Inon Schenker, PhD, MPH - Jerusalem AIDS Project, Israel and Swaziland
Dr. Inon Schenker is a researcher and senior consultant to government ministries, the Israel Defense Forces, the UN, and other international agencies, specializing in HIV/AIDS prevention. Dr. Schenker was the founding chair of The Jerusalem AIDS Project. For two years he worked as a scientist with the World Health Organization at its headquarters in Geneva. He has also served as team leader and evaluator for several national AIDS programs around the globe.
Since 2006, Dr. Inon Schenker has lead "Operation AB," an initiative on male circumcision for HIV prevention, responding to requests from African countries interested in rolling out MC services and training.
The HIV/SRH Integration site interviewed Dr. Schenker about his experiences with providing integrated services.
Please describe your program involving male circumcision for HIV prevention.
The Jerusalem AIDS Project was established twenty years ago as a non-governmental organization (NGO) focusing on prevention of HIV infection in adolescents. Until recently, the organization was working on interventions in the area of school-based HIV prevention and the capacity building of educators and people who are serving communities in the field. We’ve developed concepts, materials, and workshops designed to introduce issues regarding sexuality and HIV prevention also to the most conservative communities where Jewish, Muslims, and Christians live in the Middle East. The work we conducted over the last 18 years allowed us to form good relationships with other stakeholders, including international and multilateral agencies such as the UN and USAID.
My interest in male circumcision for HIV prevention began in 2000 when I co-Chaired a first informal WHO consultation on MC for HIV prevention held in Durban, South Africa. Following the consultation I began to pay close attention to the ongoing development of the controlled trials which set the stage for all the activities that are currently being conducted around the world in this area. It was at the end of the summer of 2006 that I realized that the controlled trials had a missing link. If male circumcision was proven as an intervention that could dramatically reduce infection, then who would do the job? Who would be out there conducting circumcision on adults? More than that, who has expertise to train local African doctors in this area? What would be the right context? Would this be a one-time operation in the Urology department of a medical institution?
It was at that point when the Jerusalem AIDS Project began to investigate what had been happening in Israel in the course of the last decade. Israel is a mostly circumcised community. For religious reasons, Jews, Muslims, and (for hygienic reasons) Christians circumcise their male children at a very early age. Muslims circumcise their sons by the age of 13. In Israel, boys are circumcised at a very early age, at birth or a couple of months after delivery. Jews circumcise their sons on the 8th day after birth.
Many inhabitants who migrated to Israel, mainly from Eastern Europe, arrived uncircumcised and wished to be circumcised as adults. It’s interesting because it’s the only phenomena of its kind in the world -- Jewish people, religious or not so religious, came into Israel and demanded that the state (Ministry of Health and Ministry of Religious Affairs) provide the service of male circumcision to consenting adults. There were several reasons for this request. One was the growing feeling of self identity and interest to relate to the community. The immigrants just arrived and wanted to feel like they were a part of the nation. Another reason was social: mothers and fathers of adolescent boys didn’t want their kids to be different than the others. Israel has boarding schools, gym classes compulsory military service and many other situations where boys change together and may be exposed to each other's genitals.
We are talking about a very important decision making process that is now 18 years old.. The policy situation Israel was going through 10-15 years ago relating to male circumcision is basically what African countries are going through today.
Over 80,000 adult male circumcisions under local anesthesia have been conducted in Israel in the course of the last fifteen years, and there’s no precedent for that anywhere in the world. Large-scale circumcision was becoming a process. It’s not that you come once in a while and you do a session and you circumcise a couple of times. The state of Israel developed a system for massive male circumcision of adults under local anesthesia, serving thousands and thousands of men were 'standing in line waiting' to be circumcised.
Swaziland was the first country to contact the Jerusalem AIDS project with a request to support their interest in scaling up male circumcision services. That was in the beginning of 2007. The Family Life Association of Swaziland (FLAS) and the Jerusalem AIDS Project established a project to introduce a model for integrating HIV and SRH training and service delivery, patterned after service delivery approaches in Israel. This is how the Jerusalem AIDS Project and FLAS together with the Hadassah Medical Organization and the government of Swaziland became pioneers in the provision of training in adult male circumcision through a community/clinic-based model in Africa.
Is this exchange still going on currently with Swaziland?
Yes. We have developed a pilot project that was finalized in February 2008, ripe for replication and expansion a month and a half ago. Under this project, three delegations of Israeli surgeons and public health experts traveled to Swaziland. Each delegation stayed in Swaziland for two weeks with the aim of training local doctors, nurses, and other staff members of FLAS on male circumcision for HIV/AIDS prevention and SRH. The pilot project was completed at the end of February 2008, and was reported in Mexico at the International AIDS Conference and other international conferences and in peer-reviewed journals. This will hopefully lead other countries in Africa, including Swaziland, to find ways to replicate this model in their countries.
When did the pilot program begin?
The memorandum of understanding between the project and the relevant institutions and Swaziland was defined in April 2007. The pilot project started officially in October 2007 when the first delegation of JAIP\Hadassah trainers were sent to Swaziland in October 2007. The pilot was basically 2 weeks, repeated three times in the course of these months.
What parties were involved in this decision making process of how to go about this pilot project? It was people from FLAS, Swaziland governance, as well as people on your end but was there anyone else involved with deciding on how to go about this pilot project?
No, it was an NGO-to-NGO initiative with the support of the Swazi government. We are an NGO, but we always respect the host country and require that activities that we are involved in will be endorsed by the host government. The decision making regarding the action plan, the goals and objectives has always been at the level of FLAS and the Jerusalem AIDS Project. The Hadassah Medical Organization of Israel provided technical and generous financial support. Tuttenaur, specialists in infection control, donated autoclaves.
Did the Israeli delegation perform any operations or only provide training?
The Jerusalem AIDS Project and Hadassah did not come to Swaziland to provide service delivery. We came as consultants to the government of Swaziland and FLAS. Our aim was to conceptualize and strengthen the links between a dramatic effort in HIV prevention and a great opportunity in integrating HIV and SRH services. We came to assist in the training of local doctors, nurses, social workers, and staff members who can increase the intake in Swaziland of adult male circumcision and HIV prevention. About 10% of Swazi doctors were trained in performing adult circumcision. Swaziland is a very small country and 10% of the doctors is basically 12 doctors. These trained doctors were immediately integrated into the service delivery scheme with intake of clients increasing to 10-12 a day per doctor in one location.
What did the training consist of?
Doctors that have been trained in medicine already have a high level of knowledge of anatomy and physiology. Because they come with that skill and that knowledge, the training on the actual surgical techniques is short. It is important to mention that the training needs to be connected to the point of integration. If you bring in a surgeon and all he does is removal of foreskin, this is a mistake. In Swaziland, we made the suggestion that if a patient's first encounter with a health provider occurs when seeking circumcision, the surgeon should spend a few more minutes addressing other SRH issues of that particular man. It is also important for the nurse to inquire about SRH when he or she comes for intake and initial history and checkup before surgery. This is a crucial point in our opinion. The ability to integrate HIV and SRH around male circumcision is there because men would otherwise never come to a health care facility for an operation unless there was an emergency. Male circumcision could be an entry point to address issues of voluntary testing and counseling. Male circumcision could also be a point of entry for improving education about sexual health issues.
How did the providers feel about the training they received? Were they hesitant at first or did they see this as an exciting opportunity? What experience has your team had with the Swazi providers?
I think this is a very important question. I’m sure that because we are still in the process of learning lessons from this initiative that perhaps it will take some more time to digest all that we have learned in the interaction. But it's quite obvious that there are striking lessons which come out of this experience. One lesson is that health care providers, whether doctors or nurses or other involved individuals in the health care, were open to accepting a new dimension in their workload and in their life. They never needed to take on board male circumcision.
Optimal training occurs in a non-patronizing, enabling environment. We sometimes see providers from the North coming in and saying, "We know how to do it. Just listen to us.” This was not our approach; this is not how the Jerusalem AIDS Project works with educators and with doctors. As an organization which was established in 1968, FLAS is much more a veteran than us and has worked on the ground with the Swazi community. FLAS was able to take on a new challenge which was never known in Swaziland. That made FLAS become excellent teachers to our teams in this area.
The second lesson is that the interest is not only driven by materialistic incentives. We found a lot of heart in the people that we have been working with. All the Israeli doctors, for example, had volunteered their time. They were able to provide some of their expertise and experience rewarding interactions.
On the Swazi side, we did not need to push people to come to the training. But we could only train all those that were suggested by the government to be trained. This is for two reasons. The government policy at the moment in Swaziland restricts provision of male circumcision to only physicians. One can train nurses on surgical techniques. Yet, this task shifting needs a clear government policy in place. Also, we could not train a huge audience because of the short time of the project and the limited funding that we received.
Is there anything else you wanted to mention regarding your pilot project?
Integration is important. In order to reach a significant number of men who would voluntarily undergo male circumcision, we need to be open and broad minded and do a good professional job not only in developing countries but also in the developed world in order to solicit the existing expertise. We have to make sure that we don’t restrict ourselves to developing countries, but also reach out to potential contributors and collaborators in the developed world.
Contact information
Dr Inon Schenker
Director, Operation AB
The Jerusalem AIDS Project
POB 7179, Jerusalem, Israel 91077
Tel: +972 2 6797677
Fax: +972 2 6797737
Email: jaipolam@yahoo.com
Web: operation-ab.org