Swaziland is the first country in the world to support a national male circumcision (MC) plan with an accelerated initiative, named Soka Uncobe. In January 2010 national level planning started, and under the guidance of the national MC Task Force led by the Ministry of Health (MOH), the Accelerated Saturation Initiative (ASI) concept was developed. ASI was presented to the Cabinet for approval in February 2010. In preparation for the project, the MC Task Force formed an ASI sub-committee comprised of four working groups: mapping and policy, logistics, human resources, and MC operations. The Government of the Kingdom of Swaziland (GKOS) launched the Soka Uncobe brand in March 2011. Soka Uncobe translates in SiSwati to circumcision is to conquer. From April 2011, 10 initial MC MOVE (Model for Optimizing Volume and Efficiency for MC services) teams were working in all four regions of the country. The MC MOVE teams implemented from April to December 2011. Each team was composed of a site manager, physician, nurses, counselors, an expert client, hygienist, receptionist, data capturer, and a runner. The activation of the MOVE teams included provider training and supervision, drafting and finalizing clinical and adverse event protocols, and the establishment of surgical marquees and tents for outreach clinics.
This e-Toolkit shares the activities and development of the MOVE clinical teams. In addition, it documents the development and dissemination of the communications strategy and materials.
The Kingdom of Swaziland is divided into four administrative regions: Hhohho, Manzini, Lubombo and Shiselweni. According to the 2007 National Census, the current population of Swaziland is 1,018,449. Swaziland is at the epicenter of the global HIV/AIDS pandemic, suffering from the world’s highest prevalence rates of HIV and TB. Twenty-six percent of Swaziland’s adult population (aged 15-49) is infected with HIV, while prevalence amongst pregnant women attending ante-natal care (ANC) facilities stands at 42%. HIV prevalence increases with age in Swaziland: according to the 2006/7 DHS, the age-sex specific HIV prevalence among the 15-19 year old age group was estimated at 10% for females and 2% for males, while for those 25-29 the respective prevalence is as high as 49% (females) and 28% (males).
HIV incidence is estimated at 2.6%, meaning that 32 new infections occur each day in the country. Life expectancy has dropped to an estimated 43 years and 40% of Swazis are under 15, based on the most recent census data available (2007). Various studies have identified the following main drivers of the epidemic as multiple concurrent partners (MCPs), low levels of male circumcision, inconsistent use of condoms and long periods of premarital sexual activity.
Swaziland had one of the lowest male circumcision rates in the world with 8% of adult males circumcised, according to the 2006/2007 DHS. A high level of potential interest in male circumcision was reported in a study carried out in the Manzini region in January 2006 in research led by partner agencies. This pre-disposition was further assessed through a national pulse-taking study in combination with triangulation research on perceptions, attitudes and behaviors towards MC. As mentioned, in 2010, the GKOs developed the ASI. Soka Uncobe is led by GKO's Ministry of Health (MOH). It is funded by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and implemented and led by Futures Group in partnership with Matchboxology, Population Services International, Jhpiego, the Family Life Association of Swaziland, John Snow Incorporated and the Partnership for Supply Chain Management. The organogram of the Soka Uncobe structure, provided here, outlines the relationships between the MOH, PEPFAR and implementing partners. Several PEPFAR funding mechanisms were used to fund Soka Uncobe. This is also outlined in the organogram, which is a high level depiction of the management structure for MC project implementation.
With ASI planning in 2010, implementation of the ASI began in 2011. Clinical services began under the ASI in February 2011, and the Soka Uncobe brand was launched in March 2011. The period beginning in July 2011 marked the first quarter where all elements of the initiative were in place at scale, including the mass media campaign, community mobilization, supply infrastructure, waste management, clinical services and monitoring and evaluation. As part of the ASI, the MOH and implementers partnered with the Ministry of Education (MOE) to engage Swaziland’s school system so as to increase the uptake of MC among school-going young men. The initiative followed previous initiatives in Swaziland and was named The Back to School (BTS) campaign. The BTS campaign, which scaled up communications in June 2011 and clinical services in the middle of August 2011, was a milestone for all technical components of the accelerated initiative. Regional waves in Manzini and Hhohho were implemented from October through December 2011, with communication activities focusing in each region and scaled up services.
In November 2011, implementing partners gathered with PEPFAR and GKOS representatives to discuss the milestones, challenges and successes of the project. In addition, participants discussed recommendations for moving forward with MC in Swaziland. The recommendations included reduced clinical teams, reduced number of sites, and increased clinical outreach. For communication efforts, the recommendations focused on increasing ownership of demand creation teams at the site level, increasing door to door activities and ensuring that messages respond to the research about the barriers to action for MC. These recommendations were realized and changes to implementation began on January 1, 2012 with a reduced clinical component and focused communications efforts.
Although the Soka Uncobe campaign ended March 31, 2012, circumcision in Swaziland continues. Soka Uncobe was planned as a short, intense campaign. After the campaign, male circumcision services will be provided in the current health system in Swaziland, including health centres, private providers and hospitals. The Combination Prevention Program, led by the Ministry of Health and funded by PEPFAR, will continue with male circumcision related communications and services. Male circumcision will be offered at select health centres and will expand to more centres over time. Circumcision as an HIV prevention effort is fully supported by the Ministry of Health and will continue to be offered in Swaziland.