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Winnie Mandela Male Sexual Health Clinic Celebrates its 10,000th Circumcision in 2012

Inspiring quotes about innovation and working together plaster the walls at the Winnie Mandela Male Sexual Health Clinic in Tembisa, South Africa, based in a township outside of Johannesburg. But the sentiment is far more than decorationâitâs the heart and brains that drives the clinic to become a model of success.

Using metal cargo containers as low-cost buildings for the clinic, developing the team strategically, creating mobilized outreach community programs, setting up HIV counseling and testing (HCT) as a first separate stage, creating an electronic-based system, and creating a diversity of counseling services are the cornerstones of their successes. âWe are always looking for innovation,â said Helen Kirsby-Green, Director of Operations. âWe are determined to constantly review and change to serve our patients and the community better.â The location for the medical male circumcision (MMC) clinic was carefully chosen near a primary care facility to serve a poor, dense population of 80,000 with squatter camps, people out of work, and a hub of people coming and going. Yet the area has important catchments to bring people in, like a library, schools, hospital, and taxi stands.

But if they had waited for people to come in, they wouldnât have celebrated serving their 10,000th circumcised client on October 26, 2012, after officially opening in little more than one year. They started at 20 clients per day and are now at 80.

MMC clinics are just one tool in the national plan to lower the rate of HIV in South Africa. Multiple studies have shown that circumcision reduces rates of HIV by 60%. But the clinic goes beyond just MMC. It is designed to be a hub of integrated care and counseling that achieves a greater health impact in the community.

Outreach teams are an essential key to success by educating and recruiting patients, generating community demand, and building trust in the community. The teams and their mobile vans reach out to workplaces, labor unions, public places like train stations, taxi stands, shopping malls, and schools. They even go door-to-door, reaching out to shacks in the surrounding squatter camps. In addition to recruiting men to undergo medical male circumcision â an evidence-based method of preventing HIV transmission -- these teams provide HIV counseling and testing and other health services.

The clinic is a smooth set of operations: incoming men are divided into âbuddyâ teams, supporting each other through each efficient step of being registered, counseled and tested for HIV, introduced to the procedure, undergoing health examination, and finally ending with the circumcision. This buddy system in a setting of quality and quantity creates a safe, trustworthy, and nurturing environment. No patient wanders or wonders where heâs to go, and theyâre never alone.

A separate parent-preadolescent program was developed for those younger than 15 years (studies show most adolescents are sexually active at age 15). The mother and child are kept together. Staff has learned that the parent doesnât brief the child beforehand, and that the child doesnât tell the mother about the 48-hr hygiene practices after MMC to ensure rapid healing. So both are instructed at the same time.

Finally each male going through the process is exposed to gender education. Aurum educates boys and men about masculinity and dispels gender stereotypes that are common in the area. The counselors work to build knowledgeable ambassadors in the community, since friends believe what friends say. Itâs an open forum, where older males can overhear the teenâs discussion and learn. Older men also receive messages on reducing multiple, concurrent sexual partners.

Aurum Research Institute launched the Winnie Mandela Male Sexual Health Clinic with funding from PEPFAR through CDC in March, 2012. In October 2012 Aurum circumcised their 10,000th patient, John John Tsietsi Nkuna, aged 40 years.

Case Study

Skolnikland is in Eastern Africa, with a population of 30 million people. The country has a plains region, a hill region, and a region with high mountains. It has a number of ecosystems. The plains are dry for much of the year, there is some rainforest, and the rest of the country includes both hills and mountains. There are two seasons of heavy rainfall.

The citizens come from several ethnic groups that tend to live in their own regions and speak different languages. The ethnic groups largely follow one of three different religions. The large cities are mixed ethnically. One ethnic group is economically and socially very dominant. The people from this group live in the capital and most of the large cities. The national language is the language of this dominant ethnic group.

According to World Bank criteria, Skolnikland is among the poorest countries in the world. The economy has been growing at about 4% per year on average over the last decade, but the economy had very slow economic growth in the decades prior to that. The richest 10% of the population controls 80% of the national income.

About 80% of the people live in rural areas and 20% in urban areas. The number of people living in urban areas has been growing recently at an increasing pace. Most people earn their livelihood in agriculture but there is an increasing garment manufacturing industry in the two largest cities. There are also a number of mining industries. In addition, other export industries are beginning to grow, mostly focused on the export of commodities to China.

The total fertility rate is about 4.5 but it has been declining slowly over the last two decades, from over 6. There is an almost equal number of men and women in the population. Infant mortality is about 90 per 1,000 live births. Maternal mortality is about 500 per 100,000 live births. Thirty-five percent of the children are underweight for age.

The adult literacy rate is about 40%. The educational enrollment rate, especially for girls at the primary and secondary levels, has been growing slowly, but steadily. Most recently, this rate has been growing at an increasing pace and about 75% of the girls now attend school regularly, although many of them are of very low quality.

Only about 50% of citizens have access to safe water. Only about 30% have access to sanitary disposal of human waste.

HIV prevalence is 7% of the adult population. The number of new HIV cases annually has begun to plateau. About half of the people eligible for treatment for HIV are on treatment. Malaria is rampant in the plains.

Investments in the road system have been growing at a solid pace in the last decade and the use of private automobiles has begun recently to increase more rapidly.

Skolnikland has a pluralistic health system that is made up of public and private institutions, publicly financed providers, licensed private providers, unlicensed medical practitioners, and traditional healers. There is no health insurance, except for some free services for the poor in the few publicly financed hospitals, which the better off people do not attend. The health system is not very effective or efficient and is generally of low quality. The HIV, TB, and malaria programs are not effective or efficient and they are just beginning to adopt paradigms for services that follow global best practices.

QUESTION 26

What is a DALY?

Refer Case Study from question 1 to answer this question.

A. An indicator that compares the burden of deaths across the population of different countries.

B. A composite health gap indicator that measures the amount of health and disability-free life that is lost because of disease, injury, and premature death.

C. A WHO indicator used to summarize the expected number of years to be lived in good health.

QUESTION 27

What is an example of a conditional cash transfer that you can use to improve child health?

Refer Case Study from question 1 to answer this question.

A. Provide tax breaks to families with children.

B. Give money to mothers whose children received a full course of vaccination.

C. Pay higher fees to vaccination programs with better outcomes.

QUESTION 28

What usually takes place during the demographic transition?

Refer Case Study from question 1 to answer this question.

A. Fertility falls before mortality falls

B. Mortality falls and then fertility falls

C. Mortality and fertility fall at the same time

QUESTION 29

Which force is likely to have the greatest direct impact on epidemiological change in the medium and long terms on today's middle-income countries?

Refer Case Study from question 1 to answer this question.

A. Population growth

B. Population aging

C. Urbanization

QUESTION 30

Which is the most accurate statement about the distribution of age at death in Niger (a very low income country) and Norway (a very high income country) today?

Refer Case Study from question 1 to answer this question.

A. About 5% of the deaths in Niger are among those under 15, while the overwhelming majority of deaths in Norway are among those over 65.

B. About 30% of the deaths in Niger are among those under 15, while the overwhelming majority of deaths in Norway are among those over 65.

C. The overwhelming majority of deaths in both countries occur among people aged 65 and over.