Wednesday, April 6, 2011

If Mass Male Circumcision Fails, Will We Be Told?

In order to implement HIV prevention, treatment and care programs, countries need adequate health facilities, with sufficient numbers of trained staff and supplies of equipment and drugs. Most high prevalence HIV countries don't have these.

A quick look a health statistics for most African countries show that they can't even cope with the most basic health issues, such as clean water and sanitation supply, nutrition or prevention and treatment of common diseases, such as water borne conditions and acute respiratory problems.

It is said that Africa has 24% of the global disease burden but only 3% of the world's health workers. It's common for countries and regions to have only one doctor for every 50 or 100,000 people. There are too few health facilities, they are all short of supplies and service provision can not meet demand, or services are of very low quality, or both.

None of this is particularly new. A glance at health service provision assessments from Measure DHS shows that the countries who have the worst problems often have the worst health services.

So it's not surprising that Kenya's ambitions to circumcise 1.1 million men in the space of a few years is proving quite challenging. An assessment of the first year or two of this program, which claims to have already circumcised 230,000 men, should worry those who have gone through the operation, as well as those who are planning to do so.

There is no mention of the numbers of men who have been infected with HIV or any other sexually transmitted disease since undergoing the operation. This is worrying because the whole aim of the exercise is to reduce HIV transmission. Those who have opted to be circumcised will need to be followed up for some time, but HIV transmission rates in the intervention are are massive.

If the program is going well, releasing the figures could help with enrollment. But if it is not going as well as expected, perhaps some problems should be aired and ironed out now to limit the amount of damage that could be done.

The assessment of health facilities involved in the parts of Nyanza selected for the intervention is not wholly encouraging. One of the 'minimum criteria' for service provision was "Sterilization and infection control compliance." Only two thirds of the facilities have autoclave equipment. No mention is made of whether the equipment is used, or used properly. And going by other similar assessments, most facilities don't have written procedures for sterilization and infection control.

Out of the 81 facilities assessed, none of them possessed all seven of the criteria necessary to provide safe services. Most didn't have enough doctors or clinical officers to perform circumcisions, although they were the only staff authorized to do so prior to the mass circumcision program.

85% of hospitals had enough nurses, so they were trained to perform the operation. How these facilities managed to cope with routine, non-HIV emergencies is not made clear. Indeed, it is to be wondered if all this information about health facilities will have any impact on the health development agenda, or if non-HIV health issues will continue to be ignored.

So far, much of the resources and personnel required have been supplied by donors. Whether the program can be continued using existing capacity, whether the program is sustainable, is debatable. And whether it can be continued safely is something I wouldn't like to bet on. I'm sure those who are being offered the services would have the same worry, if they had access to unbiased information.

The efforts to make mass male circumcision rollout seem successful suggest that a lot more could be done to develop health services in resource poor countries. But the lack of effort to deal with non-HIV health development issues suggests that little will be done. Ultimately, the program could result in similar or even higher rates of HIV transmission. It just remains to be seen how long it will take before useful data becomes publicly available.


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