Summary

This activity received $400,000 in FY 2007 plus up funds to CDC ($350,000) and USAID ($50,000).

Background

Evidence from two decades of observational and clinical studies suggests that male circumcision can

significantly reduce HIV transmission by as much as 60%. In Malawi, data generated from the national DHS

survey of 2004 indicated that 20.7% of the male population aged 15-49 years is circumcised. There is a

strong association between male circumcision and religious affiliation or ethnicity in the country. Fifty-five

percent of all circumcised individuals are Muslim. Of all Muslims in Malawi, 93% are circumcised, compared

to less than 25% in other groups.

Two ethnic groups, the Yao and Lomwe, account for 78% of the circumcised population. A total of 86% of

Yao and 34% of Lomwe are circumcised. Estimates of other ethnic groups indicate that less than 10% of

them are circumcised. Logistic analysis (using un-weighted data) while controlling for ethnicity showed that

circumcision was not a significant predictor of HIV status. In Malawi, HIV prevalence is substantially higher

overall among ethnic groups that circumcise, however circumcision was associated with reduced

prevalence within these groups.

It is with this background that the National AIDS Commission (NAC) in collaboration with the Ministry of

Health (MoH) organized a two day national stakeholders' consultative workshop on male circumcision and

HIV prevention early in 2007. The consensus from the delegates was that male circumcision should be

considered as part of a comprehensive HIV prevention strategy. The delegates however cautioned that

some critical issues need to be addressed before a national policy on male circumcision was adopted. The

MoH and NAC sought assistance from the USG, WHO, and UNAIDS to meet these needs.

In order to address key issues around the acceptability and feasibility of incorporating male circumcision

into a national HIV prevention strategy, NAC will use Emergency Plan (EP) support in 4 key areas: rapid

assessment of current social/cultural/infrastructure that affect male circumcision as a prevention factor;

consultation with critical constituencies, including traditional and religious leaders and policy makers; an

effective communication strategy; and targeted operations research in areas identified by the rapid

assessment and consultations.

NAC will look into other aspects of acceptability and feasibility of male circumcision with the support of

additional partners, including WHO and UNAIDS.

Activity 1: Rapid Assessment

Malawi wants to develop a national strategy on male circumcision based on sound evidence of Malawi's

ability to implement such a policy if and when it is enacted. Important to this decision is a clearer

understanding of the extent of male circumcision in the country: who practices circumcision, why it is

practiced, acceptability of male circumcision, implications for religious and cultural practices, and the

readiness of Malawi to include male circumcision as part of a national HIV prevention strategy. WHO and

UNAIDS developed a generic tool to support a rapid assessment of a country's readiness to include male

circumcision as part of an HIV prevention strategy.

The USG team will provide funds for and work in concert with NAC, MOH, and UNAIDS to recruit 2 local

consultants as well as an international consultant to support this effort. The consultants' initial task would be

to adapt the rapid assessment tool to the Malawi context. The tool will be piloted in one district in the central

region, refined, and finalized for national use.

Three multi-sectoral teams will be constituted to conduct the assessment. The assessment will be

conducted using the adapted tool in all 28 districts of the three regions of the country. The assessment will

include site visits, facilities surveys, questionnaire administration to focus groups, and assessment of

existing service providers, future demands for services, surge potential, as well as interview of potential

service recipients. At the conclusion of the assessment, a consensus meeting will be held to discuss the

findings. A final report will then be generated. The report will contribute to the development of national policy

on male circumcision as an HIV prevention strategy in Malawi.

Activity 2: Consultation with Strategic Constituencies

The HIV prevalence in Malawi is 14% and male circumcision is seen in only 20% of the population. Where

male circumcision is practiced, it is deeply rooted in culture, tradition, and religion. For male circumcision to

be considered as part of an HIV prevention package, a serious effort should be made to consult with key

stake holders who potentially could guide such a program. A forum for these constituents to raise their

concerns and have key questions answered is vital. The USG resources will be used in conjunction with

other partners to convene multiple consultations with key stake holders (religious leaders, traditional

leaders, health policy makers, youth, and women). A final consensus meeting that would advise the MoH

on policy development around male circumcision will be convened.

USG Malawi will fund the convening of three national consultative meetings for religious leaders, traditional

leaders, and government policy makers. This will be followed by meetings for religious and traditional

leaders in each of the three provinces. Findings from the consultations will be shared at a dissemination

meeting of all stake holders. The result of this activity will contribute to the development of a national policy

on male circumcision.

Activity 3: Communication Strategy

Critical to considering the inclusion of male circumcision as part of a national HIV prevention policy is the

need for an effective communication strategy especially as constituents are consulted. The USG through

PSI will assist the MoH and UNICEF with developing content for communication pieces that will be used in

the consultation process targeting different populations. Relevant focus groups will be constituted,

messages will be developed and piloted, and IEC materials will printed and distributed.

Activity Narrative:

Activity 4: Critical Operations Research

It is anticipated that the rapid assessment will raise some questions with regard to gaps in the current

knowledge and practice of male circumcision in Malawi. EP funds will be used in conjunction with other

partners to support time-limited operations research that will help answer some of those questions. For

example, through questionnaire driven sampling, efforts would be made to understand confounding factors

for the high prevalence of HIV infections among communities with the highest proportion of male

circumcision, the Yao, and the Lomwe ethnic groups.

With the PEPFAR activities, as well as activities supported by other development partners, NAC will be able

to facilitate national discussions on the accessibility and feasibility of male circumcision as a prevention

method as well as recommend additional policies and guidelines in this area.