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Progress in Voluntary Medical Male Circumcision Service Provision — Kenya, 2008–2011

In 2007, the national prevalence of HIV in Kenya was 7.1% among persons aged 15–64 years, with provincial prevalence rates ranging from 0.8% in North Eastern Province to 14.9% in Nyanza Province (1). Although an estimated 85.0% of males in Kenya are circumcised, nearly half of all uncircumcised men live in Nyanza Province, where circumcision prevalence is only 48.2% (1). Based on the results of three randomized controlled trials in 2007 showing that medical male circumcision is effective in reducing HIV acquisition among men by approximately 60%, the World Health Organization and the Joint United Nations Programme on HIV/AIDS issued recommendations urging countries to offer male circumcision as an additional HIV prevention intervention (2). Kenya's Ministry of Health (MOH) prioritized the implementation of voluntary medical male circumcision (VMMC) services by targeting areas with low prevalence of male circumcision and high HIV prevalence (3). This report summarizes the progress of the VMMC scale-up in Kenya during 2008–2011. By December 2011, a total of 340,958 males had been circumcised in 260 CDC-supported sites.* Among those VMMCs, 280,713 (82.3%) were conducted in Nyanza Province. A total of 273,115 (80.1%) VMMC clients were aged ≥15 years, and 49,162 clients (14.4%) were aged ≥25 years. VMMCs performed among clients aged ≥25 years increased from 5,938 (11.9%) in 2009 to 24,945 (14.9%) in 2011. Providing VMMC services to males aged ≥25 years remains a key challenge to reaching Kenya's national target of 80% VMMC coverage among uncircumcised males aged 15–49 years by the end of 2013.

Kenya's Prime Minister launched the VMMC for HIV prevention program in 2008 following intense public consultations among various stakeholders, including youths, religious and women's groups, professionals, and the Luo Council of Elders (4). Based on 2009 census data, members of the Luo community constitute approximately 70% of Kenya's traditionally noncircumcising ethnic communities. Other noncircumcising ethnic communities include the Turkana, Teso, and segments among the Luhya and Pokot ethnic groups. Together, these communities constitute approximately 15% of Kenya's population (5). Approximately half (52.9%) of the uncircumcised males reside in Nyanza Province, with most of the remainder residing in Rift Valley, Nairobi, and Western provinces (Table 1) (6). In total, 73% of the estimated 1.4 million HIV-infected persons in Kenya reside in the same four provinces (1). The highest HIV prevalence rates among uncircumcised males aged 15–64 years are in Nyanza (17.3%), Rift Valley (7.0%), Nairobi (20.2%), and Western (6.8%) provinces (6). These areas were selected as priority regions for implementation of VMMC to achieve 80% coverage (860,000 circumcisions) by July 2013 to reduce HIV transmission in Kenya (7). The MOH strategy has prioritized targets in three phases. Phase one targets uncircumcised males aged 15–49 years, with a goal of achieving 80% circumcision coverage by July 2013. Later phases target males aged <15 years and male infants for future VMMC programming. This report describes progress achieved during phase one of VMMC implementation, through December 2011.

Data were collected from MOH-approved client forms and standardized data collection summary tools for VMMC. Information on client age, district of residence, HIV test results, intra-operative and postoperative adverse events (AEs),type of service providers, and postoperative reviews were collected from CDC-supported sites. CDC support includes site renovation, procuring surgical instruments and supplies, and hiring clinical staff members to provide VMMC for HIV prevention. Analyses included only those VMMCs that were conducted by partners receiving CDC support. Univariate and bivariate analyses were conducted using statistical software to determine progress.

Kenya's 4-year VMMC target is to circumcise 860,000 (80%) of uncircumcised males aged 15–49 years by 2013. During 2008–2011, trained clinicians performed 391,383 VMMCs for HIV prevention in Kenya, of which 340,958 (87.1%) were conducted in 260 MOH sites supported by CDC-funded partners, from which the data were obtained. Of those 340,958 VMMCs, 167,952 (49.3%) were conducted in 2011, compared with 50,051 (14.7%) in 2009 and 114,735 (33.7%) in 2010 (Table 2). Overall, 273,115 (80.1%) VMMC clients were aged ≥15 years (median: 17 years). Half (49.8%) of the circumcisions were in males aged 15–19 years, while those aged 20–24 and ≥25 years accounted for 15.8% and 14.4%, respectively (Table 2).

Provider-initiated HIV testing and counseling is offered to all VMMC clients and was accepted by 266,117 (78.0%) males, of whom 5,215 (2.0%) were diagnosed as HIV-infected and referred to care and treatment services. HIV-testing rates and numbers among VMMC clients increased from 60.5% (4,976 clients) in 2008 to 86.4% (145,040 clients) in 2011 (Table 2).

Task-shifting of VMMC surgical roles to nonphysicians has contributed to increases in VMMCs by nurse and clinical officers.§ During 2008–2011, nurses and clinical officers performed 142,732 (41.9%) and 185,760 (54.5%) circumcisions, respectively. In 2008, nurses performed only 1,295 (15.8%) surgeries, progressively increasing to 80,221 (47.8%) during 2011. In 2009, only 7.4% of VMMCs were conducted by medical officers, while nurses performed 26.7% of the 50,051 VMMCs and clinical officers conducted 63.9%. As a result, the proportion of VMMCs performed by medical officers declined substantially, from 24.4% in 2008 to 0.2% in 2011 (Table 2).

VMMC services initially were delivered at fixed sites in provincial, district, or subdistrict hospitals. Based on data for VMMC service delivery types, 49.9% of VMMCs in 2008 were performed at fixed locations. By 2011, less than a third (30.5%) of VMMCs were performed at fixed locations as outreach or mobile services (e.g., performed in tents, prefabricated structures, schools, or community centers) became more feasible alternatives for service delivery (Table 2).

Although recommended, only 27.5% of 340,958 total clients returned for postoperative review within 7 days of surgery during 2008–2011. The number of clients returning for postoperative review increased from 4,147 in 2008 to 43,570 in 2011, but the proportion decreased from 50.5% to 25.9%, respectively. During 2008–2011, overall moderate or severe postoperative AEs were experienced by 2.6% of those clients returning for review, declining from 4.6% in 2009 to 1.9% in 2011. The overall proportion of intraoperative AEs was 0.2%, with continuous reductions from 1.5% in 2008 to 0.1% in 2011 among all surgery providers (Table 2).

VMMC services began earlier in Nyanza Province than elsewhere (Table 3). Overall, 82.3% of 340,958 VMMCs have been conducted in Nyanza Province, as of December 2011, whereas 8.3% and 6.6% were conducted in Nairobi and Western (Teso District) provinces, respectively. Rift Valley Province accounted for <0.7% of total VMMCs.

Reported by

Peter Cherutich, MBChB, Athanasius Ochieng, MBChB, Davies Kimanga, MBChB, National AIDS and STI Control Programme, Kenya. Zebedee Mwandi, MBChB, Samuel Mwalili, PhD, Kipruto Chesang, MBChB, Nancy Knight, MD, Div of Global HIV/AIDS, CDC Kenya. Jonathan Grund, MA, MPH, Naomi Bock, MD, Div of Global HIV/AIDS, CDC. Corresponding contributor: Zebedee Mwandi, zmwandi@ke.cdc.gov, +254728 608 750.

Editorial Note

VMMC is an effective HIV prevention intervention that reduces the risk for HIV acquisition among men and can be performed safely by nonphysicians in Kenya after receiving training based on World Health Organization guidelines. Modeling studies estimate that if VMMC coverage reaches 80% of eligible males, approximately 47,000 new HIV infections can be averted in 15 years in Nyanza Province alone (8). However, challenges to VMMC implementation remain, including increasing acceptance among males aged 25–49 years, increasing the proportion of clients returning for recommended postoperative review, and promoting medical rather than traditional or cultural circumcision in traditionally circumcising communities.

Kenya has made progress toward the 80% VMMC target by circumcising 52.2% of uncircumcised males in Nyanza Province, but with considerable variations in coverage by age. Coverage among males aged 15–19 years in some districts has reached 70%. Overall median client age is 17 years, suggesting older males (aged 25–49 years) are largely still not accessing VMMC. Providing VMMC services to younger males will benefit the next generation as they become sexually active. However, most new HIV infections occur in males aged 25–44 years, and thus they are a priority group for VMMC to provide a more immediate impact on the HIV epidemic. Strategies to attract older males for VMMC urgently need to be explored and evaluated.

Another challenge to VMMC implementation in Kenya is the variation in coverage across provinces. Several districts in Nyanza and Western provinces are approaching the 80% VMMC target among males aged 15–19 years, but many other districts are well below this target. Given the limited precision of district-level VMMC coverage data and population shifts in Kenya, accurately gauging coverage rates at the district and subdistrict levels has been difficult. More precise client demographic data could be used to help guide VMMC scale-up strategies and ensure reliable VMMC coverage.

Low compliance with follow-up after VMMC surgery also is a challenge to the VMMC program in Kenya. VMMC clients are recommended to return for postoperative review within 7 days of surgery, but almost seven in 10 males did not return. Although the AE rate is consistently low among those returning for follow-up, the substantial loss-to-follow-up rate makes accurate AE reporting difficult. Based on low return rates, MOH and CDC are conducting active surveillance activities to determine possible reasons for loss-to-follow-up and reliable postoperative AE rates.

In spite of multiple challenges, Kenya has made considerable progress toward its goal of 80% VMMC coverage. Aspects of Kenya's VMMC strategies might be appropriate for programs in other sub-Saharan countries implementing VMMC for HIV prevention.

Acknowledgments

Kawango Agot, Impact Research and Development Organization – Kenya. Walter Obiero, Nyanza Reproductive Health Society – Kenya. Patrick Oyaro, Kenya Medical Research Institute/Family AIDS Care and Education Svcs – Kenya. Alice Njoroge, Eastern Deanery AIDS Relief Program – Kenya. Alpa Patel-Larson, Div of Global HIV/AIDS, CDC Kenya.

References

  1. National AIDS and STI Control Programme. Kenya AIDS Indicator Survey 2007: final report. Nairobi, Kenya: Ministry of Health, National AIDS and STI Control Programme; 2009. Available at http://nascop.or.ke/library/3d/KAIS_2007_Final.pdf. Accessed November 20, 2012.
  2. World Health Organization, UNAIDS. New data on male circumcision and HIV prevention: policy and programme implications. Geneva, Switzerland: World Health Organization; 2007. Available at http://www.who.int/hiv/pub/malecircumcision/research_implications/en/index.html. Accessed November 20, 2012.
  3. National AIDS and STI Control Programme. National guidance for voluntary male circumcision in Kenya. Nairobi, Kenya: Ministry of Health, National AIDS and STI Control Programme; 2008. Available at http://malecircumcision.org/programs/documents/KenyaMCguidance.pdf. Accessed November 21, 2012.
  4. Mwandi Z, Murphy A, Reed J, et al. Voluntary medical male circumcision: translating research into rapid expansion of services in Kenya, 2008–2011. PloS Med 2011;8(11):e1001130.
  5. Kenya National Bureau of Statistics, ICF Macro. Kenya demographic and health survey 2008–09. Nairobi, Kenya: Kenya National Bureau of Statistics; Calverton, MD: ICF Macro; 2010. Available at http://www.measuredhs.com/pubs/pdf/fr229/fr229.pdf. Accessed November 20, 2012.
  6. Mwandi Z, Bunnell R, Cherutich P, et al. Male circumcision programmes in Kenya: lessons from the Kenya AIDS Indicator Survey 2007. Bull World Health Organ 2012;90:642–51.
  7. National AIDS and STI Control Programme. Kenya national strategy for voluntary medical male circumcision 2008–2013. Nairobi, Kenya: Ministry of Health, National AIDS and STI Control Programme; 2009. Available at http://nascop.or.ke/library/VMMC/VMMC%20Strategy.pdf. Accessed November 20, 2012.
  8. US Agency for International Development. The potential cost and impact of expanding male circumcision in Nyanza, Kenya. Washington, DC: US Agency for International Development; 2009. Available at http://www.malecircumcision.org/programs/documents/Kenya11209.pdf. Accessed October 25, 2012.

* Analyses conducted in this report are limited to the 340,958 VMMCs conducted by in-country partners receiving CDC support. An additional 50,425 VMMC procedures were performed in Kenya during 2008–2011 through support from other donor agencies. No other data were collected pertaining to those VMMCs.

AEs are complications related to male circumcision surgery. AEs have been defined by Kenya's Ministry of Health and include specific descriptions of the type of event (e.g., infection, bleeding, or swelling), severity (e.g., mild, moderate, or severe), and time of onset (intraoperative or postoperative).

§ A clinical officer in Kenya is a member of a health-care provider cadre who has expanded diagnostic and treatment authority but with less training than a medical officer (similar to a physician's assistant in the United States).


What is already known on this topic?

Voluntary medical male circumcision (VMMC) is an effective human immunodeficiency virus (HIV) prevention intervention in settings with high HIV prevalence and low rates of male circumcision.

What is added by this report?

Kenya's Ministry of Health, with support from CDC, is leading a VMMC for HIV prevention program that has resulted in 340,958 circumcisions in 260 sites in Kenya during 2008–2011. This report summarizes progress toward reaching the national target of 80% VMMC coverage among uncircumcised males aged 15–49 years by July 2013. In Nyanza Province, 52.2% of the target has been reached as of December 2011. A total of 273,115 (80.1%) of VMMC clients were aged ≥15 years, and 49,162 clients (14.4%) were aged ≥25 years. VMMCs performed among clients aged ≥25 years increased from 5,938 (11.9%) in 2009 to 24,945 (14.9%) in 2011.

What are the implications for public health practice?

Kenya's VMMC program relies on political and community support, routine provider-initiated HIV testing and counseling, shifting of surgical tasks, and various types of service delivery to achieve its goals. Aspects of Kenya's VMMC strategies might be appropriate for programs in other sub-Saharan countries implementing VMMC for HIV prevention.


TABLE 1. Number and percentages of total population, estimated human immunodeficiency virus (HIV)–infected persons and uncircumcised males, HIV prevalence in uncircumcised males and voluntary medical male circumcision (VMMC) targets, by selected priority areas for VMMC scale-up — Kenya, 2008–2011

Area

Total population aged 15–64 yrs

Estimated no. of HIV-infected persons aged 15–64 yrs

Uncircumcised males aged 15–64 yrs (%)

HIV infected uncircumcised males aged 15–64 yrs (%)

80% VMMC target (males aged 15–49 yrs) by 2013

No.

(%)

Nyanza

2,806,000

417,000

(29.7)

(52.9)

(17.3)

426,500

Rift Valley

4,838,000

304,000

(21.7)

(16.7)

(7.0)

188,500

Western

2,152,000

115,000

(8.2)

(10.2)

(6.8)

57,000

Nairobi

2,073,000

183,000

(13.0)

(9.7)

(20.2)

129,500

Other

8,115,000

384,000

(27.4)

Not available

(5.8)

58,500

Total

19,984,000

1,403,000

(100.0)

Not available

(13.2)

860,000


TABLE 2. Number and percentage of voluntary medical male circumcisions (VMMCs) reported annually, by age group, provider, human immunodeficiency virus (HIV) testing and counseling (HTC) acceptance, and adverse events (AEs) rate among VMMC clients — Kenya, 2008–2011

Characteristic

2008

2009

2010

2011

Total

No.

(%)

No.

(%)

No.

(%)

No.

(%)

No.

(%)

VMMCs overall

8,220

(2.4)

50,051

(14.7)

114,735

(33.7)

167,952

(49.3)

340,958

(100.0)

VMMC by age group (yrs)

<15 (includes infants)

2,166

(26.4)

18,269

(36.5)

28,824

(25.1)

18,584

(11.1)

67,843

(20.0)

15–19

2,332

(28.4)

18,656

(37.3)

50,968

(44.4)

97,977

(58.3)

169,933

(49.8)

20–24

1,912

(23.3)

7,188

(14.4)

18,474

(16.1)

26,446

(15.7)

54,020

(15.8)

≥25

1,810

(22.0)

5,938

(11.9)

16,469

(14.4)

24,945

(14.9)

49,162

(14.4)

VMMC provider

Medical officer

2,002

(24.4)

3,691

(7.4)

849

(0.7)

347

(0.2)

6,889

(2.0)

Clinical officer

3,580

(43.6)

31,970

(63.9)

64,865

(56.5)

85,345

(50.8)

185,760

(54.5)

Nurse

1,295

(15.8)

13,373

(26.7)

47,843

(41.7)

80,221

(47.8)

142,732

(41.9)

Other

1,343

(16.3)

1,017

(2.0)

1,178

(1.0)

2,039

(1.2)

5,577

(1.6)

HTC

VMMC clients accepting HTC

4,976

(60.5)

31,632

(63.2)

84,469

(73.6)

145,040

(86.4)

266,117

(78.1)

HIV prevalence

60

(1.2)

181

(0.6)

1,952

(2.3)

3,022

(2.1)

5,215

(2.0)

Intraoperative review and AEs

Intraoperative AE

126

(1.5)

307

(0.6)

140

(0.1)

132

(0.1)

705

(0.2)

Postoperative follow-up

4,147

(50.5)

17,029

(34.0)

29,131

(25.4)

43,570

(25.9)

93,877

(27.5)

Postoperative AE*

134

(3.2)

775

(4.6)

775

(2.7)

804

(1.9)

2,468

(2.6)

Service delivery type

Fixed

4,102

(49.9)

14,061

(28.1)

33,674

(29.3)

51,282

(30.5)

103,119

(30.2)

Outreach

2,123

(25.8)

30,624

(61.2)

50,326

(43.9)

74,010

(44.1)

157,083

(46.1)

Mobile

331

(4.0)

2,928

(5.9)

12,750

(11.1)

16,870

(10.0)

32,879

(9.6)

Unknown

1,664

(20.2)

2,438

(4.9)

17,985

(15.7)

25,790

(15.4)

47,877

(14.0)

* Percentages for postoperative AEs are calculated using the number of clients returning for follow-up as the denominator.


TABLE 3. Number and percentage of reported voluntary medical male circumcisions (VMMCs) performed in priority regions, and coverage against 4-year targets — Kenya, December 2011

Area

HIV prevalence in uncircumcised males aged 15–64 yrs

Date services started

VMMCs (all ages)

2013 VMMC target (males aged 15–49 yrs)

VMMCs target coverage (males aged 15–49 yrs)

Weighted %

(95% CI)

No.

(%)

No.

(%)

No.

(%)

Nyanza

17.3

(13.3–21.2)

2008

280,713

(82.3)

426,500

(49.0)

222,552

(52.2)

Rift Valley

7.0

(2.0–11.9)

2011

2,538

(0.7)

188,500

(22.0)

2,339

(1.2)

Western/Teso

6.8

(2.0–11.6)

2010

22,554

(6.6)

57,000

(7.0)

17,302

(30.4)

Nairobi

20.2

(12.8–27.5)

2010

28,337

(8.3)

129,500

(15.0)

25,022

(19.3)

Other

Not published

2010

6,816

(2.0)

58,500

(7.0)

5,900

(10.1)

Total

340,958

(100.0)

860,000

(100.0)

273,115

(31.8)

Abbreviations: HIV = human immunodeficiency virus; CI = confidence interval.


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