FINAL_VMMC_OPERATIONAL_PLAN_2018-2022_v2_HMf_v1_ms1[1].doc

SCALING UP VOLUNTARY MEDICAL MALE CIRCUMCISION FOR HIV PREVENTION

2018/2023

LESOTHO OPERATIONAL PLAN

Preface Voluntary medical male circumcision has been shown to reduce the risk of heterosexual HIV transmission to men, but does not provide complete protection from HIV infection.

The three randomized controlled trials carried out in RSA, Kenya and Uganda showed that voluntary medical male circumcision performed by well-trained medical professionals was safe and reduced the risk of acquiring HIV infection by about 60%. According to the studies, Voluntary medical male circumcision does not provide complete protection against HIV infection as circumcised men can still become infected with the virus and, if HIV-positive, can infect their sexual partners. There is a need therefore to intensify information and education that voluntary medical male circumcision is not a magic bullet.

Lesotho embarked on VMMC service delivery in February 2012. A competency based training was held for providers in 4 hospitals where VMMC service implementation started. The focus was on mastery of knowledge and skills to provide comprehensive services. Country engaged international master trainers to capacitate the country teams. The master trainers offered mentorship to country teams to be able to build their own capacity to have a pool of providers and trainers. The program was progressed fast and services were rolled out to 10 districts with the support of other implementing partners.

A comprehensive package of HIV infection Prevention services affords the clients the opportunity to reach and to benefit from the safe facility-based voluntary medical male circumcision services in Lesotho.

It is important to note that facility-based voluntary medical male circumcision is not intended in any way to replace current prevention programmes and traditional initiation practices, but rather to complement their work and be integrated in all services. This is critical to ensure the long term sustainability of the HIV prevention services in Lesotho with the aim of meeting the felt and unfelt needs of the Basotho community.

Voluntary medical male circumcision is provided as part of a package of prevention measures such as: consistent, correct condoms use and disposal, reduction of sexual partners, delayed onset of sexual relations, adherence to safe sexual practices, prompt treatment of STIs, linking of clients who test positive for HIV into care and treatment.

The Ministry thus thanks all institutions and individuals for their commitment and hard work in the development of the VMMC Policy.

Acknowledgements The writing of this document has been a collaborative effort of the Ministry of Health with technical input from the World Health Organisation and Futures International. The document was written in two stages. The first stage was a draft Lesotho VMMC Policy, Strategy and Implementation Plan that was completed in 2009. This version lacked the operationalization of the strategic targets. In consultation with the TWG, it was agreed in 2012, that the document should be revised to include an operational strategy which unpacks the targets across the five year period of the programme. A number of key individuals and organisations supported the Ministry of Health during the two phases of developing the draft VMMC programme policy, strategy and implementation documents.

The MOH thus acknowledges the support of the following key individuals and organizations or agencies who committed their time into ensuring that the document is successfully reviewed .Particular gratitude is directed to the Male Circumcision Technical Working Group of 2018 for their efforts:

Overall Coordinator VMMC;Mrs Likabelo Toti-Mokoteli-MoH,Technical Working Group Chairperson, Dr.Tapiwa Tarumbiswa;HIV Manager-MoH, Mr.D.B Phenethi, HIV and communications officer-MoH, Dr. Hamid Mandali; VMMC Technical Advisor-Jhpiego,Motselisi Molorane-Moeno-Jhpiego; Program Coordinator, Ms Litsoanelo Sekoto Motsoahae; VMMC Technical Officer-Jhpiego, Mr.Phoka Maile Program Coordinator-LENASO. ‘Mamokete Sepheka-Ntsupa VMMC Technical Officer-Jhpiego, Ms. ‘Mabafokeng Makhobotloane Senior Clinical manager–PSI, Mr. Makhebe Khomolishoele;TB/HIV Coordinator MoH/Jhpiego,Mrs Mareitumetse Ramokhele;EIMC Technical Officer-Jhpiego, Mrs Morongoe Nyakane;M&E Officer- MoH,Mrs Mathabang Mokoena;M&E Officer-Jhpiego,Mr Khotso Mahlalefa,QA/QI Advisor-AIDs-free, Mr.Khasoane Masheane;Project Manager-LENASO, Mr.Teboho Mohlabi;Communication & Advocacy Manager-NAC,Ms Sophia Mashape Program Manager-PMU,Mrs Bokang Lefaso;Pharmacist-MoH The Ministry of Health is grateful to the World Health Organisation and Futures International for their technical assistance during development of this document. This was through the provision of respective consultants: Dr Susan Tembo ;HIV/TB Advisor-WHO.Development Associates and Mr Carl Schutte (Costing), Strategic Development Consultants. The Lesotho Joint UN Team on AIDS (JUNTA) availed Mr Boaz Cheluget, the M&E Advisor, UNAIDS, to compile the section on Monitoring and Evaluation.

Abbreviations and Acronyms

ABC

Abstinence, Be faithful, Condomise (ACSM) Adcovacy communication and social mobilization

AIDS

Acquired Immune Deficiency Syndrome

ART

Anti-retroviral therapy

CBO

Community based organization CQI Continuous Quality Improvement

CHAL

Christian Health Association of Lesotho

DGHS

Director General of Health Services EIMC Early Infant Male Circumcision

FBO

Faith Based Organizations

HIV

Human Immune Deficiency Virus

HTS

HIV Testing Services

IST/ESA

Inter-country Support Team for Eastern and Southern Africa

IPC

Interpersonal communication

LPPA

Lesotho Planned Parenthood Association

MC

Male Circumcision

VMMC

Voluntary Medical Male Circumcision

M&E

Monitoring and Evaluation

MOH

Ministry of Health

NAC

National Aids Commission

NGO

Non-Governmental Organization OTH Online Training Hub

RCT

Randomized Controlled Trial

SBCC

Social Behaviour change communication

TWG

Technical working group

UNAIDS

Joint United Nations Programme on HIV and AIDS

VMMC

Voluntary Medical Male Circumcision

WHO

World Health Organization Table of Contents

2Preface

3Acknowledgements

4Abbreviations and Acronyms

7Section I: Lesotho Policy on Safe Voluntary Medical Male Circumcision for HIV Prevention

7Background and Introduction

8Country situation analysis on voluntary medical male circumcision for HIV prevention

101.Policy Goal, Objectives and Context

101.1.Policy Goal and Objectives

101.2.Guiding Principles

111.3.Scope of application

112.Voluntary Medical Male Circumcision Policy Statements

122.1.Target population

122.2.Service providers

132.3.Facilities

132.4.Integration

142.5.Costing and Financing

142.6.Quality assurance

152.7.Communication and Advocacy

162.8.Human Rights, Ethics and Legal Issues

162.9.Socio-Cultural Issues

173.Research

174.Monitoring and Evaluation

175.Institutional Arrangements

175.1.The National AIDS Commission

185.2.The Ministry of Health

185.3.Lesotho Male Circumcision Technical Working Group

205.4.Development Partners

21Section II: Operational Strategy for Scaling up Safe Voluntary Medical Male Circumcision in Lesotho

21Strategies for reaching the eligible population to attain VMMC coverage of 80%

24Objective 1: Create and strengthen an enabling environment for the full scale up of well-coordinated safe medical male circumcision services

26Objective 2: Maximize supply of male circumcision services among males aged 15-49 and neonates for HIV Prevention

30Objective 3: Maximize demand of male circumcision services for males aged 15-49 and neonates

32Section III: Costing the implementation plan

32Objective

32Methodology and assumptions

32Overview of the VMMC costing model methodology

32Financial vs. economic costing

33Costing perspective

33Full vs. incremental costing

33Development of costing model

34Development of unit costs

34Operational assumptions

34Implementation plan time frames

35Phased roll out process

35Service delivery assumptions

35Results of the costing

35Specific costing assumptions

38The unit cost of circumcisions performed

38Distribution of implementation plan costs

41Section IV: A monitoring and evaluation framework for the implementation of VMMC Strategy in Lesotho

49Data Reporting Tools

51Annex 1: Logistic Framework for VMMC Operational Plan Lesotho 2012-2016

Section I: Lesotho Policy on Safe Voluntary Medical Male Circumcision for HIV Prevention

Background and Introduction According to the 2014 LDHS, 25% of adults age 15-49 in Lesotho are HIV positive. HIV prevalence is higher among women 30% than men 19%. More recent data from LePHIA survey of 2017 show that, the HIV prevalence in Lesotho is 25.6% and the incidence is 1.2% among adults ages 15-49.

In response to HIV challenge in the country, Lesotho government adopted the medical male circumcision services as one the prevention methods against HIV.

Male circumcision has been shown to reduce the risk of HIV transmission from infected sexual female partners to uninfected sexual male partners. Several studies in sub-Saharan Africa, including clinical trials conducted in South Africa, Kenya, and Uganda (Auvert et al 2005; NIAID 2006) have documented that the protective effect of male circumcision is significant.. In Lesotho there is a potential to avert 20% new infection if 80% (330,000 males) of all eligible men are circumcised by 2019.

According to recent LePHIA results, the burden of HIV infection varies across the country. HIV prevalence among adults ages 15-59 years ranged from 17.8% in Butha Buthe to 29.3% in Mohale’s Hoek.

Country situation analysis on voluntary medical male circumcision for HIV prevention Since the introduction of VMMC in 2012, over 180,000 VMMCs have been performed nationally to date (March 2019); 57% of these VMMCs have been performed in the early three years (6,960 VMMCs in 2012, 32,865 VMMCs in 2013 and 36,130 VMMCs in 2014) when the VMMC services were actively in all 10 districts across the country. Thus far, however, the number of VMMCs performed each year has fallen short of annual targets as the active program implementation has been in only five districts supported by PEPFAR. For example, the estimated 78,000 VMMCs performed in 4 years of program implementation from 2014 to 2018 represents only 37% of the 210,000 national target. Moreover, 2018 VMMC volumes have been far lower than the 2013-2017 targets laid out initially

The VMMC service have been incorporated into private clinics to improve uptake, especially the ages of 15 to 29 years. The private clinics are more active in PEPFAR supported districts than non-PEPFAR supported districts.

From the beginning of the program, services were offered by clinical personnel where doctors were the only cadre allowed to conduct the procedures and nurses where to assist during the procedure and after procedure care of the wound. Since 2017, the program endorsed nurses to conduct the procedure after a study that proved competency of nurses to conduct the procedures with the same outcomes as doctors with lesser adverse events (AEs).

The program has been experiencing, some challenges which led to the low uptake of the services among which some are more structural and others more of implementation design. The structures in country still not yet highly owning the program services such that the services are more driven by implementing partners supported by donors. Donors have limited funds towards this expensive intervention which has high impact to the future of curbing HIV especially new infections.

Policies have to be refined to accommodate evolution of VMMC services where now the program services have to be next to the door of the potential client. The services potentially should be highly accessible in mobile packages and devices which are conveniently and easily to be offered.

Referral structures and practices should highly be identified where every stakeholder should take a charge in referring potential client for VMMC services. Leaders should highly be sensitized to make VMMC services their regular talk whenever they are addressing their communities. This will be possible when every responsible ministry will endorse the VMMC services as part of their reporting items bi-annually and annually.

Current program capacity is significantly less than theoretical capacity. Over the past five years, health care professionals in the country—including physicians, nurses, and clinical officers—have been trained as VMMC providers on the preferred method, dorsal slit. However, not all MOH health care workers (HCW) trained are currently providing VMMC, and those who provide services do so anywhere between one and six days per week depending on the site, its service delivery model, demand, and availability of resources and time. Many of the direct service deliveries are done my implementing partners’ staff and this is not sustainable. Therefore, while the country theoretically has the capacity to complete 330,000 as projected initially.

The government has to take charge to embrace collaboration and partnerships among partners who are working in achieving the goals set and objectives of combating HIV in the country. VMMC services

PLANNING FORWARD: 2018-2022

This operational plan will accelerate the scale-up of the VMMC national program that was officially launched by the government in 2012 with an initial operational plan which ended 2017. The roll-out of this revised operational plan will build upon the efforts already underway and the systems in place. As such, implementation of the operational plan can start immediately across all pillars and build exponentially as the program scales up. Demand creation need not wait for service delivery, for example, but should concurrently scale-up and be continuous.

Proposed pillars for this operational plan are;

Pillar 1: Leadership and Advocacy

Pillar 2: Governance and Coordination

Pillar 3: Service Delivery

Pillar 4: Communication and Demand Creation

Pillar 5: Monitoring and Evaluation

Pillar 6: Early Infant Male Circumcision

Summary of gap analysis Actual capacity is significantly less than theoretical capacity.

Main challenges of the program to date will be addressed with this operational plan.

These include:

1) the need to generate stronger demand and ownership

2) the need to ultimately scale-up service delivery capacity, particularly in all districts and villages, and better match demand and supply;

3) the significant financial gap and therefore the need to focus more on efficiency

4) the need for stronger management and coordination systems to ensure targets are met.

1. Plan’s Goal, Objectives and Context Basing on WHO VMMC 2021 strategy, where the goals are mentioned below, Lesotho as the country implementing VMMC program, plans align herself with WHO ambitions;

a. 90% of males aged 10–29 years will have received VMMC services by 2021 in priority settings in sub-Saharan Africa; and

b. 90% of males aged 10–29 years will have accessed age specific health services by 2021, tailored to their needs.

The government of Lesotho has developed this plan on voluntary medical male circumcision and HIV prevention. It is complemented by an operation strategy for 2017-2022 with high level costs and a costed implementation plan. A monitoring and evaluation framework is presented also in this plan. These will provide a framework to guide policy-makers and all implementers in the public, NGO, FBO and private sectors to ensure the provision of safe, accessible, acceptable, affordable and sustainable services. Lesotho has adopted a comprehensive HIV prevention approach in order to deal with the multiple factors that contribute to the spread of HIV infection in the country. The Lesotho HIV & AIDS National Strategic Plan (NSP) includes measures addressing prevention, treatment, care, support and follow up and creating an enabling environment for a scaled up and better coordinated national response to the epidemic. The projected targets presented in the table below:

(to inset the confirmed target from MOH and NAC)

1.1. Goal and Objectives

The overall goal of this plan is to contribute to halt the spread of HIV infection leading to an HIV-free generation in Lesotho.

The purpose is to provide a framework for policy-makers and implementers to support scale up of safe, culturally and socially acceptable, accessible, affordable and sustainable voluntary medical male circumcision as an integral component of the HIV prevention strategy in Lesotho.

Objectives

More specifically the operational plan seeks to:

1. To continue creating an enabling environment for the scale-up of well-coordinated safe voluntary medical male circumcision services;

2. Increase capacity of the country to offer safe voluntary medical male circumcision services in both the urban and rural parts of Lesotho; and

3. Increase demand for voluntary medical male circumcision services by use of multisectoral approach

1.2. Guiding Principles

This policy shall be implemented in the context of the National HIV & AIDS Policy, HIV Prevention Strategy, Health Sector Strategic plan, HIV Testing and Counselling (HTC) policy, National M&E plan, other relevant Policies and Strategies of Lesotho, National Communication Policy including Behaviour Change Communication (BCC) strategy and shall be guided by the principles outlined in the National HIV and AIDS Policy; with the key relevant ones being:

· Respect for human rights , with full adherence to medical ethics and human rights principles. Informed consent, privacy and confidentiality, no discrimination and stigmatization, and absence of coercion will be assured.

· Compliance with national and international declarations signed and ratified by the Government of Lesotho.

· Integration with and strengthening other HIV prevention services, care, treatment and support and reproductive health services.

· Involvement of all key stakeholders, including communities, and services shall therefore be provided taking into account the Basotho socio-cultural context.

· Use of an evidence-based approach to guide safe facility-based voluntary medical male circumcision programming and service provision.

1.3. Scope of application

The policy shall apply to Government and all other stakeholders in the public, NGO, FBO and private sectors involved in safe voluntary medical male circumcision programme for HIV prevention in the country. In particular all relevant Government ministries and bodies, local and international NGOs and FBOs, private health practitioners, cultural leaders, stakeholders and other partners are required to adhere to the enunciated policy. The policy shall complement and synergize with the National HIV and AIDS Policy and shall be revised as new information on voluntary medical male circumcision and HIV prevention becomes available in Lesotho.

The policy measures outlined in this document shall be used to guide the development of the national strategic and implementation plan, guidelines and protocol, operational plan, programme implementation, quality assurance procedures in the context of service delivery, and resource mobilization for safe voluntary medical male circumcision in Lesotho.

2. Voluntary Medical Male Circumcision Plan Statements

The Government of Lesotho recognizes voluntary medical male circumcision as an effective HIV prevention strategy in the fight against HIV and AIDS, hence its commitment to continue implementing the VMMC program effectively.

This plan addresses a number of aspects such as:

· The key target age group for males to have a direct and future impact. cadres of healthcare workers to provide voluntary medical male circumcision services;

· service delivery models , from facility to mobile services

· Methods of voluntary medical male circumcision, where the safest method identified and recommended by the=is plan is Dorsal Slit method. Thus moving forward, Forceps guided method should not be used.

· Integration of voluntary medical male circumcision with other reproductive health services where VMMC services should be part of services offered at male clinics too.

· Quality assurance and quality improvement should be part and parcel of VMMC services.

· Monitoring, Evaluation and Research should emphasize the use of data for VMMC services uptake and planning to reach every client possible.

· VMMC services should be costed with the aim of having these services affordable by the government for sustainability

· Communication, Advocacy and Demand Creation should highly be targeted and human centred, where beneficiaries should be advising the program on how to reach and offer them VMMC services.

· Human rights, ethics and legal issues; and socio cultural considerations are part of this plan.

2.1. Target population

Safe voluntary medical male circumcision services, as part of the national comprehensive HIV prevention package, shall be available to boys and men of all age groups who voluntarily request the service. HIV-negative males shall especially be targeted to maximize the public health benefit with regard to HIV prevention. For immediate effect, males between ages 10-49 shall be targeted while the early infants shall be targeted for long term sustainability.

EIMC should be provided by trained and competent nurses and doctors. It shall be provided at hospitals and health centres, provision of services shall target neonates from o to 8weeks and shall be integrated in to maternal and neonatal health services.

2.2. Service providers

2.2.1. Safe medical male circumcision services shall be offered by allowed VMMC trained nurses and medical doctors Task shifting has proven to improve VMMC services uptake thus this strategy should be implemented and guided.

2.2.2. HTS Counsellors, Paramedics, Social Workers and medical assistants shall be equipped with training to provide the minimum package of VMMC services (see 2.4.1 below for specification of the minimum package).

2.2.3. The VMMC program will venture into HIVST approach. The distributors will range from nurses, counsellors to the teams that create demand for VMMC services. This will encourage adult clients to know their statuses at their own time and privately thus for those who test negative, will decide to stay negative and chose to circumcise. For those who will test positive, they will be referred and be able to access care and treatment services.

2.3. Service delivery model

2.3.1. The minimum standards are required for a setting to offer VMMC service safely with high quality of care to protect the client. These setting still include the following;

· Fixed sites ( hospitals, health centres, health post)

· Mobile services ( surgical tents, mobile units, convenient building)

· Emergency management should be of higher priority.

· Availability of competent and trained VMMC service providers

· There is compliance to Infection Prevention Practices (IPC) at the points of service delivery.

· provisions for client referrals are in place in the event of serious adverse effects; and

· HIV testing and counselling services are available on site or by referral.

· Clients who test positive for HIV shall be referred for care and treatment

2.3.2. All health facilities/structures that meet the above minimum criteria can be equipped and brought up to standard to meet the minimum quality assurance standards for safe medical voluntary medical male circumcision service delivery. Therefore, all the facilities will be assessed prior to providing services to ensure they meet the minimum requirements.

2.3.3. VMMC program will venture into the use of GIS mapping which will help the program in planning, implementation and reporting. GIS system should be able to offer details like general population, specific population, age groups, names of villages, health facilities, number of eligible clients for VMMC services, roads condition and when are they passable plus coordinates of targeted areas.

2.3.4. The Director General of Health Services as advised by Lesotho Male Circumcision Technical Working Group shall be responsible for the assessment of health facilities within the NGOs, private sector and FBO health facilities which will need to be approved to offering of the VMMC services.

2.4. Integration

2.4.1. Safe voluntary medical male circumcision services shall be offered as part of a comprehensive HIV prevention package. The recommended minimum package includes:

· Social Behavioural Change communication (SBCC) for HIV prevention;

· Advocacy communication and social mobilization (ACSM)

· Access to HIV testing services (HTS);

· STI diagnosis and treatment;

· Safer sex counselling;

· Promotion and provision of condoms; and

· Safe voluntary medical male circumcision surgical procedure as described in the national guidelines and protocols.

2.4.2. Safe voluntary medical male circumcision shall be used as an entry point to reach males with wider sexual and reproductive health services and support for optimum benefit i.e. VMMC is an entry point to prevention, treatment, care, support and follow up services/strategies.

2.4.3. Continual consultations shall be held with chiefs and traditional initiators so that they support VMMC scale up and integrate voluntary medical male circumcision as part of the package offered to initiates.

2.5. Costing and Financing

2.5.1. In line with other public health and HIV interventions such as the provision of antiretroviral therapy, and other minor operations, voluntary medical male circumcision for HIV prevention shall be provided at a low cost. VMMC shall be provided at a minimal cost in NGO, FBO and private facilities.

2.5.2. Costing for programming and service delivery should include elements of a comprehensive package of voluntary medical male circumcision services which consists of communications, HIV testing and counselling, pre-and post-circumcision information and education, behavioural counselling and training, in addition to the actual surgery. The cost will include providing services closer to the communities, thus increasing access to the services.

2.5.3. Additional technical and financial resources shall be mobilized from the government budget as part of the commitment of the Government from other bilateral and multilateral funding mechanisms.

2.5.4. Efficient use of resources is required and measures shall be put in place to ensure safe voluntary medical male circumcision and does not divert resources from other essential interventions.

2.6. Quality assurance/Quality Improvement

2.6.1. Lesotho has existing protocols, standards operating procedures and guidelines that are applicable to circumcision service delivery. Among others Infection prevention and control, surgical procedure, HIV testing services, management of STIs and AEs and quality improvement/assurance.

2.6.2. Voluntary medical male circumcision services will be provided according to WHO Minimum standards for the delivery of safe quality services. These standards shall guide the service delivery model:

· guidance on supervision and management of services;

· the minimum package of services;

· competency of providers;

· information dissemination;

· assessment, care and follow up of clients;

· availability of drugs, supplies and equipment;

· continuity of care and referral systems;

· Formation of Continuous Quality Improvement(CQI) teams at the sites

· development of quality indicators

· Monitoring and evaluation of performance.

2.6.3. Surgical circumcision shall be performed under local anaesthesia in order to scale up services at as many facilities and providers as possible for HIV prevention.

2.6.4. Dorsal Slit method will be the only method for surgical procedure to all clients served under the VMMC program

2.6.5. The use of male circumcision approved device shall be used as an alternative method to conventional surgery

2.6.6. Certification and regulation of all service providers shall be done within the medico-legal framework and the governing bodies such as the Lesotho Nursing Council and the Lesotho Medical Dental and Pharmacy Council.

2.6.7. Facilities shall adhere to timely procurement and distribution of safe voluntary medical male circumcision equipment, materials and consumables as per the Procurement and Supply Management Regulations of the Government of Lesotho.

2.7. Communication and Advocacy

2.7.1. In order to support the promotion of safe voluntary medical male circumcision as HIV prevention intervention; a national voluntary medical male circumcision communication strategy shall be developed and shall be a component of the National BCC strategy.

2.7.2. The communication strategy shall promote community dialogue and debate on this issue and highlight appropriate local messaging and effective mobilization of mass media. It shall also address myths, cultural norms, attitudes, values and misconceptions on voluntary medical male circumcision and ensure accurate information for decision making for various partners and community groups.

2.7.3. Key communication messages shall be developed to target men, young people, religious and community leaders, traditional leaders, prisoners, miners, existing potential association and women, such as:

· Male circumcision is an additional HIV prevention measure promoted in the context of comprehensive HIV prevention strategies.

· Male circumcision does not provide 100% protection from HIV infection and circumcised men should use other effective HIV prevention measures including abstinence, partner reduction, consistent and correct condom use, Prep, PEP and knowledge of HIV status of oneself, and sexual partners and treatment as prevention.

· Complete healing from male circumcision surgery requires 6 weeks of abstinence, masturbation. Resumption of sexual relations before the end of this period may increase the patient’s risk of HIV infection acquisition.

2.7.4. Barriers to communication between generations (parents and children) on issues of sex and sexuality should be addressed as they are critical. Women and girls should also be involved in discussions of and decisions on voluntary medical male circumcision

2.8. Human Rights, Ethics and Legal Issues

2.8.1. The Government of Lesotho shall ensure that safe voluntary medical male circumcision is provided with full adherence to medical ethics and human rights principles and comply with the national legal framework. Informed consent confidentiality and absence of coercion should be assured.

2.8.2. For neonates, infants and minors, informed consent shall be sought from, parent(s) or guardian(s) (including care-givers and social workers where the law provides). They would be given sufficient information regarding the benefits and risks of the procedure in order to determine what is in the best interests of the child. As minors become competent to make decisions, their views should be increasingly taken into account and informed, non-coerced assent should be sought. The age of consent is from 18 years.

2.8.3. HIV testing services (HTS) shall be routinely offered to all males prior to circumcision, but refusal to take an HIV test is not grounds for denial of the service.

2.8.4. Circumcision shall be provided to men living with HIV or unknown status if they request it unless medically contra-indicated. All eligible HIV positive men will be referred to HIV and AIDS care and treatment services.

2.8.5. Effective social and behavioural communication strategies shall be put in place to avoid the emergence of stigma and discrimination with respect to either circumcised or non-circumcised males.

2.8.6. An enabling environment shall be put in place for safe voluntary medical male circumcision through the involvement of all key stakeholders, and consultation for voluntary medical male circumcision may include discussion with sexual partners.

2.9. Socio-Cultural Issues

3.9.1. Scaling up of safe voluntary medical male circumcision shall be sensitively handled, with respect shown for Basotho culture and gender implications. The Government of Lesotho shall ensure that safe voluntary medical male circumcision is promoted and delivered in a culturally appropriate and acceptable manner.

3.9.2. The government shall ensure engagement and participation of key opinion leaders in communities and the socio-cultural implications in safe voluntary medical male circumcision programmes.

3.9.3. The need for advocacy, communication and social mobilization should not hold back policy implementation. However, operational research into the socio-cultural meanings and impacts of safe voluntary medical male circumcision shall be carried out to guide programming.

Demand creation strategies The program shall be made visible through publications, presentations, and media use The program shall work with mobile companies to support initiatives to attract targeted audience

The program shall work with other partners in mobile information booths where clients could access information and possible referral There shall be multisectoral collaboration between ministries on HIV prevention issues

The program shall work closely with other partners on mobile visual aids on TB, HIV & AIDS prevention for educational purposes

3. Research

3.1 The MC Technical Working Group shall determine the research topic or agenda in collaboration with the Ministry of Health.

3.2 Operational research on safe voluntary medical male circumcision and HIV prevention shall be supported. This shall include formative research and evaluation of different models of service delivery.

4. Monitoring and Evaluation

In line with the “Three Ones Principles” (One National Policy & Strategy, One Coordinating body, One M & E System), the monitoring and evaluation system for safe voluntary medical male circumcision are integrated into the existing national monitoring and evaluation system. Standard monitoring and evaluation indicators related to the goal and objectives of safe voluntary medical male circumcision programming are being used to track the provision of routine service delivery. Quality indicators including HIV testing and counselling and management of adverse events are also captured in the system. Standardized data collection, interpretation and dissemination systems shall be developed and need to be maintained. All indicators are captured in the Lesotho DHIS2 at the facility level. This system captures data from all sectors, including the private sector and NGOs. Standard monitoring and evaluation indicators related to the goal and objectives of safe voluntary medical male circumcision programming shall be developed. These shall include supply at service delivery point, behaviour change, demand and social cultural issues. Others are quality indicators which include HIV testing and counselling and management of adverse events.

The target numbers to be reached in each target group shall be assessed according to epidemiological and demographic data.

Standardized data collection, interpretation and dissemination systems shall be developed and need to be maintained.

In line with the “Three Ones Principles” (One National Policy & Strategy, One Coordinating body, One M & E System), the monitoring and evaluation system for safe voluntary medical male circumcision shall be integrated into the existing national monitoring and evaluation system. The database shall be developed to capture data from all sectors, including the private sector and NGOs.

5. Institutional Arrangements

The Government of Lesotho intends to move fast and in a strategic manner with the implementation of voluntary medical male circumcision for HIV prevention in the country. It shall provide the required leadership in the planning and implementation of safe facility-based voluntary medical male circumcision scale-up, in mobilization and efficient use of resources while ensuring transparent accountability.

5.1. The National AIDS Commission

The National AIDS Commission (NAC) is mandated by the Act to coordinate the multi-sectoral response to HIV & AIDS in the country. The response is defined by National AIDS Policy and the National HIV and AIDS Strategic Plan, which includes VMMC as a key intervention for preventing new HIV infections. Therefore, VMMC will be addressed as one of the activities coordinated by the Commission.

Civil society organisations and private sector are coordinated through self-regulating umbrella organisations. Development partners are coordinated through specific forums including the Partnership Forum (see 5.4 below). Ministry of Local Government and Chieftainship plays an important role in facilitating coordination of the decentralised response through the District AIDS Committees (DAC) and Community Councils AIDS Committees (CCAC).

5.2. The Ministry of Health

The Ministry of Health (MOH) leads the health sector HIV and AIDS response and shall therefore also lead the implementation of this safe voluntary medical male circumcision policy. Specifically, the MOH shall focus on:

· Provision of technical guidance and support on safe voluntary medical male circumcision services;

· Provision of safe voluntary medical male circumcision services through the public health system;

· Coordination of the provision of safe voluntary medical male circumcision by all partners, including those in the public/government, NGO, FBO and private sectors; and documentation of best practices through regular monitoring and evaluation of voluntary medical male circumcision services and programmes.

The Directorate of Disease Control within the Ministry of Health (MOH) shall be directly responsible for coordinating the planning and implementation of safe voluntary medical male circumcision services, ensuring that services are linked with and where possible integrated with other HIV and AIDS, and reproductive health services. The Ministry of Health shall expand the human resource capacity of Directorate of Disease Control to ensure that it can carry out these additional tasks.

At the operational level, the coordination of the response to HIV and AIDS has been decentralised to districts, umbrella organisations, and key government ministries such as the Ministry of Local Government and Chieftainship (MOLGC), Ministry of Social Welfare, and the Ministry of Gender, Youth, Sport and Recreation. VMMC will fall under these decentralised structures.

Pillars identified that could lead to the highly improved uptake of VMMC services are well elaborated below;

Pillar 1: Leadership & Advocacy Sustained national political leadership, advocacy, and the involvement of key stakeholders and opinion leaders will be critical to the success of the national VMMC program in Lesotho moving forward. Advocacy efforts for VMMC will identify and engage individuals at the national, district, and community levels. These efforts will include stakeholders from the highest levels of national government to traditional, community and religious leaders. While each stakeholder group will play a different role, the advocacy and outreach efforts of all will be important for boosting uptake of VMMC services nationally.

To improve and strengthen political leadership, focal point persons have to be identified within the government at all levels. In particular, the MoH will be responsible for taking the lead and driving the VMMC agenda forward and actively. Cooperating partners will play a vital role by providing technical and financial support to help strengthen the capacity of the MoH to lead program roll-out. All partners should be engaged, those who work in prevention and even those who are working on care and treatment together with those working on other health and development issues apart from HIV/AIDS.

National Level At the national level, VMMC champions should be identified from within the broader community, including political, traditional and religious leaders, and other popular (male and female) community figures such as musicians, fashion models, athletes, and radio disc jockeys (DJs). These VMMC champions should commit to a minimum number of national media appearances, as well as a minimum number of community appearances each year to advocate for VMMC. Furthermore, to ensure that VMMC has the cross-cutting support necessary for wide-scale roll-out, collaboration should be sought between the MoH and other line ministries, as well as across branches of the MoH (e.g., Maternal and Child Health (MCH), Family Health, Mental Health). The VMMC agenda should be highlighted and prioritized by the existing inter-ministerial committee on HIV of the National AIDS Council (NAC), which will serve as a platform for advocacy.

The National Male Circumcision communication strategy should have detailed strategies on messaging and key themes on VMMC.

The official launch of national VMMC documents should be planned and attended by key stakeholders and high-level opinion leaders. A VMMC advocacy toolkit containing informational materials, frameworks, and other tools to support the dissemination of targeted (by age, gender, position, etc.) audience-appropriate VMMC messages should be developed and distributed. Materials tailored specifically for female audiences should be included in the advocacy toolkit in order to address the role women play in demand generation (i.e., in infant, adolescent and adult VMMC decision-making), and because it is vital that women themselves accurately understand the benefits of VMMC, the partial effectiveness of VMMC for men, and VMMC’s lack of protection against HIV for individual women.

National-level advocacy meetings should be designed to inform and sensitize key opinion leaders in Lesotho and will be held to include members of parliament, members of underlying ministries, traditional leaders, women’s groups, religious leaders, and business leaders. Advocacy efforts directed at national media, including heads of news media agencies, will be prioritized.

District Levels At the district level, advocacy activities will feed into those that occur at the district level. District Medical Officers (DMOs), Public Health Nurses (PHNs) and District Health Managers will distribute information to key district authorities and ensure that VMMC is regarded as a key component of the overall health program in their districts. Moreover, they will have responsibility for making sure that information provision is integrated throughout the program and is reaching women (including through MCH related services).

VMMC will be officially launched in each of Lesotho’s district; guidance for launch dates and program content will be provided at the national level. VMMC advocates will be asked to participate in district planning meetings as well as the launch, especially in districts that have traditionally been resistant to VMMC uptake. Sensitization workshops with key provincial opinion leaders will be held. Training in communicating about VMMC with both males and females will be done for health promoters, with the representation from each district.

Information regarding VMMC will flow through normal MoH channels for health-related informational materials, and will be disseminated by DHMs, PHNs and DMOs and, then to the facility level. Each district will appoint an individual to coordinate VMMC communication efforts at the district level; this individual will advocate for the acceptance of the procedure among local headmen, key community opinion leaders, and important community based organizations (CBOs), including women’s groups. This person will be responsible for identifying, engaging and coordinating the efforts of community groups. At the district level, advocacy will be largely grassroots; much of the information to be disseminated will also flow through the existing health committees. Emphasis will be placed on generating community-owned leadership in driving a gender-sensitive VMMC agenda.

In addition to playing a leadership and advocacy role within the country, Lesotho’s VMMC decision-makers will also advocate for VMMC scale-up at the global level, by disseminating evidence from Lesotho’s experiences to the global community via publications and key conferences, as appropriate.

Pillar 2: Governance & Coordination MoH governance and coordination at national and district levels will be instrumental to achieving the targets and ensuring accountability at all levels. The implementation of VMMC will be aligned to the existing MoH structure. Ongoing monitoring of progress at the provincial and district levels will be critical to inform decision-making at the national and programmatic level to ensure that resources are optimized to meet national targets.

National Level The priority at the national level will be in strengthening coordination, reorganizing existing national service delivery, and improving the management of the national program in line with this operational plan. Major tasks will include orienting DHMs, PHNs and DMOs in planned VMMC activities, re-organizing partners to align VMMC responses to national targets and operational plan activities, and supporting district offices to engage in preparatory activities to set up a platform for operational plan implementation. The MoH will also be responsible for collecting and analyzing financial and program performance data to ensure that the program is on track to meet its targets and to identify any potential implementation challenges. Coordination at this level will be critical in defining the pace at which districts and provinces will be able to implement VMMC activities.

Identification of human resources to provide administrative leadership and governance at MoH headquarters, provincial and district health offices should continue and remain as a priority. At the national level, a core technical team should be headed by the VMMC Coordinator under the Directorate of Disease Control. This VMMC team will assume day-to-day administrative functions related to VMMC programming in Lesotho, executing decisions on behalf of the MoH.

All major decisions regarding VMMC will be made by the MoH in consultation with the national VMMC Technical Working Group (TWG).

Partner organizations will engage in VMMC programming through the national VMMC TWG, which will be called and chaired by the Directorate of Disease Control. The national TWG should comprise sub-committees— e.g. Service Delivery, Quality Assurance and Training, Communication and Demand Creation, and M&E and Research and Traditional Taskforce. These subcommittees will also play a leading role in the roll-out of VMMC, and will continue to provide guidance for all involved in VMMC throughout the ranks. The VMMC TWG subcommittees will make recommendations on the scale-up of VMMC services at the national level, which will then inform the decisions of the national VMMC TWG.

All partners will be accountable to the MoH to align their VMMC programming to the requirements of the operational plan. All partners will be expected to work closely with the national VMMC core technical team and the TWG through the VMMC Coordinator in implementing VMMC activities, which will be expected to conform to existing systems of accountability at the district and national levels.

District Level At the district level, a Coordinator/Focal Person should assigned to coordinate VMMC services whose responsibilities should be;

Working with service delivery teams at the district level to conduct facility assessments to inform decisions regarding VMMC sites, both present and future;

Conducting Joint (implementing partner with MOH) technical supportive supervision;

Ensuring VMMC is included in Districts’ PHC meeting;

Being responsible for the inclusion of VMMC in district-level action plans;

Facilitating collaboration between districts and partners;

Aggregating and analyzing VMMC outputs collected at the district-level on a monthly/ quarterly/ annual basis;

Identifying programmatic gaps and adjusting work plans and budgets accordingly; and

Providing extra support to districts not meeting targets.

Pillar 3: Service Delivery of VMMC Linking Services with Demand A priority for Lesotho’s VMMC program is to link service delivery with demand generation. Given that district targets vary significantly, careful planning will be used to ensure that resources made available to each district match the district’s level of demand, and that service delivery models are selected based on the district’s defining characteristics. These include the district-level target population of adult HIV-negative uncircumcised men, number and type of existing facilities and number of HCWs. As part of the operational plan roll-out, each district will develop its own costed implementation plan tailored to this set of key defining characteristics.

VMMC Coordination and Service Delivery Models All VMMC service delivery activities in Lesotho will be coordinated at the district level. In response to the diffuse distribution of the population and the acute shortage healthcare workers in certain settings, outreach services will continue to be an important part of VMMC services scale-up in Lesotho. Strong coordination around the movement of human resources and supplies will be needed to ensure that all VMMC services offered within each district include a complete and comprehensive service package that meets the established guidelines, evenin remote settings. The district health management teams will also be responsible to oversee all scheduling and logistics for VMMC service delivery.

Public health facilities offering the standard VMMC package will be categorized into four service levels according to the facility type, availability of human resources, and the amount of support needed. Technical and financial support from collaborating partners will be focused on assisting facilities within each district to take ownership of the seven core VMMC-specific service delivery responsibilities: 1) community-level demand generation, 2) clinical service provision, 3) infection prevention, 4) behavioral counseling, 5) quality assurance, 6) data management, and 7) supply-chain management.

The four service levels are further described below:

Level A: A district hospital which will take on full responsibility for all seven core VMMC service delivery responsibilities and will also provide…