The mechanism goal is provision of voluntary medical male circumcision (VMMC) for HIV prevention in Kenya. The objectives are in line with Kenyas Partnership Framework and GHI. They are 1. Support to government of Kenya in strengthening capacity of systems and services for VMMC implementation; 2. Implement and scale up quality and safe VMMC; 3. Ensure VMMC services are integrated with comprehensive HIV prevention, care and treatment services; 4. Create and sustain informed demand for VMMC in the target communities; 5. Support scale up of evidence based interventions targeting MSM in Kisumu city and its environs.

NRHS has been implementing VMMC for HIV prevention and also services targeting MSM. With PEPFAR funding, they have successfully met their VMMC targets (Has done 75,000 circumcisions using COP 2010 funds), adopting cost efficient approaches like task-shifting, task-sharing and use of electrocultery. Capacity building by training HCW on VMMC has also been undertaken and will make program more cost efficient. Other efficient approaches include undertaking VMMC in outreach and mobile sites.

VMMC is done in MOH facilities, minor theatres are refurbished/renovated, equipped with surgical instruments and training HCW for sustainability purposes. At the conclusion of the award, trained HCW will be able to continue providing VMMC services.

Geographical coverage of NRHS CoAg is wide (Nyanza, Nairobi, Teso and Turkana). Distances between facilities are long, and all service provision teams require moving nearly every day. NRHS has been using 16 vehicles (15 vehicles purchased by IRDO in FY07 and FY08. One vehicle purchased in FY10). During Rapid Results Initiative (RRI) periods they hire other vehicles. This will continue in COP 2012. This activity support GHI/LLC.

The Kenya Government/MOH recognized MC as an additional HIV prevention intervention in 2007 and PEPFAR supported developed of MC policy guidance, MC strategy and communication strategy, and adapted/adopted other relevant documents (VMMC clinical Manual, M&E indicators/tools to guide service delivery and demand creation and tracking. The programs objective is to circumcise men aged 15 49 years by 2013 and reach 80% coverage. Four regions (Nyanza, Western, Turkana and Nairobi) with low MC rates and high HIV prevalence have been identified by for priority scale up. Nyanza Province has MC rates of 48% and HIV prevalence of 14.9%. HIV prevalence among the uncircumcised Luo is 17%, and MC rates is estimated to be 22% (KDHS 2008/9). Nairobi Province has MC rates of 83% and HIV prevalence of 8.8%. The Turkana region in also has high HIV prevalence rate and low MC rates, estimated to be 16%. Since 2008, VMMC services have been provided through PEPFAR implementing partners working at Ministry of Health (MoH) facilities, to over 300,000 males. However, huge gaps still exist, and while coverage is nearly 50% in some Nyanza districts, it is very low in other regions like Nairobi, Turkana and Teso. In 2012, NRHS will contribute to addressing the gaps existing in Nyanza, Western, Nairobi and Turkana areas

NRHS will provide MC services to 115,885 boys and men aged 15 years and above in all 4 regions (53,267 men in Greater Siaya,20,487 men in Nairobi, 21,643 men in Teso/Busia,20,488 men in Turkana)

Current coverage of VMMC services in Siaya County is nearly 50%, while it is still below 5% in other regions

NRHS (clinical & M&E) staff and the district M&E subcommittee will conduct quarterly support supervision visits to VMMC sites to ensure quality assurance, using the adapted QA tools and ensure reporting is done through the MOH M&E reporting system.

NRHS will ensure requisite demand for services in generated among males and females in and around the catchment area of each facility where VMMC services are available, and explore other approaches for efficiency including conducting outreaches and mobiles, use of electrocultery, as well as moonlight services where applicable.

As part of comprehensive prevention package, all clients will be provided with the minimum package of services at site according to national guidelines, which include opt out HTC for VMMC clients and their partners, age appropriate sexual risk reduction counseling, counseling on abstinence during 6 week healing period, and promotion of correct and consistent condom use

Where necessary, HCW teams to provide VMMC services will be trained to build their capacity, using the MOH training guidelines

Linkage with other services within facilities and within districts/counties will ensure VMMC is part of comprehensive package of prevention package. Identified men with HIV will be appropriately linked to Care and treatment sites, giving preference of referral to the sites of their choice to reduce Loss To Follow up. Active linkages with other programs has been established, with cross referrals to care and treatment for HIV positive men, as well as referral of uncircumcised men from routine HTC sites and discordant couples to VMMC services

Regular EQA from WHO and PEPFAR teams has ensured VMMC activities adhere to international standards. Service provision will be monitored using the standardized VMMC reports and evaluated regularly through the MOH M&E reporting

NRHS will continue to expand access to a high quality comprehensive package of services targeting mainly MSM, majority of will be men engaged in sex work in Kisumu city and its environs. High risk sexual behavior prevalent among male sex workers including incorrect and inconsistent condom use, low knowledge of HIV status, multiple sex partners, excessive alcohol and drug use, transactional sex and low adherence to treatment will be addressed. This mechanism will support implementation of the Combination Prevention Interventions for MSM as defined in the National Guidelines for the package of services for SWs. These comprise evidence-informed behavioral, biomedical and structural interventions. The program will support the adaptation and implementation of an evidence-informed behavioral intervention (EBI) that has a sufficient goodness of fit with the local context. EBIs may include Mpowerment or Many Men Many Voices. This will be an EBI that targets sexual risk behaviors among MSM including involvement in sex work as a main occupation, higher risk among receptive partners, low condom use, multiple sexual partners and sexual acts, bisexual partnerships etc. Biomedical interventions include HTC, STI screening and treatment, TB screening and referral to treatment, HIV care and treatment and pre-exposure prophylaxis (PrEP). There is also a strong consideration for initiating Treatment as Prevention for these MARPS groups and initiating PrEP where feasible. Other important service components include screening for drug and alcohol abuse and referral for treatment and provision of psychosocial support. Structural interventions will focus on enhancing a 100% Condom Use Program (CUP) nationally, mitigation of sexual violence and support to expand choices beyond sex work as a risk-reduction strategy.

The existing site/drop-in-center will be supported to intensify coverage and increase access to services for MSMs in Kisumu, closely collaborating with the other implementing partners, particularly the Liverpool VCT clinic in Kisumu City to improve their capacity in serving high-risk populations. Though estimated size of MSM in Kisumu is estimated to be nearly 1870, the HIV prevalence is high. From a recent respondent-driven sampling survey among 415 MSM in Kisumu, the overall HIV prevalence was 12%, but among those older than 30 years had HIV prevalence o f 34%. Quality assurance will be enhanced through close project monitoring, use of standardized national tools and program improvement through regular staff and peer review forums. Program staff will receive regular training and orientation on current practices. Services provided through this mechanism are closely linked to other public and non-government services e.g., the clinics/drop in centers are registered to receive some drug supplies from central drug procurement mechanisms and report to their local district and provincial health authorities. These include other supplies e.g., condoms, IEC materials and training opportunities, that are organized for service providers in the Kisumu region.

This mechanism has a well-established M&E plan, with a data officer on site who collates data, analyzes and shares it with program staff to help inform the project better.