n/a

New/Continuing Activity: Continuing Activity

Continuing Activity: 18607

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

18607 12069.08 U.S. Agency for US Agency for 8154 5967.08 Contraceptive $0

International International Security Fund

Development Development

12069 12069.07 U.S. Agency for US Agency for 5967 5967.07 Contraceptive $0

International International Security Fund

Development Development

Program Budget Code: 04 - HMBL Biomedical Prevention: Blood Safety

Total Planned Funding for Program Budget Code: $200,000

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

BLOOD SAFETY OVERVIEW:

Lesotho's health services are currently compromised by a chronic shortage of safe blood for transfusion. The demand for blood

and the Lesotho National Blood Transfusion Service (LNBTS) workload has increased dramatically as a result of the growing

need for blood transfusions for HIV-related and ART-induced anemia. Currently, LNBTS is the sole blood provider in Lesotho and

collects only 1.4 units per 1000 population, far less than the WHO-recommended 10-20 per 1000. LNBTS has only a single

mobile blood collection team (1 registered nurse and 1 office assistant) that covers the entire country and can be away from

Maseru for extended periods. During these extended blood drives, blood is transported back to LNBTS by government and

hospital transport systems. Collection is usually planned on a short-term basis and is largely reactive. As donors are

predominantly school children, chronic shortages become acute during school holidays. National law allows children as young as

12 to donate, but LNBTS, with the assistance of PEPFAR partner SBFAF, targets school children age 16-18. Currently, 97% of

donors are voluntary, non-remunerated donors. Seventeen percent of donors report having given already in the previous 12

months. Most importantly, the prevalence rate of HIV among first-time and regular/repeat blood donors is 4.5%.

BLOOD SAFETY USG FY 2008 ACTIVITIES:

PEFPAR supports the LNBTS through implementing partner Safe Blood for Africa Foundation (SBFAF). In FY 2008, with a budget

of $60,000, SBFAF will carry out training and support to develop a voluntary blood donor program, train administrative and donor

staff in developing quality systems, train clinical and nursing staff in rational blood use, and train technical and lab staff on lab

systems quality. LNBTS has also funded a dedicated staff person for LNBTS to help coordinate blood donations.

BLOOD SAFETY USG FY 2009 SUPPORT:

In COP 2009, SBFAF intends to establish a more integrated approach to blood safety in Lesotho, with potential cross-cutting

benefits not only to Biomedical Prevention, but also to Adult and Pediatric Treatment, Counseling and Testing, and Laboratory

Infrastructure. SFBAF will establish an in-country presence to assist in building local capacity and more closely integrate with

other partner prevention programs. The possibility of sharing office space with other partners will be explored

Proposed areas of support include: providing LNBTS with blood collection equipment and vehicles for additional mobile blood

collection, and installing updated equipment in hospital blood banks. SBFAF will also work to improve organizational structure

and blood policy, following WHO BTS Guidelines. To ensure long-term sustainability, SBFAF will continue providing management

and leadership development. Innovative youth oriented donor recruitment programs known as "Club 25" will be strengthened and

will promote HIV prevention through peer support, safe lifestyles and regular counseling and testing for blood donors. Participants

from other countries in "Club 25" activities report lower sero-conversion rates than non-participants.

BLOOD SAFETY LEVERAGING AND WRAP-AROUNDS

SBFAF intends to support the collaborative partnership between LNBTS and Lesotho National Red Cross, which emphasizes the

role of Red Cross volunteers in recruiting blood donors and building awareness and skills in HIV counseling. SBFAF will also

coordinate with MCC on the plans for building a new blood transfusion unit.

BLOOD SAFETY PROPOSED COMPACT EXPANSION:

PEPFAR/Lesotho does not anticipate further scale-up for blood safety activities under a Partnership Compact. As Compact

negotiations are only at the early stages, we understand that we may need to revise expectations, and will work closely with

MOHSW to identify critical areas for scale-up.

MALE CIRCUMCISION OVERVIEW

Three randomized, controlled trials in Africa have confirmed that male circumcision (MC) reduces the likelihood of female to male

HIV transmission by approximately 60% and modeling studies suggest that MC could prevent up to 5.7 million new HIV infections

over the next twenty years. In March 2007, WHO and UNAIDS issued guidance urging countries with high HIV prevalence and

low MC rates incorporate MC into their HIV prevention programs as part of a comprehensive package that includes abstinence,

partner reduction, condom promotion, HIV counseling and testing and STI treatment.

As one of the highest HIV prevalence countries in the world, Lesotho stands to benefit tremendously from the scale-up of safe,

comprehensive MC services. While MC is a promising intervention that could potentially prevent millions of new HIV infections,

safe MC services require well-trained healthcare providers, appropriate infection prevention and control practices, and sufficient

space, equipment and supplies. In addition to the surgical procedure, other essential elements of MC services that must be taken

into account include informed consent, pre-operative HIV counseling and testing, post-operative care and risk reduction

counseling, and a minimum package of other male reproductive health services, such as treatment of STIs , and condom

distribution.

According to the 2004 DHS survey, 48% of 2,800 male respondents aged 15 to 59 have been circumcised. A June 2008

MOHSW report further explains that the percentage of men circumcised was similar among men aged 20 to 59. However, only

21% of men aged 15 to 20 were circumcised. The limitation of this survey, and similar studies on circumcision in Lesotho, is the

lack of differentiation between partial circumcisions (not protective against HIV) performed by traditional circumcisers in initiation

schools and complete, surgical circumcisions that provide an estimated 60% protection against HIV per unprotected sexual act

with an HIV-positive individual. It is believed that traditional circumcision in Lesotho is often incomplete; in other words, traditional

circumcisers may not remove the entire foreskin, leaving traditionally circumcised men at high risk of acquiring HIV. Clear,

effective communication about male circumcision is essential in any country which is planning to implement MC for HIV

prevention, but particularly in a country like Lesotho, where it is necessary to explain the difference between traditional and

complete medical circumcision and where some men may need to be "re-circumcised" in order to obtain the HIV prevention

benefits of MC. It will also be important to involve the traditional circumcisers in the program to ensure their buy-in and support.

The MOHSW report indicates that approximately 15,000 circumcisions are performed annually in Lesotho. Of these, between

3,000 and 4,000 are carried out in GOL facilities, and 1,000 to 2,000 are carried out in private practices and the Lesotho Planned

Parenthood Association (LPPA) clinic. The remaining estimated 10,000 are performed in initiation schools. Anecdotal information

from GOL, private physicians and the LPPA indicates that the existing level of service delivery does not meet the current demand,

which is around 24,473 MC /per year and that long waiting lists, particularly in urban areas, are common.

MALE CIRCUMCISION USG FY 2008 ACTIVITIES:

PEPFAR/Lesotho has been active in providing support to MOHSW for male circumcision. At this time, MOHSW has not yet

developed a policy on MC or a strategic plan for roll-out of services. Two USG partners, JHPIEGO and PSI, have funding to assist

MOHSW as they move forward with policy development. Just recently, MOHSW formally requested PEPFAR assistance, and

PEPFAR will be working closely with the MOHSW MC focal person and MC task force. Given the serious cultural sensitivities

around provision of MC, USG is engaging with traditional healers and initiation school leaders to further understand these cultural

sensitivities.

Policy issues on which PEFPAR will work with MOHSW include: minimum package of services for adult males, task shifting for

direct service provision, use of anesthesia, role of traditional initiation leaders and relationship with initiation school-provided

partial circumcisions, timeframe of scale-up, infant and young child service provision. PEPFAR will also help MOHSW to

simultaneously develop a communication strategy. A critical component of our MC strategy is advocacy for task-shifting of MC

from doctors to well-trained and supervised nurses. This is critical due to human capacity resource constraints in Lesotho.

PEPFAR/Lesotho also plans to conduct a study tour for MOHSW policy makers and traditional leaders to countries where MC is

taking place, so that they can see various models as they determine how to roll out MC activities in Lesotho.

MALE CIRCUMCISION USG FY 2009 SUPPORT:

As MOHSW determines a way forward on MC, PEPFAR/Lesotho remains very much engaged. Given the slow pace of work on

MC in Lesotho, there is a significant pipeline of MC funds with current partners, so PEPFAR/Lesotho will program a conservative

amount of FY 2009 funds. These funds will go to a TBD partner, as USG waits to see who is awarded the follow-on to the central

project working on MC, currently held by JHPIEGO. PEPFAR/Lesotho is ready to significantly scale up funds for MC when

MOHSW approves a policy and is ready to move forward with service provision.

Our TBD partner will work closely with MOHSW and other partners to provide training for health care providers and roll out safe

and comprehensive MC services as part of a comprehensive approach to HIV prevention. To begin, our TBD partner will

implement activities including:

•Development of an MC scale-up plan including selection of future MC sites

•Procurement of key MC supplies and equipment (autoclaves, surgical instruments, gloves, sutures, local anesthesia and other

consumables)

•Development/adaptation of MC data collection forms

•Development of a brief MC orientation package

•Orientation of staff and management at sites selected to implement MC services (including selection of providers and counselors

for training)

•Training of MC service providers and MC counselors (to include provider-initiated HIV testing and counseling)

•Training on infection prevention and control (with emphasis on instrument processing)

•Supportive supervision and follow-up for recently trained MC providers and counselors

•Analysis and reporting of MC data to MOHSW, PEPFAR, WHO and other key partners

MALE CIRCUMCISION LEVERAGING AND WRAP-AROUNDS

PEPFAR, along with implementing partner JSI, is a member of the MOHSW MC task force, and as such works closely with other

development partners in policy development and advocacy around MC. PEPFAR is also collaborating closely with MCC to ensure

that MCC-renovated clinics and hospitals have procedure rooms available to conduct MC when service delivery rolls out.

MALE CIRCUMCISION PROPOSED COMPACT EXPANSION

As PEPFAR/Lesotho moves forward to negotiate a Partnership Compact with GOL, expansion and strengthening of prevention

services is a critical focus. When MOHSW develops an MC policy, we anticipate scaling up funding to provide training and

implement services. If our Compact is approved, we anticipate potentially reaching 30,000 men with MC. As Compact negotiations

are only at the early stages, we understand that we may need to revise expectations. We plan to address gender issues and

ensure policies that improve implementation of services (i.e., task-shifting to nurses) as noted in the Guidance documents we

received from the Deputy Principals, and we will be in touch with our core team and DP "friend" as we move forward.

Table 3.3.04: