INCREASING MALE CIRCUMCISION UPTAKE AMONG REFERRED RAKAI PROGRAM COHORT PARTICIPANTS

Transcription

1 INCREASING MALE CIRCUMCISION UPTAKE AMONG REFERRED RAKAI PROGRAM COHORT PARTICIPANTS BY KIGHOMA NEHEMIA MEDIUM TERM FELLOW 2011

2 INCREASING MALE CIRCUMCISION UPTAKE AMONG REFERRED RAKAI PROGRAM COHORT PARTICIPANTS BY Kighoma Nehemia, MSc.HSM MEDIUM TERM FELLOW OCTOBER 2011

3 Table of Contents Table of Contents... i List of Tables... iii List of Figures... iv Declaration... v Acknowledgements... vi Acronyms and Abbreviations...viii Operational definitions... ix Executive Summary.... x 1. INTRODUCTION AND BACKGROUND Introduction to the problem Background to institution Reason for improvement Justification Current situation/baseline Objectives... 8 General objectives:... 8 Specific objectives: Problem analysis (root causes) Development and implementation plan of counter measures PROJECT IMPLEMENTATION (METHODOLOGY) Designing of health education messages and IEC materials Health education sessions a. Phone contact b. Physical re notification i

4 Follow up of clients who never turned up for surgery PICTORIAL FLOW OF ACTIVITIES Monitoring Data Analysis PROJECT OUTCOMES PHONE CONTACTS LESSONS LEARNT CHALLENGES EXPERIENCED AND HOW THEY WERE OVERCOME CONCLUSIONS RECOMMENDATIONS Follow up/scale up strategy Reference APPENDICES Appendix 1. Implementation plan Appendix 2 : Information sheet for referred cohort clients Appendix 3: Cohort Re notification Form Appendix 4: SMS message Appendix 5: RCCS referral form ii

5 List of Tables Table 1: Social Demographic characteristics Table 2: Circumcision status and client characteristic by Period Table 3: Distribution of phone contact status Table 4: Circumcision status and client characteristic by study Period Table 5: Attempts to locate Table 6: Reason(s) for not turning up for circumcision by age group (N=133) Table 7: Reason for not turning up for circumcision by marital status Table 8: Reason for not turning up for circumcision by Phone contact Table 9: Other Reasons for not turning up for surgery Table 10: Project Schedule iii

6 List of Figures Figure 1: Flowchart showing flow of clients for surgery... 6 Figure 2: No. of referred cohort clients for circumcision and No. of clients circumcised per month... 7 Figure 3: MMC uptake before Intervention period... 7 Figure 4: Clients perceived reasons for not turning up for MC... 8 Figure 5: Counter Measure Matrix Figure 6: Scheme of the referred cohort clients Figure 7: Before Intervention period N= Figure 8: Intervention period N= Figure 9: Distribution of Phone contact (N=423) Figure 10: MC uptake by phone contact and period during comparison period Figure 11: MC uptake by phone contact and period during intervention period Figure 12: MMC uptake by Re notification Figure 13: MMC uptake by Phone contact Figure 14: Summary of referred cohort clients who never turned up for circumcision iv

7 Declaration I Kighoma Nehemia do hereby assert that this work is solely my project since the beginning of implementation to end of project. The end of project report entitled Increasing Male Circumcision Uptake among Referred Rakai Program Cohort Participants has been prepared by myself and submitted in the fulfillment of the requirement of the Medium Term HIV/AIDS Fellowship Program at Makerere University School of Public Health and this type of report has never been submitted for any academic or non academic qualifications either in full or in part to any institution. Signed: Date: Kighoma Nehemia, Medium Term Fellow. Signed: Date: Dr.Kigozi Godfrey Institution Supervisor. Signed: Date: Dr. Hudson Baliddawa Academic Supervisor. v

8 Acknowledgements I extend my sincere thanks to the MakSPH CDC HIV/AIDS program for the scholarship award to attend the Fellowship program and funding of my project at Rakai Program. Thanks to my institution mentor Dr.Kigozi Godfrey for on sight supervision, mentorship and for his tireless effort in making my project implementation success and guidance during proposal and report writing. I also extend my sincere thanks to my academic mentor for the support he rendered to me since development of the proposal to end of project implementation. Special thanks to my family for the support they rendered to me during the implementation period and while I was away at the University. Thanks to Dr. Adrian Musiige who constantly encouraged me to take the course and the support given to me during the application process. My sincere gratitude to my Fellow Fellows who always inspired me during Fellowship period and company while at the School of Public Health. Thanks to the RHSP Management for allowing me take the Fellowship program and the support rendered to me during the project implementation period. Many thanks to Mr. Richard Musoke the RHSP statistician, who did the data analysis and without his effort analysis would not be possible. My gratitude to the Rakai Program fraternity for the support they rendered to me during the implementation period. vi

9 Thanks to the CQI team for the guidance during problem identification and working together during the implementation period. Thanks to the Circumcision Clients who came for surgery at the RHSP centre Kalisizo. Lastly I thank Mr.Denis Tumuramye who assisted in making phone calls and sending text messages to clients. vii

10 Acronyms and Abbreviations BV CHM Bacterial Vaginosis Community Health Mobilizers CQI GUD H/E Continuous Quality Improvement Genital Ulcer Disease Health Education HIV HPV Human immunodeficiency virus Human papilloma Virus HSV2 Herpes Simplex Virus type 2 IEC Information, Education and Communication MC MMC QA/QC Male circumcision Medical male circumcision Quality Assurance and Quality control RCCS RCT RHSP SMC UNAIDS UVRI VHT Rakai Community Cohort Study Randomized Controlled Trial Rakai Health Sciences Program Safe Male Circumcision The Joint United Nations Programme on HIV/AIDS. Uganda Virus Research Institute Village Health Teams WHO World health Organization. viii

11 Operational definitions. Cohort Participants Referred Clients Uptake: Men participating in the RCCS Clients referred from RCCS during RCCS annual survey. Willingly received male circumcision from Rakai Program facility. Walk ins Men who are not participants in Rakai Community Cohort Study ix

12 Executive Summary. Three RCTs in Uganda, Kenya and South Africa showed a 50 60% efficacy of MMC for HIV prevention and given the benefits and uptake of circumcision, the Uganda MoH launched a policy to guide SMC practice in the country. The RHSP has been offering free MC to both cohort and non cohort clients. RHSP has been offering free MMC to males aged 12 and above in Rakai and neighboring districts since Despite the provision of free MMC, prevalence among non Muslim uncircumcised men in the cohort communities remains modest (~28% in 2010). However, over a period cohort uptake has been declining by survey rounds. Therefore there is need to increase the proportion of referred participants receiving circumcision, increase enrolment into MC related studies and reduction in HIV acquisition by men. The project will be implemented by Rakai Health Sciences Program which was established in 1987 as Rakai Project and is a collaboration between researchers from UVRI (MOH), Makerere University, Columbia and Johns Hopkins Universities, USA. The program is a community based HIV/STI research and service delivery organization. The level of MC uptake for the referred cohort clients is unacceptably low 20% thus having low MC coverage among referred clients and resulting into low enrolment into male circumcision related studies. x

13 The intervention is intended to increase MC uptake from 20% to 34% so as to increase MC coverage by increasing the proportion of referred cohort participants by June The main project objective was to increase MC uptake in Rakai, Uganda among referred cohort clients so as to improve MC uptake by June The specific objectives was to increase MC uptake among referred cohort participants from 20% to 34% by June 2011 and document strategies used to improve uptake of MC by June MC uptake increased from 20.5% to 32.4% and among the participants with phone contacts uptake increased from 19.4% to 32.6%. The intervention (Phone contact and re notification) significantly increased MMC uptake among men referred by RCCS Adjusted Odds Ratios (95%CI) 2.01(1.42,2.83), p values < Re notification had similar levels of MMC uptake as phone contact, however, using a phone contact is cost effective, Adjusted Odds Ratios (95%CI) 1.15(0.73,1.82), p values Providing health education and information sheets to clients to address myths and beliefs, reduced fear of injury to 1.5% and fear of pain to 2.26% The total budget was USH 5,738,000 (US$2,500.22) covering all costs during project implementation. xi

14 1. INTRODUCTION AND BACKGROUND Introduction to the problem. Three RCTs in Uganda, Kenya and South Africa showed a 50 60% efficacy of MMC for HIV prevention 1, 3. In March 2007, WHO/UNAIDS recommended that MMC be provided as part of a comprehensive package for prevention of HIV acquisition in men 2. MMC has also been shown to have other benefits including improved genital hygiene, reduction of STIs in men (HSV2, HPV, GUD) 4,5 and reduction of STIs in female partners of circumcised men (GUD, HPV, HSV2, BV) 4,6. In October, 2010 the Uganda MoH launched a SMC policy to guide MC practice in the country. The Rakai Health Sciences Program (RHSP) is offering free MC to males aged 12 and above in Rakai and neighboring districts since 2007 including cohort participants and walk ins. All males in Rakai and neighboring districts are encouraged to receive MC for HIV prevention and other related benefits. The Rakai Community Cohort Study conducts annual surveillance among ~6000 men and 8000 women aged 15 years and above resident in Lyantonde and Rakai Districts. RCCS conducts community epidemiologic and behavioral studies to document the HIV/STD epidemics and risk factors, implements HIV/STI preventive services, provides a unique resource for hypothesis generating and hypothesis testing research on HIV and other infections (including TB, malaria, STDs, HPV) and on maternal and child health (including prevention of mother tochild HIV transmission and screening for cervical neoplasia) 1

15 Only 25% of men residing in the cohort area were circumcised mainly for religious reasons. Rakai cohort survey findings indicate that over 70% of men in the cohort said they would be willing to be circumcised if the service was provided free of charge. The cumulative level of MC Prevalence ( ) in non Muslim RCCS men was 25.8%, however prevalence of circumcision in the Rakai Cohort was 48.9% in 8 years. Similar levels of MC acceptability have been reported in South Africa 7, 65% and Kenya 7, 8, 65%. The overall uptake rate for cohort and walk ins for male circumcision is relatively high 60% among eligible clients at the Rakai Health Sciences Program, however, the level of uptake for the referred cohort clients is low 20% (unpublished data) Background to institution The Rakai Health Sciences Program was established in 1987 as Rakai Project and is a collaboration between researchers from UVRI (MoH), Makerere University, Columbia and Johns Hopkins Universities, USA. It is a community based HIV/STI research and service delivery organization that has conducted a number of research studies including Randomized trials of new prevention strategies including Medical Male Circumcision for HIV/STI prevention in men and women. The program offers a wide range of health services including health education, HIV/AIDS counseling, condom promotion, domestic violence prevention, treatment of STIs, and provision of free male circumcision since 2007 when the trial findings were communicated. 2

16 Rakai Health Sciences Program conducts annual surveillance among 14,000 through the Rakai Community Cohort Study (RCCS) and during the survey, male participants are encouraged to receive circumcision. So far RHSP has circumcised over 20,000 males in Rakai and neighboring districts. The Rakai Program has been monitoring uptake of MMC through the cohort surveys. During the survey interviews, male participants are asked whether or not they are circumcised, uncircumcised men are educated about MC and are offered free circumcision. Participants who are interested in circumcision are given referral chits and referred to the circumcision team Reason for improvement. Since the beginning of the MC trial in 2004, the cumulative prevalence of MC in the cohort has risen from 21% to 48.9% in The rate of increase in MC prevalence by survey round is however declining. During the current survey round (Round 14), of the 2,194 men who reported being uncircumcised, only 577 (26.3%) indicated willingness to be circumcised of whom only 59 (10.2%) turned up for circumcision. Despite the provision of free MMC, prevalence among non Muslim uncircumcised men in the cohort communities remains modest (~28% in 2010), and between January and September 2010, MMC uptake among referred cohort clients was unacceptably low (20%) In order for Medical Male Circumcision to be an effective HIV prevention strategy, there is need for high population coverage of over 70%. Therefore there is need to identify and address factors that influence MC uptake. The CQI team 3

17 comprised of James Nkale and Joshua Mwinike Study Supervisors, Enos Baghendaghe and Richard Mayanja QA/QC, Grace Kigozi and Nehemiah Kighoma Study Coordinators, Herbert Mayengo Data management officer, Denis Tumuramye Hub leader. The team was selected according to the departments that implement and offer quality control of MC services in the program. Since 2007, the team has been implementing MC services and it has a vast experience in translating research into program. A team of eight CQI members sat and generated many issues by brain storming and by consensus selected one problem low uptake of MC among the referred clients from Rakai Program Community Cohort study. Justification Data from the Rakai cohort shows that there is low level of MC uptake among cohort participants (20%). Indentifying and designing strategies to improve MC uptake is critical since MC can only be used successfully as an HIV prevention strategy if a critical mass of men in the population is circumcised as indicated by modeling. For MMC to be effective as an HIV prevention strategy, there is need to achieve high population coverage within the shortest time possible There is therefore need to design effective interventions that will enable rapid roll out and coverage of MMC. The effectiveness and efficiency of MC as an HIV/STI preventive strategy increases with increase in MC prevalence in the community. Monitoring MC prevalence in the Rakai cohort provides an opportunity to evaluate and improve strategies of mobilizing men for MC. 4

18 Lessons learnt from this project will not only help to improve uptake of MC in Rakai and neighboring districts but will as well inform policy and other programs that are rolling out MC on practical strategies of increasing uptake of MC as an HIV/STI prevention strategy. Therefore the intervention will provide information that will inform MMC roll out programs and policy makers on strategies that can increase MMC coverage in target populations. The team estimated to increase MC uptake from 20% to 34%, so as to increase MC coverage in the cohort by increasing the proportion of referred participants from the cohort to MC facility by June This will be achieved by reminding clients through text messaging and phone calls. Increasing level of uptake will enable the program to increase turn up of clients for circumcision thus improving the enrolment into male circumcision related studies, and reduction of HIV acquisition in males as a long term strategy. The assessment for the project progress was done at the Rakai Program facility where clients receive circumcision. 5

19 Figure 1: Flowchart showing flow of clients for surgery. Referred clients from RCCS Turn Up at facility Group health educatio Group counseling Never turn up at facility. Never turn up for MC Referred for treatmen Preoperative assessment/ consenting VCT Return for MC Received MC /Theatre Decline MC Home 3.0. Current situation/baseline. To date RHSP has circumcised over 20,000 males aged 12 and above from both cohort and non cohort areas in Rakai and neighboring districts. Men from the cohort are referred to receive surgery at RHSP. Figure 2 shows number of men referred and those who received MC by month starting from January to September Three hundred thirty two (332) men were referred from the cohort to the circumcision team for MC and only 68 (20.5%) received the service. This level of MC uptake is unacceptably low and therefore the need for improvement. 6

20 Figure 2: No. of referred cohort clients for circumcision and No. of clients circumcised per month Figure 3: MMC uptake before Intervention period The MC uptake was 20.5% before the implementation period. During the RCCS, men who refuse MC are asked to give reasons why they decline MC. Figure 3 shows distribution of reasons why men decline surgery and the commonest reasons given were fear of pain (66.4%) and fear of injury to the penis (44.1%). Other reasons cited included forgetting the day of surgery, getting the day of appointment wrongly, religious and traditional beliefs, and belief that they are not at risk of HIV acquisition. 7

21 Figure 4: Clients perceived reasons for not turning up for MC 3.1. Objectives General objectives: To increase MC uptake in Rakai, Uganda. Specific objectives: 1. To increase MMC uptake among referred cohort participants from 20% to 34% by June Document strategies used to improve uptake of MC 4.0. Problem analysis (root causes). Fishbone was used to analyze root causes for low MC uptake by referred cohort clients and root causes were categorized basing on clients perception about male circumcision, surgical procedure and myths about male circumcision. 8

22 The fishbone below represents root causes for low MC uptake by referred cohort clients. May not turn up because they are working Cost of transport from home to collection stations. Forgetting day of surgery Getting the day wrongly for appointment. Not reading appointment card. Client Belief that they are not at risk of HIV. Lack of knowledge about procedure MC procedure/surgery Fear of pain, Injury to the penis Religious beliefs Traditional beliefs Low MC uptake by cohort clients Myths The CQI team had to brainstorm the causes for low uptake of MC by referred cohort clients and by consensus made the major causes then segmented the causes into major categories basing on the clients, procedure and myths. The verification for reasons for not turning up for surgery was through review of Rakai Program cohort data which was collected during the annually RCCS surveys. 9

23 5.0. Development and implementation plan of counter measures. Figure 5: Counter Measure Matrix. Problem Root causes Countermeasures. Practical method Lack of knowledge about procedure. Fear for pain and injury to the penis. Develop Health education materials & Conduct community sensitization Conducting group and individual H/E about the MC procedure LOW MC UPTAKE Forgetting the day of surgery, getting the day of appointment wrongly Religious and traditional beliefs. Belief that they are not at risk of HIV Getting phone. Developing text messages Routinely issue appointment card Develop Health education materials & Conduct community sensitization Sending text messages Making Phone calls Emphasis on reading the appointment card Conducting group and individual H/E and / community sensitization about the MC PROJECT IMPLEMENTATION (METHODOLOGY). During RCCS annual surveys, participants are given information about MC services and are asked whether they are circumcised. For those that are not circumcised are encouraged to be circumcised and information sheet read to them. If he is willing to receive surgery then he is given an appointment date for surgery. After the interview, the client is given a referral form where phone contacts and physical addresses were recorded. The clients are provided transport by collecting them before or on the day of surgery from their communities and after surgery they are taken back to the community. Despite facilitating them with transport before implementation period, still clients would not turn up for surgery. All referred cohort clients are registered in a book with their phone and physical 10

24 contact addresses that are used to contact them and also used in case they did not turn up for surgery. The activities conducted were developing of the information sheet, SMS messages and phone call messages. The project implementation period was from March to June 2011 during which SMS and phone calls were made to clients and physical re notification. Designing of health education messages and IEC materials. Developed male circumcision information sheet that included information on the MMC procedure, wound care, benefits and complications. It was read and given to participants during RCCS annual surveys and those willing were referred to RHSP center for MMC. Translation of this document was done to enable clients understand the message. Health education sessions. During the RCCS annual surveys, the team conducted health education sessions and/ community sensitization to groups and or individuals about the benefits of MC and free MC services available at RHSP. The sessions were intended to allay perceived fears and myths about MC procedure. Health education materials that addressed root causes were used during health education sessions and supplied to clients. However, prior to the RCCS annual surveys, general health education including circumcision information was given to the study community and during RCCS interview at the hub, focused health education was also given to the participants. 11

25 Appointment cards These were routinely issued and emphasize was put on the surgical appointment date so that clients know where to check when they need a reminder of the appointment date for surgery. Referred RCCS clients were registered daily in a log book and their phone & physical contact addresses recorded. Two strategies were used: phone contact and physical re notification. a. Phone contact Developed SMS messages and phone call messages that were used during the project implemetation. Phone calls and text messages were sent to those that had phone contact. Phone calls and text messages information indicated the date of surgery, location and time of collection of the clients. Phone calls were made to remind clients about the surgery appointment two days before the day of surgery followed by an SMS. On average at least two phone calls were made followed by one SMS which served to keep reminding the client even after the call. The SMS was made to remind clients in case they forget the appointment date for surgery after a call. SMS were also sent to those whose telephones were off or unavailable at the time of contact and several attempts were made to call them, however, some of the clients responded to acknowledge receipt of SMS. Clients were collected to come for surgery and even before the intervention clients used to be collected but MC uptake was still low. Therefore, phone calls and text messages were developed to increase uptake of MC in the cohort. 12

26 b. Physical re notification For clients that did not have a phone or any phone contact (a phone contact with friend or relative), physical re notification was done a day or two days before surgery. Follow up of clients who never turned up for surgery. Referred clients from cohort who never turned up to the facility to receive circumcision were contacted 1 month after appointment date and ascertained reasons as to why they did not turn up for surgery. The re notification form was filled and reasons to why the clients did not turn up were ascertained and data entry was done from data office. This was made to assess reasons to why they never turned up and in future to be able to layout strategies for improving MC uptake in the cohort. 13

27 PICTORIAL FLOW OF ACTIVITIES Interviewer with client read for MMC referral Nurse logging in referred RCCS clients Clinician making phone calls Clients boarding track from field MMC in progress in RHSP theare. Clients waiting for surgery 14 Clinician discharging clients

28 Monitoring Data was collected on Social demographics, number of clients referred, number with phones access, number contacted on phone (call/sms), and number that turned up for surgery. The progress of the project was done to monitor the number of referred cohort clients that received surgery at the Rakai Program facility through the existing MC data management system. Monthly reports were used to monitor project progress and the results recorded. Data entry was carried out at the RHSP Center, using screens with programmed range and consistency checks. Subjects are identified by unique alphanumeric check digit study ID numbers which prevent keying errors. All service card/forms were double entered to monitor entry errors. Experienced data managers in Kalisizo constructed relational data bases, and data sets maintained in Rakai. Security was maintained by storing all data files on password protected machines accessible only to data managers and analysts. Hard copy service cards/forms were stored in locked file cabinets in secure locked rooms. Data Analysis Data entry was done in visual foxpro and analysed using Stata version 11. Graphs and figures were generated from MS Excel. Analysis Plan During the Intervention period, clients considered comprised of men referred by RCCS within the period of 1 st March and 30 th June 2011, all men referred but 15

29 with appointments for surgery before 1 st March 2011, had participated in cohort activities and circumcised between 1 st march and 30 th June 2011 were included (These were assumed to have been called) lastly all men who were attempted for re notification and turned up for surgery were included but excluded in the referred by RCCS because of double counting. Note: All clients attempted for renotification had appointments lying outside the comparison period (Before Intervention period). Before Intervention period (Comparison group) has individuals referred by RCCS during the period of 1 st Jan to Sept 2010 and individuals notified by Circ team with appointments lying within the same period and had been interviewed in the cohort within a period of 12 months. Outcome; If an individual with an appointment in the comparison period (before implementation period) was circumcised within that same period, he was considered as having the outcome of interest. Similarly, individuals with appointments and circumcisions done in the intervention period (implementation period) or anyone attempted for re notification and circumcised were considered to have the outcome of interest. 16

30 PROJECT OUTCOMES. Figure 6: Scheme of the referred cohort clients 423 participants were referred from RCCS during the annual survey. Table 1: Social Demographic characteristics. Project implementation Period Before implementation Period n % n % Total Age group < < < Marital Status Married Never married Separated Phone Contact Yes No % were years old, 50.4% married men and among those referred 66.7% had phone contacts. 17

31 Table 2: Circumcision status and client characteristic by Period Characteristic Period Number Circumcised/N Proportion Circumcised (%) Overall Comparison period 68/ Intervention period 137/ Phone contact No Phone Comparison period 28/ Intervention period 45/ Have Phone Comparison period 40/ Intervention period 92/ During Comparison period 332 men were referred of which 68 men were offered circumcision while during intervention period 423 men were referred and 137 were offered circumcision. 18

32 Figure 7: Before Intervention period N=332 Figure 8: Intervention period N=423 The MMC uptake increased from 20.5% to 32.4% by June 2011 by the referred cohort clients as indicated in Figure 5 and Figure 6. 19

33 PHONE CONTACTS. Table 3: Distribution of phone contact status Category Numbers % Total number of clients 423 Number of clients with phone contacts 282/ Number of clients without phone contacts 141/ Number of clients contacted successfully 269/ Number of clients with wrong phone contacts 13/ % were the clients contacted on Phone and 4.6% had wrong telephone numbers. Figure 9: Distribution of Phone contact (N=423) 66.7% of the cohort clients referred had phone contacts indicating majority of the clients had phone contacts and they were likely to be contacted. 20

34 Figure 10: MC uptake by phone contact and period during comparison period Figure 11: MC uptake by phone contact and period during intervention period MMC uptake among those with phone contact increased from 19.4% to 32.6% as shown in Figure 9 and Figure 10 21

35 Comparing circumcision & phone contact during intervention period Figure 12: MMC uptake by Re notification Figure 13: MMC uptake by Phone contact Making phone calls is as good as re notifying clients, however, it is cheaper using phone contacts 22

36 Table 4: Circumcision status and client characteristic by study Period Characteristic Study Period Number Circumcise d/n Proportion Circumcised (%) Overall Comparison period 68/ Phone contact Adjusted Odds Ratios (95%CI) p values Intervention period 137/ (1.42,2.83) <0.001 No Phone Comparison period 28/ Intervention period 45/ (0.97,3.01) Have Phone Comparison period 40/ Age Group Intervention period 92/ (1.39,3.32) <20 Comparison period 28/ Intervention period 46/ (1.38,4.27) <30 Comparison period 19/ Intervention period 37/ (0.72,2.47) <40 Comparison period 18/ Intervention period 39/ (0.96,3.69) Comparison period 3/ Marital Status Intervention period 15/ (0.97,16.42 ) Not married 40/ Intervention period 62/ (1.15,2.94) Married Comparison period 28/ Intervention period 75/ (1.28,3.52) More circumcisions were done in intervention period (32.4%) compared to the comparison period (before implementation Period) (20.5%) and more married people were circumcised compared to the unmarried. There were more young (less than 20 years) men circumcised compared to the older men (20 years plus). 23

37 Men with phone contacts in intervention period (32.6%) were more likely to be circumcised than those with phone contacts in the comparison period (19.4%). MMC uptake increased significantly from 20.5% to 32.4% by June 2011 The intervention (Phone contact and re notification) significantly increased MMC uptake among men referred by RCCS. Table II: Circumcision status and client characteristic by phone contact Overall Age Group Physical Re notification 45/ Circ/N (%) Adjusted Odds Ratios (95%CI) p values Phone Contact 92/ (0.73,1.82) <20 Physical Re notification 22/ Phone Contact 24/ (0.41,1.87) <30 Physical Re notification 7/ Phone Contact 30/ (0.57,3.64) <40 Physical Re notification 9/ Phone Contact 30/ (0.56,3.50) Physical Re notification 7/ Phone Contact 8/ (0.31,4.23) Marital Status Married Physical Re notification 21/ Phone Contact 54/ (0.56,2.04) Not married Physical Re notification 24/ Phone Contact 38/ (0.66,2.40) MC uptake by Physical Re notification accounted for 31.9 % and Phone Contact 32.6%, P= In the intervention period, no difference in MMC uptake among men who were contacted by phone compared to those who were re notified. 24

38 FOLLOW UP OF CLIENTS. For clients that did don t turn up for surgery, attempts were made to ascertain reasons as to why they did not turn up for surgery. Figure 14: Summary of referred cohort clients who never turned up for circumcision Number Referred = 423 Number Circumcised= 137 (32.4%) Never turned up for circumcised = 286 (67.6%) No. failed to re notify = 47 (16.4%) No. attempted for re notification = 239 (83.6%) Attempted and not seen = 114 (47.7%) Attempted and seen = 125 (52.3%) Table 5: Attempts to locate. Attempts made n % Total Seen Away Work Away School Visiting Other Out Migrated A total of 239 cohort participants who did not turn up for circumcision were attempted for re notification. Out of these, 125 were contacted and the table below shows the reasons why they did not turn up for surgery. 25

39 Table 6: Reason(s) for not turning up for circumcision by age group (N=133) Reason for not turning up for surgery <20 20 <30 30 < n % n % n % n % Total Too Busy Refused By Spouse No longer interested Fear of Injury Fear of Pain Against traditional beliefs Still Undecided Transport Health problems Burial Other Being busy was cited by 65% of the respondents as the reason for failing to turn up for circumcision regardless of age group. A lower percentage of individuals aged 40 and above cited being busy compared to other age categories. Fear of pain and fear of injury to the penis reduced mostly likely due to health education and supply of information sheet to clients. Table 7: Reason for not turning up for circumcision by marital status Reason for not turning up for surgery Married Not married n % n % Total Too Busy Refused By Spouse No longer interested Fear of Injury Fear of Pain Against traditional beliefs Still Undecided Transport Health problems Burial Other

40 Among married men, the percentage of who reported that they failed to turn up for surgery due to being busy was higher than that of the unmarried. Table 8: Reason for not turning up for circumcision by Phone contact Reason for not turning up for surgery No Phone Contact Have Phone Contact n % n % Total Too Busy Refused By Spouse No longer interested Fear of Injury Fear of Pain Against traditional beliefs Still Undecided Transport Health problems Burial Other Men with phone contacts were more likely to cite being busy as the reason for failing to honor their surgical appointments. Table 9: Other Reasons for not turning up for surgery In Other reasons for not turning up for surgery are as below: Reason n % No Time to come for surgery Turned up but was not circumcised At School Refused by parents Attending to relative Forgot appointment Total Verification of receipt of SMS was assessed when some clients could call back saying they have got the message and they shall come on the appointment date, however, other clients did not respond to the SMS. Therefore, mechanisms should 27

41 be put in place to verify text messages either by asking them where is the message on your phone or what made you come for surgery. Even though phone calls were used to increase update of MC, this strategy can also work well for follow up of clients in programs. LESSONS LEARNT. The phone calls and SMS increased MC uptake from 20.5% to 32.4% during the implementation period. Phone contact achieves similar MMC uptake levels as Physical re notification and therefore Phone notification is much cheaper than physical re notification. Comparing clients in comparison period and implementation/intervention period with phone contacts, MC uptake increased for 19.4% to 32.6%. The clients responded to SMS by calling back after receipt of SMS. During the implementation period, it was noted that given health education messages and giving information sheet, reduced fears about MC side effects. Though clients were collected to come for surgery this did not affect the outcome since before the intervention, clients were collected but uptake was still low. MMC uptake increased significantly among, married and unmarried men, as well as for all age groups except among those in age group and among those who had phone contacts It was observed that the clients used the opportunity of using the phone to inform the health worker about any complications and management of adverse events/post operative complication was done over the phone, therefore, Phone contacts can be used by Clinicians to manage complications. Service delivery 28

42 programs could use phone contacts for monitoring including ART adherence/honoring appointment dates. Though MMC uptake increased significantly, it was still less than 50%, therefore other interventions/strategies are still needed. Therefore, MC may not be effective if other measures of mobilization are not put in place to have high MC prevalence in the communities. However, being self selected MC clients are likely not to be at high risk group and therefore MC coverage may not have an impact on HIV acquisition by men, if high risk groups are not targeted. CHALLENGES EXPERIENCED AND HOW THEY WERE OVERCOME Some telephone numbers were not available when contacted, therefore several calls were made to the participants. Some clients gave out wrong phone contacts and other clients gave phone contacts that belong to their friends or parents especially students. There is therefore need for prior collection of correct phone contacts. Some clients promise to call back to confirm their coming but they did not do so thus miss them on the day of surgery. Another challenging issue was flopping of scheduled CQI team meetings due to busy schedules by CQI team on Program work. Delay in procurement process due to Program accounting bureaucracy which resulted into implementing one month later that impacted on the implementation period. 29

43 SUMMARY Cohort participants that were referred were contacted through phone calls followed by SMS. The intervention (Phone contact and re notification) significantly increased MMC uptake among men referred by RCCS. MMC uptake increased among, married and unmarried men, as well as for all age groups except among those in age group and among those who had phone contacts. In the intervention period, no difference in MMC uptake among men who were contacted by phone compared to those who were re notified. The main challenge during implementation period was wrong telephone numbers accounting for 4.6% and phone number belong to parents or friends. CONCLUSIONS MC uptake increased from 20.5% to 32.4% and MMC uptake increased irrespective of whether one had a phone contact or not, married or not. Among those with phone contacts in the comparison and intervention period increased from 19.4% to 32.6%, therefore this strategy can be used to scale up MC among those with phone contacts. MMC uptake increased significantly in all age groups except years, most probably being a mobile and difficult to catch group Giving health education and information sheet probably reduced fears about MC side effects. Where no systems are in place to collect phone contacts before, contact persons in villages/communities like VHTs/CHW could be used to get phone contacts. 30

44 RECOMMENDATIONS In absence of structure in place in obtaining phone numbers, programs can use the existing structures like VHTs/ CHW to get contacts from clients. IEC materials are important in allaying fears about MC services. Institution. Rakai Program will continue to use the phone calls and SMS to remind clients about surgical appointment dates. Though MMC uptake increased, it was still less than 50%, therefore other interventions/strategies are still needed. MUSPH CDC HIV/AIDS Fellowship Program Phone contacts can work well in monitoring HIV/AIDS programs in increasing adherence and /honoring scheduled appointment dates. The school to encourage the academic mentors to offer support supervision despite their busy schedules otherwise most of the mentorship may be left solely with the institution mentors. Future plans. Dissemination plan. I intend to write a manuscript and publish my work and if funding allow, will present during scientific conferences. Dissemination workshop will be conducted at end of the project to MakSPH CDC HIV/AIDS Fellowship Program and to RHSP to inform staff about the new strategies of increasing MC uptake. 31

45 Follow up/scale up strategy. RHSP has started using phone contacts instead of driving to the clients to remind them of the day of surgery. Other organizations that are scaling up MC can utilize this model of increasing MC uptake and ART programs for follow up of clients on treatment and or HIV/AIDS care. It is a model that can be used for ART adherence and honoring appointment dates. 32

46 Reference. 1) Auvert B, Taljaard D, Lagarde E, Sobngwi Tambekou J, Sitta R, & Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med 2005;2(11):e298 2) WHO/UNAIDS 2007, WHO AND UNAIDS announce recommendations from expert meeting on male circumcision for hiv prevention. Wednesday, 28 March, GMT, CET dations_en.pdf 3) Bailey RC, Moses S, Parker CB, Agot K, Maclean I, Krieger JN, Williams CF, Campbell RT, & Ndinya Achola JO. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007;369(9562): ) Tobian A, Serwadd d, Quinn TC, Kigozi G, Reynolds S, Makumbi F, Suntoke T, Watya S, Wawer MJ, Gray RH. Trial of male circumcision: Prevention of HSV 1 in men and vaginal infections in female partners. 15 th Conference on Retroviruses and Opportunistic Infections, February 3 6, Hynes Convention Center, Boston, MA. Abstract 28LB 5) AAR. Tobian, D Serwadda, T C. Quinn, G Kigozi, O Laeyendecker, B Charvat, M Riedesel, A Oliver, LH. Moulton, M Z. Chen, S J. Reynolds, M J. Wawer, and R H. Gray. Male Circumcision Prevents Acquisition of Herpes Simplex Virus type 2 (HSV 2) Infection in HIV Negative Men in Rakai, Uganda. NEJM 2008, submitted 6) R H Gray, G Kigozi, D Serwadda, F Makumbi, F Nalugoda, S Watya, L Moulton, M Z Chen, N K Sewankambo, N Kiwanuka, V Sempijja, T Lutalo, J Kagayii 2, F Wabwire Mangen R Ridzon, M Bacon, C Williams, M J. Wawer. The effects of male circumcision on female partner s genital tract symptoms and vaginal infections in a randomized trial in Rakai, Uganda. Amer J Obstet Gynecol 2008, in press 7) N. Westercamp and R. C. Bailey Acceptability of Male Circumcision for Prevention of HIV/AIDS in Sub Saharan Africa: A Review AIDS Behav May; 11(3): Published online 2006 October 20. doi: 8) Bailey, R. C., Muga, R., Poulussen, R., & Abicht, H. (2002). The acceptability of male circumcision to reduce HIV infections in Nyanza Province, Kenya. AIDS Care, 14(1), [PubMed] 33

47 Appendix 1. Implementation plan Table 10: Project Schedule. APPENDICES Activities Proposal writing &submission Meetings Developing H/E materials Developing text messages Forms preparations Activity planning Conducting H/E sessions/ community sensitization Giving out H/E materials to clients Routinely issue and emphasis on appointment card Making phone calls to remind clients Sending text messages Client renotification Completing data entry and cleaning Data analysis Report writing Preparation of Dissemination PPT Result dissemination Nov Dec 2010 Jan 2011 Feb 2011 Time Frame Mar. April May 2011 June 2011 July 2011 Aug

48 Appendix 2 : Information sheet for referred cohort clients. 35

49 Appendix 3: Cohort Re notification Form 36

50 37

51 Appendix 4: SMS message 38

52 Appendix 5: RCCS referral form 39