama (first fruit), held at eNyokeni Royal Palace in Nongoma. Invited to that occasion, OAC delegation was welcomed by His Majesty who made specific reference to their contribution to the Province fight against AIDS and by the MEC for Health, Dr. Sibongiseni Dhlomo. OAC Delegation Leader, Dr. Inon Schenker, committed then OAC’s technical assistance to the Province in doubling the number of MMCTs trained and facilities initiated, pending funding. OAC delegation was then invited to take part in the ceremony in which His Majesty, King Zwelithini, exposed the first group of youth circumcised iziChwi (Super Warriors in isiZulu) mandating medical male circumcision to be pre requisite for joining the iziChwi regiments. The Government of South Africa – through the National Department of Health and the Foreign Workforce Management – highlighted the professional credibility, integrity and goodwill of OAC team members volunteering in South Africa. The NDOH included OAC in its collection of 'best practice' as an MMC program to be followed by the 'tried and rested' manual. The Foreign Workforce Management endorsed OAC surgeons and nurses availability as volunteers. KZN Premier, Dr. Zweli Mkhize said in his State of the Province Address on 24.2.2010, referring to OAC support to KZN: "… a major advancement in the fight against HIV and AIDS was the announcement by Isilo to revive male circumcision. The announcement assisted greatly in focusing on action than endless debates….. We are grateful for the support from Islamic and Jewish communities in this regard." MEC Health, Dr. S. Dhlomo (in the picture above on the right) visited Asiphile and discussed with Dr. Douglas Ross, STMH CEO (on the left), Mr Robin Maarman, Unit Manager (center) and OAC members the continuation of the program in 2011, adding his support. Dr. Dhlomo visited Asiphile Clinic on 15 December 2010 and commended its staff and management and the OAC training team on site.

ACKNOWLEDGING SUPPORTERS AND DONORS The success of OAC-STMH facility initiation and training project in South Africa has been made possible by significant partners. OAC and STMH would like to acknowledge and thank 37 | P a g e

organizations and donors for their support for this pioneering project in medical male circumcision scale up in South Africa. KwaZulu Natal Health Leadership – The Honorable MEC for Health, Dr. Sibongiseni Dhlomo is guiding the health sector, with full respect and collaboration with traditional leaders, through a historic period; reviving the Zulu tradition of circumcision and communicating to Zulu men and women the significance of the one-time cut within Zulu culture as an important mean to dramatically reduce HIV infection. Dr Sandile Tshabalala, the Programme Manager of the Medical Male Circumcision and Traditional Medicine Programme of the Provincial Health Department is very familiar with OAC-STMH cooperation and its impact on the scale up of VMMC in KZN using the FGT. Implementers – St Mary’s Hospital, Mariannhill, decided to launch a VMMC program in April 2010. Less than three months later Asiphile was seeing the first VMMC clients. Dr. Douglas Ross, CEO of STMH, had the vision and determination to make Asiphile a Gold Standard VMMC service and was able to pull behind him a devoted team of managers and staff: Dr. Tainos Zingoni (Medical Manager), Mrs. Reddy and later Mrs. Philomena Pakade (Nursing Managers), Mrs. Sheena Hardiman (Development and Marketing Manager), Mr. Tony Lott (Financial Manager), Mr. Peter Staples (Facilities Manager) and Mr. Robin Maarman (Asiphile Unit Manager). Mr. Maarman is now among the most experienced VMMC unit managers in KZN. He demonstrated leadership, diligence and excellent negotiation skills, which enabled the setting up of the clinic, quick transition of staff from other routines to full time VMMC service delivery and the hosting of international teams. The two MMCTs of Asiphile gained by now ample experience in high volume and high quality VMMC to lead the way for others in KZN. Each one of them is commended for their dedicated work. The CEOs, medical managers and nursing managers of the respective hospitals who sent their staff for training by OAC and STMH took the first step in developing local VMMC capacities. Many of them followed up by utilizing the trained doctors and nurses effectively in rolling out their own VMMC programs. These include: Dr. Helga Holst and Dr. Jay Mannie (McCord Hospital), Mrs. Thelma Ngcobo and Dr. Gustavo Lopez (Stanger Hospital), Dr. Venkateswarlu Tallapaneni (Osindisweni Hospital), Dr. Suriya Kader and Dr. Jaishry Ramdeen (Wentworth Hospital), Dr. Jay Brijkuma (RK Khan Hospital), among others.

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Operation Abraham Collaborative Members: Jerusalem AIDS Project (JAIP); Hadassah Medical Organization (HMO); Israel Center for Medical Simulation (MSR); The Edith Wolfson Medical Center (EWMMC); Asaf Haroffe Medical Center (AHMMC); Israeli Ambulatory Pediatric Association (IAPA); The Israeli Urological Association (IUA); Israel Association of Pediatric Surgery (IAPS), Israel Perioperative Nurses Association (IPNA). In Senegal: Ministry of Health (Dept. of HIV/AIDS) and Senegal Medical Association. PEPFAR/CDC in Pretoria, South Africa – a most important and generous contributor to the fight against HIV/AIDS in Africa. The CDC Country-team in Pretoria pushed for the launch of MMC in South Africa, provided significant financial support and is orchestrating the scale up on a monthly basis. The PEPFAR\CDC support for this program is a demonstration of diligence and determination. Being inclusive of international technical assistance as part of development aid from the American People is commendable.

Discovery Health, Johannesburg, South Africa - a leading private sector health insurer with significant impact on healthcare in the country. Discovery Health support for the program reached further than its financial contribution as it demonstrated corporate social responsibility in a most meaningful way.

Victor Daitz Foundation, Durban, South Africa -This foundation operates as a charitable trust founded by Victor Daitz. The Victor Daitz Foundation makes a major contribution towards the charitable needs of all community groups in South Africa, a significant portion of its funds are directed towards the HIV/AIDS epidemic and the needs of the historically deprived disadvantaged groups within South Africa. Lady Kristina and Sir Roger Moore together with other loyal donors of the Jerusalem AIDS Project made this program truly internationally funded. Meltzer, Igra, Cohen Architects provided in-kind support in translating OAC’s expertise into workable architect’s floor plans. 39 | P a g e

The Durban-based Union of Jewish Women received the first three OAC teams with warmth and wonderful hospitality and facilitated the logistics while the OAC teams were in South Africa. There are several dozens of individuals who very actively supported us at various stages of this project with wise suggestions, research, community liaison, fundraising and goodwill. While we could not name them all here, we salute each and every one for their help in making this intervention a great success.

CONCLUSIONS The OAC SHESHA Training Program, in cooperation with the Asiphile Clinic Team and St Mary’s Hospital, Mariannhill, support has demonstrated success in the consistency of positive evaluations for knowledge and skills enhancement using a team approach to delivering qualitycontrolled, best practice, high volume adult male circumcision. Recent scientific evidence has demonstrated that Medical Male Circumcision reduces female to male HIV transmission by approximately 60% and, in KZN, an area of high HIV/AIDS prevalence and low MMC prevalence, that as few as 5 to 15 MMCs will prevent one new HIV infection; MMC could prevent 6 million new infections in next 20 years. The long term effects of KwaZulu Natal in both geographical locations reduction in incidence transmission and an mortality in the years to

“Male circumcision does not provide full immunity from contracting HIV. One must always remember to be faithful and use condoms.” – Dr.

the strengthening of capacity in numbers and in varying within KZN can only lead to a and prevalence in HIV overall reduction in HIV/AIDS come.

Norah Abudhu, Kenyan

This collaboration also highlighted the importance of Physician and OAC bringing surgery closer to community through establishing community-level VMMC services. This is a direct contribution to health systems’ strengthening. It also demonstrated the efficacy of international collaboration in VMMC for HIV prevention.

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How Was OAC Founded? Responding to requests from several African countries, the Jerusalem AIDS Project, a veteran not-for-profit NGO based in Jerusalem, together with one of Israel's leading and world renowned medical organization, Hadassah Medical Organization, implemented the first pilot of OAC in Swaziland 2007-8. The successful pilot project created a wave of requests from other priority countries in Africa making it necessary to enlarge the group of Israeli providers. OAC was then established as a medical and public health technical assistance response supporting the scaling up and rolling out of preventive male circumcision services for HIV prevention in a number of African countries. Dr. Inon Schenker is the initiator and developer of OAC

What are the goals of OAC? Goal 1: Support the Strategic Action Framework to Accelerate the Scale-Up of Voluntary MMC for HIV Prevention in Eastern and Southern Africa through the provision of technical assistance in OAC's areas of expertise for priority countries. OAC are world experts in high volume and high quality adult medical male circumcision, providing technical assistance in this field. Goal 2: Transfer effectively skills and technology in MMC from Israel to African nations interested in the implementation of the OAC delivery model, which follows the MOVE concept. Goal 3: Implement an international training program utilizing volunteer surgeons and nurses with ample experience in the OAC delivery model in Africa. The training program involves teams of doctors, nurses and administrative professionals in the delivery of high volume adult male circumcision. OACâ&#x20AC;&#x2122;s goal is to respond effectively, immediately, and professionally to requests of African countries and transfer knowledge, training and technology in MMC through deployment of surgeons, nurses and public health professionals for a capacity- building training project.

What are the pillars of OACâ&#x20AC;&#x2122;s success? Build on lessons learned from Israeli and Senegalese experience in MMC Transfer knowledge, skills and technology supporting wide dissemination of MMC for HIV prevention 41 | P a g e

Tailor-made approach Cultural sensitivity, respect for local norms and rules Targeted approach, that delivers results Cost effectiveness Our team includes the world most experienced medical male circumcisers Develop international collaboration In country collaborations

Why is the level of experience of Israeli health professionals in MMC so unique? Israeli VMMC unique experience and expertise is invaluable in the international community. With more than 100,000 adult male circumcisions performed on new immigrants, mostly from the Former Soviet Union and Ethiopia. Israeli doctors performed this procedure safely and effectively at a speed of 40 and more clients per day. From 1989 to 2011, tens of thousands of MMC operations were performed in Israel (age range 6M94Y). These operations were well documented at hospital/clinic-based surgical proceduresâ&#x20AC;&#x2122; room and resulted in less than 1.5% very mild adverse events. In addition, over 70,000 Jewish, Muslim and Christian infants are circumcised traditionally in Israel every year. This vast experience is what prompted the UN Working Group on MMC, African government and civil societies to collaborate with OAC. Very few countries have experience with hospital/clinic-based MMC for adults equivalent to that of Israel. Israelâ&#x20AC;&#x2122;s experience and expertise managing infant and adult MC on a large scale in both hospitals and clinics presents a unique opportunity for knowledge-sharing and skillstransfer.

How does the Senegalese experience in MMC complement the Israeli experience? The Senegal population is 11.4 million; more than 90% are Muslim. The healthcare system is decentralized to 69 health districts. HIV/AIDS in Senegal is described as a concentrated epidemic with low prevalence at 0.7 in the general population and high prevalence in the high risk groups that includes men who have sex with men (MSM) at 21.8 prevalence rate and 42 | P a g e

female sex workers at 19.8. More women than men are HIV positive with a ratio of 2:25. There are also regional disparities. HIV prevention in Senegal has been spearheaded by significant political engagement, the formation of a multi-sectored response to the epidemic, the implementation of HIV diagnosis, testing services and the implementation of antiretroviral therapy (ART) delivery. In 1986 the first case reported of HIV in Senegal and was followed by a rapid and concerted response which has played part in the current low HIV rates. The government showed immediate commitment to prevention. The national AIDS council and AIDS/STD integration was implemented. Circumcision in Senegal is high (89%) in a background of low HIV prevalence rate. Currently most circumcisions in cities are done in a health facility by paramedical staff consequently less time is spent on initiation period. The hospital setup is preferred due to its ability to anaesthetise, aseptic procedures, good postoperative results and hospitalization if necessary. There is a need for a link between service providers and targeted communities as seen in the Casamance case study of 2006 on ‘Building synergies between clinic and traditional settings”. This case study described the need for circumcision to be safe and still maintain its cultural aspects among the Southern tribe in question. It integrated the need for sex education and promotion of behaviour change. Senegal has the expertise and experience in circumcision of boys that can be harnessed to help other countries with low circumcision rates that need scaling up of the procedure to prevent HIV. Senegal has dealt with challenges like: Poor access to health services, less commitment and interest in male circumcision by trained health professionals, as well as a weak medico-legal system. It also has experience in working effectively with traditional MC providers, integration of MC into overall health service delivery, integration of private health providers, poor communication strategies and inadequate counselling leading to confusion and misunderstandings about the degree of protection conferred by male circumcision. Risk compensation among newly circumcised men and the perceptions of non-direct benefits for women are within the wide range of lessons that can be drawn from the Senegal experience in its public health approach to circumcision and to maintaining low HIV prevalence. Similar to Israel, the FGT method is used in Senegal for male circumcision. In Senegal it is common to use the “Kocher clamp” however they are not strict to specific equipment and straight forceps have also been used. The use of clamps is also preferred by the non-medical (traditional) circumcisers that perform circumcisions mostly in rural areas. Paramedical providers perform more than 80% of circumcisions in hospital facilities. Circumcision is 43 | P a g e

performed throughout sub-Saharan Africa for multi-ethnic, religious and cultural reasons. The age of the participants varies greatly ranging from young boys to adults. In Senegal, the majority of boys are circumcised during adolescence.

OAC Senegalese members: The Senegal Medical Association- Senegal Medical association consists of 2,000 physicians in private or public sector practicing in Senegal. Physicians are from different associations existing in Senegal and are determined to work together in all medical aspects. The SMA is a member of the World Medical Association (WMA) since October 2008. HIV/AIDS Department, Ministry of Health and Prevention, Senegal- The HIV/AIDS Department is the Senegal Ministry of Health and Prevention institution in charge of coordination and implementation of national health policy related to AIDS. This department represents the health sector in a national multi-faceted AIDS control program coordinated by the National AIDS Council. Its interventions include the prevention of STI’s and AIDS, PMTCT, VCT, care, support and treatment for persons living with AIDS, OVC, blood safety & post-exposure prophylaxis, prevention and care for vulnerable groups.

What is OAC’s Capacity Statement? In November 2006 JAIP and WHO held a national consultation on MMC under local anesthesia in Jerusalem to support the review process of the UNAIDS/WHO/JEPIEGO manual on review process on the topic. JAIP chairs the Israeli Multi-Center Research Group on MC, utilizing Israeli experiences, international consultations, and over 20 years of experience in public health education for HIV prevention. Based on the experience in Israel and in Senegal OAC is currently able to consult governments, donors, implementers and research teams on: • • • •

Technical writing of proposals Country-specific costing and budget exercises Staffing for high volume, low cost, high quality (MOVE model) MMC services, including job descriptions Consulting on Facility Initiation: set-up, floor plan, commodities and equipment procurement, biohazards, protocols and internal policies, meeting donor and national guidelines Demand creation

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• • • • •

Training of all staff members, including nurses' task-sharing; we mentor trained nurses and doctors to improve results and reduce intra and post-op complications Standard operating procedures and Quality assurance Approved MMC medical devices (e.g. Pre-Pex) Clients' records, registers and reporting procedures Each of OAC’s lead surgeons performed between 3,000–9,000 adult MMCs under local anesthesia

OAC Has an Impressive Track-Record 2006 Technical assistance for WHO in developing the Manual on MMC under Local Anesthesia 2007 – 2012 Consulting PEPFAR, UNAIDS, UNICEF on roll-out operational research questions 2007

Swaziland national MMC policy development

2007 - 2008 Launching tailor made training program for MMC teams in Swaziland, with PACT and FLAS 2008 Development of a program recruiting experienced international surgeons to train local medical circumcision teams, with Hadassah and JAIP in Israel 2009 – 2012 Enhancing West African support for MMC scale up, with Senegal MOH and Medical Association 2009 Needs assessment for Uganda, with AMS 2009

Needs assessment for Lesotho, with LPPA

2009 - 2010 Development of a comprehensive Clients' Education model for MMC service providers 2010

South Africa National Department of Health recommends OAC as "best practice" in MMC


Proposal development for PEPFAR recipient in Swaziland (successful)


Proposal development for PEPFAR recipient in South Africa (successful)

2010 – 2012 SHESHA training program for MMC teams in KwaZulu Natal, South Africa; 17 teams from 13 hospitals trained 2010 University of KZN accredited SHESHA program for CPD points (34) and ethic points (2) for trained physicians; the first MMC accredited course in Africa 2011

Proposal development for PEPFAR recipient in South Africa (successful)


Proposal development for PEPFAR recipient in South Africa (under review)

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Has OAC Conducted Successful Projects in Africa Prior to KZN? Yes. OAC conducted needs assessments in Uganda, Lesotho and Namibia and managed a large scale roll out in Swaziland. Information on the Swazi Pilot (2007-2008) is provided below17. At the invitation of the Family Life Association of Swaziland (FLAS) and the National Task Force on Male Circumcision of the Swaziland government (NTF), OAC organized preliminary consultations with FLAS and NTF representatives to conduct a needs assessment of both health care professionals and health care delivery sites. OAC was tasked with recruiting teams to train-up Swazi health professionals in FLAS clinics in MC techniques as recommended by the WHO, thus building capacity to deliver this intervention in a timely and effective fashion upon completion of the pilot project. Three OAC delegations conducted trainings in Swaziland between October 2007and February 2008. The success of the training missions is reflected in the preparation of the facility, guided by OAC, as well as the training of ten authorized MMC surgeons, and the 217 clients who undertook the intervention. Client turnover time was reduced by 50%, increasing the client intake to ten clients per day. In addition to the education provided to clients, continuing education was delivered to over 350 healthcare workers at the Mbabane General Hospital (a public government hospital). In addition, stakeholders’ meetings were held for both updates and reflections to provide the impetus for the development of Swaziland national policy on MMC. OAC was invited to Swaziland in April 2007 to support the roll-out of MMC as a TA team. The MOU signed with FLAS and the Swaziland Task Force on MMC led by the government of Swaziland MOH specified request for support in: policy making, training in adult MMC of doctors and advice on facility preparedness. Under a project named: "Operation – AB” three delegations from Israel traveled to Swaziland to provide the TA requested. The core project's implementation phase involved the training of local doctors in Swaziland by doctors from Israel in the surgical procedures of adult male circumcision by the OAC delivery model. 12 local Swazi doctors underwent a training program given by Israeli doctors as part of this mission, and 210 clients have been circumcised by the Israeli teams since the start of the program.


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With funding from Hadassah Medical Organization, Jerusalem AIDS Project and Tuttenauer, in partnership with the Family Life Association of Swaziland and with support of Swaziland Task force on Male Circumcision, the project took place during October 2007-February 2008 with three delegations to Swaziland. The OAC collaborative project between FLAS and Jerusalem AIDS Project is the first project involving international training of local doctors in MMC that has been launched in Africa, with a community-based approach in service delivery at a community-level clinic. FLAS and JAIP have responded to the need for urgently and effectively scaling up adult male circumcision services in Swaziland with well-trained doctors and an efficient and organized program. Male circumcision can be an effective tool in preventing contraction of HIV/AIDS, and OAC has proved to be a thriving program that helped Swazi healthcare providers gain experience and expertise quickly, as well as improve their level and speed of service delivery.

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Further and updated information on VMMC Science, Policy, Research and Implementation could be accessed through the Clearinghouse on Medical Male Circumcision for HIV Prevention, of which OAC is a formal contributor.


OAC regularly updates its Website


St Mary’s Hospital Mariannhill website informs on recent developments in STMH


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Voluntary Medical Male Circumcision  

Real progress in the fight against HIV and AIDS in Africa

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