HIV Prevention Knowledge Base
Biomedical Interventions: Voluntary Medical Male Circumcision
Implementing Voluntary Medical Male Circumcision for HIV Prevention in Nyanza Province, Kenya: Lessons Learned During the First Year
This article discusses lessons learned in Kenya’s voluntary medical male circumcision scale up and assesses VMMC services in 16 government health facilities in Kenya’ Nyanza Province. The paper focuses on the ways that challenges were overcome at national and local levels. The article is designed to share lessons with other VMMC programs in Africa.
Voluntary Medical Male Circumcision: Strategies for Meeting the Human Resource Needs of Scale-Up in Southern and Eastern Africa
The human resources aspect of scale-up of voluntary medical male circumcision (VMMC) in eastern and southern Africa is the focus of this paper. It identifies ways to overcome the shortage of health professionals in countries where VMMC has been identified as a priority intervention. Based on a review of the literature and of a VMMC program, the authors describe various measures: task management strategies, surgical and non-surgical efficiencies, short-term redeployment of staff from other parts of the public sector, and recruitment of underutilized health workers such as those who have recently qualified or retired, as well as medical volunteers from overseas. They highlight examples from existing campaigns, such as relocating public sector staff in Tanzania, training nurses to conduct VMMC surgery in Kenya, and finding ways to utilize untapped nursing resources in Swaziland, to show how innovative approaches can overcome human resources shortages.
Voluntary Medical Male Circumcision: Translating Research into the Rapid Expansion of Services in Kenya, 2008–2011
The experience of Kenya, where approximately 290,000 men have undergone voluntary medical male circumcision (VMMC) since 2008, serves as a model for VMMC scale-up in other countries, according to this paper. Two crucial factors are the Government of Kenya’s leadership in prioritizing VMMC in the country’s HIV prevention efforts and the adoption of a strategy targeting 80 percent circumcision of all uncircumcised men by 2012. Widespread support for VMMC is attributed to the government’s prompt and ongoing engagement with politicians, community leaders, and civil society organizations. The implementation of VMMC programs has been characterized by innovation and flexibility, which has also contributed to their success, the paper states.
Voluntary Medical Male Circumcision: Matching Demand and Supply with Quality and Efficiency in a High-Volume Campaign in Iringa, Tanzania
This paper describes Tanzania’s experience in running a high-volume voluntary medical male circumcision (VMMC) campaign in which over 10,300 men were circumcised in six weeks. The number of procedures was 72 percent higher than the target, with less than 1 percent of cases encountering an adverse event and almost universal HIV testing throughout the campaign. Such good results were achieved by implementing measures to improve clinical efficiency, such as using the forceps-guided circumcision method and enabling surgical teams to operate on an assembly line of patients. Community-based client preparation and mobilization were crucial to stimulating demand for the procedure. Tanzania’s example shows that VMMC can be scaled up to high volume without adversely affecting service quality, the paper concludes.
Voluntary Medical Male Circumcision: A Qualitative Study Exploring the Challenges of Costing Demand Creation in Eastern and Southern Africa
This study looked at voluntary medical male circumcision (VMMC) demand creation with two key issues in mind: the main elements of a demand creation campaign and the impact of challenges to demand creation on the overall cost. The authors conducted qualitative interviews with seven experts who had experience in managing VMMC demand creation budgets and offering technical assistance to government VMMC programs. Given the diversity of views among informants, demand creation should be tailored to specific country contexts, the authors found. Costing exercises depend on individual country and program variations, as well as the extent and quality of programs. The authors also note the lack of data on what factors prompt eligible men to make the decision to go for VMMC. The paper offers a seven-step process for VMMC cost estimation based on key assumptions, but calls for more research into the identification and costing of core components of a VMMC demand creation program.
Voluntary Medical Male Circumcision: A Framework Analysis of Policy and Program Implementation in Eastern and Southern Africa
This paper looks at the differing degrees of progress in scaling up male medical circumcision (MMC) programs in countries in eastern and southern Africa where MMC is considered a priority. It categorized the countries according to how quickly they adopted MMC policies after the World Health Organization and the Joint UN Programme on HIV/AIDS issued recommendations for scale-up in 2007, and assessed the volume of MMCs conducted from 2008 to 2010. Among the countries considered early adopters, only Kenya is approaching the recommended 80 percent target coverage, having achieved over 60 percent coverage by the end of 2010. Overall, coverage was only 3 percent of the target, at 550,000 MMCs. The study found potential predictors of early adoption include having a national policy and focal person, as well as running a pilot program and developing an operational strategy. However, early adoption alone is not predictive of rapid scale-up of MMC—it also requires sustained leadership and country ownership, the authors conclude.
Voluntary Medical Male Circumcision: Logistics, Commodities, and Waste Management Requirements for Scale Up of Services
Costing estimates for the implementation of voluntary medical male circumcision (VMMC) programs should include the cost contribution of the supply chain and waste management as these can account for a significant proportion of total costs, according to this paper. The standard list of commodities for scale-up of a VMMC program that was developed by U.S. President’s Emergency Plan for AIDS Relief programs in collaboration with the World Health Organization and the Joint UN Programme on HIV/AIDS was used in the process of program planning for a VMMC campaign in Swaziland that targeted 152,000 VMMCs in one year. Once the researchers added the cost of the supply chain and waste management, as well as commodities for HIV counseling and testing and treatment of sexually transmitted infections, they found that these items almost doubled the total cost, adding approximately $60 to the bill per circumcision.
A Model for the Roll-Out of Comprehensive Adult Male Circumcision Services in African Low-Income Settings of High HIV Incidence: The ANRS 12126 Bophelo Pele Project
This project focused on identifying whether it is possible to implement a large-scale, high-quality adult male circumcision (MC) program in settings with high HIV prevalence, low levels of MC, and low incomes. Prior to rolling out adult MC services, the researchers took care to consult with the local community in Orange Farm township in South Africa. Surveys showed a high level of support from the community for the project, and a willingness among adult males to obtain MC. The project set up a high-volume surgery room in an existing facility, trained teams of providers, procured necessary equipment, and began dedicated communication and outreach activities to bring clients in for MC. They performed 14,011 procedures over nearly two years, with minimal adverse events. Participant and community satisfaction levels were high. While this project demonstrated the feasibility of providing high-quality, large-scale MC, only 28% of men seeking MC obtained HIV testing and counseling. One point of concern, however, was that only two-thirds of the men returned for their follow-up visit.
The Number of Procedures Required to Achieve Optimal Competency with Male Circumcision: Findings from a Randomized Trial in Rakai, Uganda
To safely implement male circumcision (MC) where the potential impact is great, programs must have skilled providers. This study in Rakai, Uganda followed a team of six newly-trained MC providers over 3,000 circumcisions to identify when they reached full clinical competency in the procedure. All providers received two or more weeks of training by an urologist; none had previously performed adult MC. Training included preoperative preparation and aseptic technique, local anesthesia, the sleeve circumcision procedure, suturing, hemostasis, and management of surgical emergencies and adverse events. The trainees performed 15–20 supervised circumcisions during training. It took providers an average of 40 minutes to complete one procedure during their first 80-100 circumcisions. As provider competency increased, this time declined to between 20 and 25 minutes. Similarly, moderate to severe adverse events (requiring treatment or surgical intervention) occurred in nearly 9% of the first 20 procedures, declined to 4% for the next 20 to 99 procedures, then leveled off to 2%. The authors conclude that newly-trained clinicians should perform their first 35-40 procedures under supervision while they gain competency in the procedure to minimize adverse events.
New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications
This statement and recommendations follow an expert review of newly-published evidence on the effectiveness of male circumcision (MC) for HIV prevention. A wide range of stakeholders attended, including researchers, women’s health advocates, government representatives, and members of civil society. The group agreed that the evidence on the effectiveness of MC for HIV prevention was “compelling,” and provided a number of policy and program recommendations resulting from the research. Topics addressed span epidemiologic, communication, cultural, human rights, and gender issue, among others. These conclusions and recommendations can help guide policy makers and program managers as they move from MC research to program implementation, roll out, and scale up.
Safety of Over Twelve Hundred Infant Male Circumcisions Using the Mogen Clamp in Kenya
Male circumcision in clinical trials demonstrated a reduction of between 50 and 60 percent in HIV acquisition. As male circumcision scales up in many countries, national strategies will most likely recommend infant circumcision. This study, conducted between September 2009 and November 2011 and involving 1,239 babies that received infant male circumcision (IMC), reports on type and severity of adverse events (AE) within an IMC intervention in Kenya. Data came from two sources—one a case/control IMC study and the other derived from routine monitoring of IMC services. In the study reported here, median age for IMC was four days, and 96 percent of post-operative reviews took place within seven days. The total AE rate was 1.5 percent, with most AE occurring in infants one month or older (3.5 percent). AE did not differ depending on provider type or experience level. Almost all parents (96 percent) reported being very satisfied with the experience. The study demonstrates that IMC can be highly successful and safe in developing countries where circumcision is not predominantly practiced.
HIV Prevention: Male Circumcision Comparison Between a Nonsurgical Device to a Surgical Technique in Resource-Limited Settings: A Prospective, Randomized, Nonmasked Trial
The authors report on a prospective, randomized, controlled trial in Rwanda comparing procedure and recovery times for circumcision via the nonsurgical PrePex male circumcision device and the dorsal-slit surgical method. Of 217 subjects aged 21 to 54, 144 were randomized to the PrePex arm and 73 to the surgical arm. Mean procedure time for the PrePex arm was 3.1 minutes, significantly shorter (p < 0.0001) than the mean procedure time, 15.4 minutes, for the surgical circumcision arm, with no adverse events reported for the PrePex device. On the other hand, mean healing time was longer for individuals in the PrePex arm (31 days) than for those in the surgical circumcision arm (23 days). In addition to a shorter procedure time, say the authors, PrePex has other important advantages for resource-constrained settings: it is bloodless, does not require anesthesia or a sterile setting, and can be carried out by nonsurgeons, such as nurses. The authors suggest that these results favor nonsurgical circumcision methods for Rwanda, which has launched a two-year campaign to circumcise two million men but has only 21 surgeons in the entire country.
Safety of Task-Shifting for Male Medical Circumcision: A Systematic Review and Meta-Analysis
This systematic review assessed the safety of medical male circumcision (MC) by non-physician providers (nurses, midwives, surgical aides, and clinical officers). The authors found task shifting of MC to trained non-physician providers in a supportive environment does not increase the frequency of adverse effects and is thus very different from MC performed by untrained or minimally trained lay providers with little or no supervision or supportive equipment. The authors, who reviewed 25,000 procedures carried out by trained non-physicians, found rates of adverse events similar to MC conducted by doctors or specialists, including urologists and surgeons. According to the authors, the quality of training and supervision and the availability of safe equipment are more likely to affect MC safety than the cadre of health professional conducting the procedure. Another safety factor is the number of circumcisions performed; one study found that adverse events averaged 3.8 percent for the first 100 procedures by trained personnel, but fell to 0.7 percent after 400 procedures. The authors also found that practitioners with more experience with MC require less time to perform it and encourage further research into the cost-effectiveness of task-shifting for MC, particularly since some men seeking MC turn to informal providers to avoid charges, often resulting in adverse effects. More research is also needed to understand other factors that may contribute to safety, including the length and duration of training, the availability of supportive medical materials, providers’ experience and skill set, and reporting of adverse events.