title: Scale-Up of Early Infant Male Circumcision Services for HIV Prevention in Lesotho: A Review of Facilitating Factors and Challenges.
abstract: The World Health Organization and the Joint United Nations Programme on HIV/AIDS recommend early infant male circumcision (EIMC) as a component of male circumcision programs in countries with high HIV prevalence and low circumcision rates. Lesotho began incorporating EIMC into routine maternal, newborn, and child health (MNCH) services in 2013 with funding from the United States Agency for International Development and United Nations Children's Fund. This presented unique challenges: Lesotho had no previous experience with EIMC and cultural traditions link removal of the foreskin to rites of passage. This process evaluation provides an overview of EIMC implementation.
  
  
  
  The Lesotho Ministry of Health and Jhpiego conducted a baseline assessment before service implementation. Baseline information from an initial assessment was used to develop and implement an EIMC program that had a pilot and a scale-up phase. Key program activities such as staff training, quality assurance, and demand creation were included at the program design phase. Facilitating factors and challenges were identified from a review of information collected during the baseline assessment as well as the pilot.
  
  
  
  Between September 2013 and March 2015, 592 infants were circumcised at 9 sites: 165 (28%) between 1 day and 6 days after birth; 196 (33%) between 7 and 30 days, and 231 (39%) between 31 and 60 days. Facilitating factors included strong support from the Ministry of Health, collaboration with stakeholders, and donor funding. Providers were enthusiastic about the opportunity to offer new services and receive training. Challenges included gaining consent from family members other than mothers, and parents' concern about pain and complications. The EIMC program also had to manage providers' expectations of compensation because overtime was paid to providers who took part in adult circumcision programming but not for EIMC. Limited human resources, including authorization only for doctors to perform EIMC, impeded provision of services.
  
  
  
  Despite communication, compensation, and task-shifting challenges, integrating EIMC services with MNCH services could be a sustainable model for EIMC service delivery in Lesotho.
authors.affiliation: Jhpiego/Lesotho, Maseru, Lesotho virgile.kikaya@jhpiego.org.
authors.forename: Virgile
authors.initials: V
authors.lastname: Kikaya
authors.affiliation: Jhpiego/Lesotho, Maseru, Lesotho.
authors.forename: Rajab
authors.initials: R
authors.lastname: Kakaire
authors.affiliation: Jhpiego, Baltimore, MD, USA.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Thompson
authors.affiliation: Jhpiego/Lesotho, Maseru, Lesotho.
authors.forename: Mareitumetse
authors.initials: M
authors.lastname: Ramokhele
authors.affiliation: Jhpiego, Baltimore, MD, USA.
authors.forename: Tigistu
authors.initials: T
authors.lastname: Adamu
authors.affiliation: Jhpiego, Baltimore, MD, USA.
authors.forename: Kelly
authors.initials: K
authors.lastname: Curran
authors.affiliation: United States Agency for International Development, Division of Global HIV/AIDS, Washington, DC, USA.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Njeuhmeli
mesh_terms: D002944:Circumcision, Male / Q000706:statistics & numerical data*; D015658:HIV Infections / Q000517:prevention & control*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007927:Lesotho; D008297:Male; D015397:Program Evaluation / Q000379:methods*