HIV Prevention via Safe Male Circumcision (SMC) Campaign

In 2007, medical research in Africa showed that male circumcision could help reduce the incidence of HIV. The Ugandan government saw an opportunity to bring about a major improvement in the nation’s health by acting on the researchers’ findings.

The challenge

The prevalence of HIV has been a major health problem in Uganda for many years, with over 7 percent of the adult population infected with HIV and more than 60,000 AIDS-related deaths per year.

However, research carried out in Uganda and two other African countries in 2007 demonstrated that male circumcision could help prevent the transmission of HIV infection from women to men. Results from the study showed an estimated efficacy of circumcision as an HIV prevention intervention of 51 percent among men aged 15-49.

Of all Ugandan men, though, 50 percent were unwilling to undergo the procedure, despite the claim that circumcising 4.2 million Ugandan men could halve the country's HIV incidence. The challenge for the Ugandan government was to initiate an effective national campaign of safe male circumcision (SMC) to help slow down and prevent the spread of HIV.

The initiative

The programme was conducted in the following stages:

  • Between 2007 and 2010, there was an information campaign on SMC and its link to HIV prevention, using resources such as public debates, national media talk shows, and educational literature.
  • In September 2010, a national SMC policy and communication strategy were launched, focused on promoting voluntary SMC for all men 15 years and older as an essential health service.
  • In December 2011, a mass communication campaign was launched to increase the uptake of SMC among men in the 15-49 age group.

The public impact

The initiative had significant public impact in terms of numbers:

  • By 2013, over 1,000 health facilities in all 112 districts of Uganda were able to provide SMC services.
  • By September of that year, nearly 1.5 million men had undergone SMC since the beginning of the campaign, which was significantly higher than the National Priority Action Plan target of 1.25 million by the end of 2013.

The question now is whether the SMC campaign will result in demonstrable reductions in the spread of HIV in Uganda.

What did and didn't work

All cases in our Public Impact Observatory have been evaluated for performance against the elements of our Public Impact Fundamentals.

Legitimacy

Public Confidence Weak

There is no evidence to suggest that people have trust in the institutions involved. In addition, convincing men in a largely non-circumcising country to accept the procedure will be an uphill battle for the health ministry, according to Uganda's 2011 AIDS Indicator Survey, about 50 percent of men are unwilling to undergo the procedure.

Stakeholder Engagement Good

The Ministry of Health and various NGOs joined forces to conduct pilot studies that eventually led to the SMC policy:

  • SMC National Coordinator Barbara Nanteza told IRIN/PlusNews: “I am working closely with the implementing partners to roll out SMC services through surgical camps, outreach and mobile teams. PEPFAR [The United States President's Emergency Plan for AIDS Relief] has given us funds to circumcise 750,000 men. [1] We will mobilise other funds from the government, UN agencies and partners,” she added.
  • The Ministry of Health, with assistance from the Health Communication Partnership and the STAR-E Project, worked with a group of concerned citizens in the Bugisu region to develop an HIV prevention campaign entitled ‘We are the Pride of our Tribe’.

Political Commitment Fair

Although the government has enacted AIDS prevention policies, there is not much backing for, and in some cases opposition to, the SMC programme from politicians:

  • President Yoweri Museveni has been a frequent critic of male circumcision as an HIV-prevention measure. [2]
  • "The circumcision effort that has so far been seen is driven by non-governmental partners and donor agencies,” said Richard Hasunira, HIV and Aids adviser for the coalition for health promotion and social development (Heps-Uganda).

Policy

Clear Objectives Good

Although the policy objectives are not discrete, forming part of an overall anti-AIDS/HIV policy, the government has set clear objectives:

  • The government said in 2012 that it hoped to circumcise one million men each year for the following three years.
  • “We are going to scale-up SMC as a key component in the core package of a combination of HIV prevention services,” said SMC national coordinator, Barbara Nanteza.

Evidence Strong

The policy was developed based on studies conducted by World Health Organization (WHO) and the joint United Nations Programme on HIV/AIDS (UNAIDS):

  • In Uganda’s Rakai District, in a study among 4,996 men ages 15 to 49, circumcision reduced the risk of HIV infection by approximately 51 percent.
  • In 2007, three randomised trials in South Africa, Kenya and Uganda showed that male circumcision reduces the risks of HIV transmission from women to men by at least 60%.
  • Based on these results, the WHO and UNAIDS issued in 2007 a set of recommendations for the use of SMC as one of the HIV prevention strategies in countries with low circumcision rates like Uganda.

Feasibility Good

Detailed situation analysis conducted before implementation of SMC found that there were too few qualified health professionals in the healthcare facilities, and there were problems in funding the programme:

  • A situation analysis by the Ministry of Health and Family Health International in 2008 revealed that the health service infrastructure already existed in all districts, but more resources were needed, including staff capable of performing the circumcision procedure, better equipment and enhanced facilities.
  • The medical circumcision procedure for the poor could be cross-subsidised by charging the wealthier households higher fees, since some residents, e.g. in Kampala, were willing to pay slightly more than residents in the other districts surveyed.

Action

Management Weak

There are too few healthcare professionals in the public health system and the management mechanisms are poor:

  • "The coverage is still low because of a host of challenges. SMC was adopted as a programme, but no budget has been allocated. Health facilities were asked to start circumcision without additional resources, including supplies,” said Richard Hasunira.
  • Scaling up the programme will be difficult in a public health system where only 63% of health worker positions are filled.
  • In the districts where the programme has been launched, stock-outs of SMC kits are common. In addition, the health ministry has not developed a framework for monitoring and evaluating the programme.

Measurement Weak

There are no clear yardsticks to measure the impact of this policy against. The health ministry has not developed a framework for monitoring and evaluating the programme.

Alignment Weak

There is a lack of coordination between donor agencies and a lack of participation by government:

  • "The circumcision effort is driven by nongovernmental partners and donor agencies, and their effort is not effectively co-ordinated," said Richard Hasunira.
  • Civil society activists said there was a need for the country's political leaders to unify their message on male circumcision, otherwise they risk confusing the public about the government's real position.