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Victor O, Phiona M, Vernon M, Thoko M, Paidamoyo G, Farai G, Joseph H, Munyaradzi T, Olban R, Pesanai C, Mufuta T, Vuyelwa SC, Sinokuthemba X, Batsirai MC, Marrianne H, Scott B, Feldacker C. Adverse Event Trends Within a Large-Scale, Routine, Voluntary Medical Male Circumcision Program in Zimbabwe, 2014-2019. J Acquir Immune Defic Syndr 2021; 88:173-180. [PMID: 34173789 PMCID: PMC8434989 DOI: 10.1097/qai.0000000000002751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 05/20/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Between 2008 and 2020, over 22.6 million male circumcisions (MCs) were performed among men ≥10 years in 15 priority countries of East and Southern Africa. Few studies from routine MC programs operating at scale describe trends of adverse events (AEs) or AE rates over time. SETTING Routine program data from a large MC program in Zimbabwe. METHODS χ2 compared characteristics of patients with AEs. Univariable and multivariable logistic models examined factors associated with AE severity. Cochran-Armitage trend tests compared AE rate trends by year (2014-2019), age, and MC method (2017-2019). RESULTS From 2014 to 2019, 469,000 men were circumcised; of the total men circumcised, 38%, 27%, and 35% were conducted among individuals aged 10-14; 15-19; and ≥20 years, respectively. Most MCs (95%) used surgical (dorsal slit or forceps-guided) methods; 5% were device based (PrePex). AEs were reported among 632 (0.13%) MCs; 0.05% were severe. From 2015 to 2019, overall AE rates declined from 34/10,000 to 5/10,000 (P-value <0.001). Severe AE rates also decreased over this period from 12/10,000 to 2/10,000 (P-value <0.001). AE rates among younger clients, aged 10-14 (18/10,000) were higher than among older age men (9/10,000) aged ≥20 years (P < 0.001); however, there was no significant association between age and AE severity. CONCLUSION AE rates each year and over time were lower than the World Health Organization acceptable maximum (2% AEs). ZAZIC quality assurance activities ensured guideline adherence, mentored clinicians to MC competency, promoted quality client education and counseling, and improved AE reporting over time. Decreases in AE rates are likely attributed to safety gains and increasing provider experience.
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Affiliation(s)
- Omollo Victor
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Marongwe Phiona
- Zimbabwe Technical Training and Education Center for Health (ZIMTTECH), Harare, Zimbabwe
| | - Murenje Vernon
- Zimbabwe Technical Training and Education Center for Health (ZIMTTECH), Harare, Zimbabwe
| | - Madoda Thoko
- Zimbabwe Community Health Intervention Project (ZiCHIRe), Harare, Zimbabwe
| | - Gonouya Paidamoyo
- Zimbabwe Technical Training and Education Center for Health (ZIMTTECH), Harare, Zimbabwe
| | - Gwenzi Farai
- Zimbabwe Technical Training and Education Center for Health (ZIMTTECH), Harare, Zimbabwe
| | - Hove Joseph
- Zimbabwe Association of Church-related Hospitals (ZACH), Harare, Zimbabwe
| | - Tinashe Munyaradzi
- Zimbabwe Community Health Intervention Project (ZiCHIRe), Harare, Zimbabwe
| | - Rutsito Olban
- Zimbabwe Association of Church-related Hospitals (ZACH), Harare, Zimbabwe
| | - Chatikobo Pesanai
- Zimbabwe Community Health Intervention Project (ZiCHIRe), Harare, Zimbabwe
| | - Tshimanga Mufuta
- Zimbabwe Community Health Intervention Project (ZiCHIRe), Harare, Zimbabwe
| | | | | | | | - Holec Marrianne
- International Training and Education Center for Health (I-TECH), Seattle, WA USA
| | - Barnhart Scott
- Department of Global Health, University of Washington, Seattle, WA, USA
- International Training and Education Center for Health (I-TECH), Seattle, WA USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Caryl Feldacker
- Department of Global Health, University of Washington, Seattle, WA, USA
- International Training and Education Center for Health (I-TECH), Seattle, WA USA
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Feldacker C, Makunike-Chikwinya B, Holec M, Bochner AF, Stepaniak A, Nyanga R, Xaba S, Kilmarx PH, Herman-Roloff A, Tafuma T, Tshimanga M, Sidile-Chitimbire VT, Barnhart S. Implementing voluntary medical male circumcision using an innovative, integrated, health systems approach: experiences from 21 districts in Zimbabwe. Glob Health Action 2018; 11:1414997. [PMID: 29322867 PMCID: PMC5769777 DOI: 10.1080/16549716.2017.1414997] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Despite increased support for voluntary medical male circumcision (VMMC) to reduce HIV incidence, current VMMC progress falls short. Slow progress in VMMC expansion may be partially attributed to emphasis on vertical (stand-alone) over more integrated implementation models that are more responsive to local needs. In 2013, the ZAZIC consortium began implementation of a 5-year, integrated VMMC program jointly with Ministry of Health and Child Care (MoHCC) in Zimbabwe. OBJECTIVE To explore ZAZIC's approach emphasizing existing healthcare workers and infrastructure, increasing program sustainability and resilience. METHODS A process evaluation utilizing routine quantitative data. Interviews with key MoHCC informants illuminate program strengths and weaknesses. METHODS A process evaluation utilizing routine quantitative data. Interviews with key MoHCC informants illuminate program strengths and weaknesses. RESULTS In start-up and year 1 (March 2013-September, 2014), ZAZIC expanded from two to 36 static VMMC sites and conducted 46,011 VMMCs; 39,840 completed from October 2013 to September 2014. From October 2014 to September 2015, 44,868 VMMCs demonstrated 13% increased productivity. In October, 2015, ZAZIC was required by its donor to consolidate service provision from 21 to 10 districts over a 3-month period. Despite this shock, 57,282 VMMCs were completed from October 2015 to September 2016 followed by 44,414 VMMCs in only 6 months, from October 2016 to March 2017. Overall, ZAZIC performed 192,575 VMMCs from March 2013 to March, 2017. The vast majority of VMMCs were completed safely by MoHCC staff with a reported moderate and severe adverse event rate of 0.3%. CONCLUSION The safety, flexibility, and pace of scale-up associated with the integrated VMMC model appears similar to vertical delivery with potential benefits of capacity building, sustainability and health system strengthening. These models also appear more adaptable to local contexts. Although more complicated than traditional approaches to program implementation, attention should be given to this country-led approach for its potential to spur positive health system changes, including building local ownership, capacity, and infrastructure for future public health programming.
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Affiliation(s)
- Caryl Feldacker
- a International Training and Education Center for Health (I-TECH) , Seattle , WA , USA.,b Department of Global Health , University of Washington , Seattle , WA , USA
| | | | - Marrianne Holec
- a International Training and Education Center for Health (I-TECH) , Seattle , WA , USA
| | - Aaron F Bochner
- a International Training and Education Center for Health (I-TECH) , Seattle , WA , USA
| | - Abby Stepaniak
- a International Training and Education Center for Health (I-TECH) , Seattle , WA , USA
| | - Robert Nyanga
- a International Training and Education Center for Health (I-TECH) , Seattle , WA , USA
| | | | - Peter H Kilmarx
- e U.S. Centers for Disease Control and Prevention , Harare , Zimbabwe
| | - Amy Herman-Roloff
- e U.S. Centers for Disease Control and Prevention , Harare , Zimbabwe
| | - Taurayi Tafuma
- e U.S. Centers for Disease Control and Prevention , Harare , Zimbabwe
| | - Mufuta Tshimanga
- f Zimbabwe Community Health Intervention Project (ZiCHIRe) , Harare , Zimbabwe
| | | | - Scott Barnhart
- a International Training and Education Center for Health (I-TECH) , Seattle , WA , USA.,b Department of Global Health , University of Washington , Seattle , WA , USA.,h Department of Medicine , University of Washington , Seattle , WA , USA
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Lebina L, Milovanovic M, Otwombe K, Abraham P, Manentsa M, Nzenze S, Martinson N. PrePex circumcision surveillance: Adverse events and analgesia for device removal. PLoS One 2018; 13:e0194271. [PMID: 29579082 PMCID: PMC5868790 DOI: 10.1371/journal.pone.0194271] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 02/28/2018] [Indexed: 11/21/2022] Open
Abstract
Background The PrePex medical male circumcision (MMC) device is relatively easy to place and remove with some training. PrePex has been evaluated in several countries to assess feasibility and acceptability. However, several studies have reported pain associated with removal. Objective To assess safety of PrePex and whether analgesia administered prior to removal reduces pain experienced by participants. Methods A multi-site non-randomized, prospective cohort study in which adult (18–45 years old) males requesting PrePex device male circumcision, were enrolled in six South African clinics from July 2014 to March 2015. Participants were routinely provided with analgesia shortly after the surveillance commenced following a protocol review. Analgesia regimen for device removal depended on medication availability at clinics. Results Of 1023 enrolled participants who had PrePex placed, 98% (1004) had the device removed at a study clinic. Their median age was 25 (IQR: 21–30) years. HIV sero-positivity was 3.6% (37/1023). Nurses placed and removed half of all devices. Adverse events were experienced by 2.4% (25/1023) of participants; 15 required surgical intervention: device displacement (5/14), early removals (3/14), self-removals (5/14) and insufficient skin removed (2/14). Majority (792: 79%) of participants received analgesia. Most received either paracetamol-codeine (33%), lidocaine (29%) or EMLA and Oral Combination (28%). A lower proportion of participants who received any analgesia (except for lidocaine) prior to PrePex removal experienced severe pain compared to those who received no analgesia (16.6% vs. 29%: p = 0.0001). Conclusion Reported adverse events during this PrePex active surveillance were similar to previous reports and to those of surgical circumcision. Pain medication provided prior to removal is effective at decreasing severe pain during PrePex device removal.
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Affiliation(s)
- Limakatso Lebina
- Perinatal HIV Research Unit (PHRU), SA MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Minja Milovanovic
- Perinatal HIV Research Unit (PHRU), SA MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kennedy Otwombe
- Perinatal HIV Research Unit (PHRU), SA MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Pattamukkil Abraham
- Perinatal HIV Research Unit (PHRU), SA MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mmatsie Manentsa
- Perinatal HIV Research Unit (PHRU), SA MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Susan Nzenze
- Perinatal HIV Research Unit (PHRU), SA MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Neil Martinson
- Perinatal HIV Research Unit (PHRU), SA MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Center for TB Research, Johns Hopkins University, Baltimore, MD, United States of America
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Tshimanga M, Makunike-Chikwinya B, Mangwiro T, Tapiwa Gundidza P, Chatikobo P, Murenje V, Herman-Roloff A, Kilmarx PH, Holec M, Gwinji G, Mugurungi O, Murwira M, Xaba S, Barnhart S, Feldacker C. Safety and efficacy of the PrePex device in HIV-positive men: A single-arm study in Zimbabwe. PLoS One 2017; 12:e0189146. [PMID: 29220392 PMCID: PMC5722373 DOI: 10.1371/journal.pone.0189146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 11/17/2017] [Indexed: 11/21/2022] Open
Abstract
Male circumcision (MC) for sexually active, HIV-negative men reduces HIV transmission and averts HIV infections. Excluding HIV-positive men from MC decreases access to additional health and hygiene benefits. In settings where HIV-testing is, or is perceived to be, required for MC, testing may reduce MC uptake. Reducing promotion of HIV testing within MC settings and promoting device-based MC may speed MC scale-up. To assess safety and efficacy of PrePex MC device among HIV-positive men, we conducted a one-arm, open-label, prospective study in otherwise healthy HIV-positive men in Zimbabwe.
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Affiliation(s)
- Mufuta Tshimanga
- Zimbabwe Community Health Intervention Project (ZiCHIRe), Harare, Zimbabwe
| | | | | | | | - Pesanai Chatikobo
- Zimbabwe Community Health Intervention Project (ZiCHIRe), Harare, Zimbabwe
| | - Vernon Murenje
- International Training and Education Center for Health (I-TECH), Harare, Zimbabwe
| | | | - Peter H. Kilmarx
- U.S. Centers for Disease Control and Prevention, Harare, Zimbabwe
| | - Marrianne Holec
- International Training and Education Center for Health (I-TECH), Seattle, Washington, United States of America
| | | | | | | | | | - Scott Barnhart
- International Training and Education Center for Health (I-TECH), Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Caryl Feldacker
- International Training and Education Center for Health (I-TECH), Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- * E-mail:
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