Mass safe male circumcision: early lessons from a Ugandan urban site - a case study

International Hospital Kampala, Uganda.
The Pan African medical journal 12/2012; 13:88.
Source: PubMed

ABSTRACT It has been proven in several randomized clinical trials that HIV transmission from female to male is reduced by 60% and more among circumcised males. The national target for Uganda by 2015 is to circumcise 4.2 million adult males, an unprecedented number requiring a pragmatic approach and effective model(s) to deliver this target. The objective of the study was to describe early lessons learnt at a start up of a mass safe male circumcision (SMC) program in an urban Ugandan site, implemented through task shifting and a private public partnership approach.
A case study of an urban SMC site in Uganda's capital, Kampala with a catchment population of approximately 0.8 million adult males aged between 15 and 49 years. Client enrollment was voluntary; mobilization was by word of mouth and through the media. Non Physician clinicians (NPC) carried out the majority of the SMCs. The SMC and voluntary counseling and testing (VCT), adverse events (AE) management and follow up were done as per set national guidelines. The supervision was by a public and private service provider. All clients were consented.
A total of 3000 males were circumcised in 27 days spread over four months. The AE rate was 2.1% all AEs were mild and reversible. No deaths occurred. The work rate was 111 SMCs per day. There was sufficient demand for SMC despite minimal mobilization effort. The bulk of the SMC work was successfully carried out by the NPCs.
Private Public Partnership and task shifting approaches were successful at the start up phase and we anticipate will be feasible for the scale up.

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    ABSTRACT: The Ugandan Ministry of Health has endorsed voluntary medical male circumcision as an HIV prevention strategy and has set ambitious goals (e.g., 4.2 million circumcisions by 2015). Innovative strategies to improve access for hard to reach, high risk, and poor populations are essential for reaching such goals. In 2009, the Makerere University Walter Reed Project began the first facility-based VMMC program in Uganda in a non-research setting. In addition, a mobile clinic began providing VMMC services to more remote, rural locations in 2011. The primary objective of this study was to estimate the average cost of performing VMMCs in the mobile clinic compared to those performed in health facilities (fixed sites). The difference between such costs is the cost of improving access to VMMC. A micro-costing approach was used to estimate costs from the service provider's perspective of a circumcision. Supply chain and higher-level program support costs are not included. The average cost (US$2012) of resources used per circumcision was $61 in the mobile program ($72 for more remote locations) compared to $34 at the fixed site. Costs for community mobilization, HIV testing, the initial medical exam, and staff for performing VMMC operations were similar for both programs. The cost of disposable surgical kits, the additional upfront cost for the mobile clinic, and additional costs for staff drive the differences in costs between the two programs. Cost estimates are relatively insensitive to patient flow over time. The MUWRP VMMC program improves access for hard to reach, relatively poor, and high-risk rural populations for a cost of $27-$38 per VMMC. Costs to patients to access services are almost certainly less in the mobile program, by reducing out-of-pocket travel expenses and lost time and associated income, all of which have been shown to be barriers for accessing treatment.
    PLoS ONE 10(3):e0119484. DOI:10.1371/journal.pone.0119484 · 3.53 Impact Factor
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    ABSTRACT: As an HIV prevention strategy, the scale-up of voluntary medical male circumcision (VMMC) is underway in 14 countries in Africa. For prevention impact, these countries must perform millions of circumcisions in adolescent and adult men before 2015. Although acceptability of VMMC in the region is well documented and service delivery efforts have proven successful, countries remain behind in meeting circumcision targets. A better understanding of men's VMMC-seeking behaviors and experiences is needed to improve communication and interventions to accelerate uptake. To this end, we conducted semi-structured interviews with 40 clients waiting for surgical circumcision at clinics in Zambia. Based on Stages of Change behavioral theory, men were asked to recount how they learned about adult circumcision, why they decided it was right for them, what they feared most, how they overcame their fears, and the steps they took to make it to the clinic that day. Thematic analysis across all cases allowed us to identify key behavior change triggers while within-case analysis elucidated variants of one predominant behavior change pattern. Major stages included: awareness and critical belief adjustment, norming pressures and personalization of advantages, a period of fear management and finally VMMC-seeking. Qualitative comparative analysis of ever-married and never-married men revealed important similarities and differences between the two groups. Unprompted, 17 of the men described one to four failed prior attempts to become circumcised. Experienced more frequently by older men, failed VMMC attempts were often due to service-side barriers. Findings highlight intervention opportunities to increase VMMC uptake. Reaching uncircumcised men via close male friends and female sex partners and tailoring messages to stage-specific concerns and needs would help accelerate men's movement through the behavior change process. Expanding service access is also needed to meet current demand. Improving clinic efficiencies and introducing time-saving procedures and advance scheduling options should be considered.
    PLoS ONE 11/2014; 9(11):e111602. DOI:10.1371/journal.pone.0111602 · 3.53 Impact Factor
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    ABSTRACT: Safe Male Circumcision is a known intervention in prevention of heterosexual HIV acquisition. However, since the roll-out of the male circumcision policy in Uganda, concerns that circumcision may lead to behavior disinhibition are rife. We assess the association between male circumcision, risky sexual behavior and HIV status among Ugandan men. Data are from AIDS Indicator Survey 2011 with 7,969 ever sexually active men aged 15-59 years. The prevalence of circumcision was 28% and most common risky sexual behaviors were; multiple life-time sexual partners, non marital sex and non-use of condoms. Adjusted logistic regression analyses showed that multiple life-time partners, OR=1.47 (95%CI: 1.28-1.68), engagement in non marital sex, OR=1.25 (95%CI: 1.03-1.50), and non-use of condom at such sex were significantly higher among the circumcised. HIV prevalence was lower among the circumcised even with risky sexual behaviors. There is need for continued sensitization on circumcision and re-packaging of the circumcision messages.
    Population Association of America 2014 Annual Meeting, Boston, MA USA; 05/2014

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