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Elkins C, Kokera S, Vumbugwa P, Gavhera J, West KM, Wilson K, Makunike-Chikwinya B, Masimba L, Holec M, Barnhart S, Matinu S, Wassuna B, Feldacker C. "Endless opportunities": A qualitative exploration of facilitators and barriers to scale-up of two-way texting follow-up after voluntary medical male circumcision in Zimbabwe. PLoS One 2024; 19:e0296570. [PMID: 38728277 PMCID: PMC11086850 DOI: 10.1371/journal.pone.0296570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 04/23/2024] [Indexed: 05/12/2024] Open
Abstract
In Zimbabwe, the ZAZIC consortium employs two-way, text-based (2wT) follow-up to strengthen post-operative care for voluntary medical male circumcision (VMMC). 2wT scaled nationally with evidence of client support and strengthened follow-up. However, 2wT uptake among healthcare providers remains suboptimal. Understanding the gap between mobile health (mHealth) potential for innovation expansion and scale-up realization is critical for 2wT and other mHealth innovations. Therefore, we conducted an exploratory qualitative study with the objective of identifying 2wT program strengths, challenges, and suggestions for scale up as part of routine VMMC services. A total of 16 in-depth interviews (IDIs) with diverse 2wT stakeholders were conducted, including nurses, monitoring & evaluation teams, and technology partners-a combination of perspectives that provide new insights. We used both inductive and deductive coding for thematic analysis. Among 2wT drivers of expansion success, interviewees noted: 2wT care benefits for clients; effective hands-on 2wT training; ease of app use for providers; 2wT saved time and money; and 2wT strengthened client/provider interaction. For 2wT scale-up challenges, staff shortages; network infrastructure constraints; client costs; duplication of paper and electronic reporting; and complexity of digital tools integration. To improve 2wT robustness, respondents suggested: more staff training to offset turnover; making 2wT free for clients; using 2wT to replace paper VMMC reporting; integrating with routine VMMC reporting systems; and expanding 2wT to other health areas. High stakeholder participation in app design, implementation strengthening, and evaluation were appreciated. Several 2wT improvements stemmed from this study, including enrollment of multiple people on one number to account for phone sharing; 2wT inclusion of minors ages 15+; clients provided with $1 to offset SMS costs; and reduced SMS messages to clients. Continued 2wT mentoring for staff, harmonization of 2wT with Ministry e-health data systems, and increased awareness of 2wT's client and provider benefits will help ensure successful 2wT scale-up.
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Affiliation(s)
- Chelsea Elkins
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Sandra Kokera
- Zimbabwe Technical Training and Education Centre for Health (Zim-TTECH), Harare, Zimbabwe
| | - Phiona Vumbugwa
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Zimbabwe Technical Training and Education Centre for Health (Zim-TTECH), Harare, Zimbabwe
| | - Jacqueline Gavhera
- Zimbabwe Technical Training and Education Centre for Health (Zim-TTECH), Harare, Zimbabwe
| | - Kathleen M. West
- Health Systems & Population Health, University of Washington, Seattle, Washington, United States of America
| | - Katherine Wilson
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, International Training and Education Center for Health, University of Washington, Seattle, Washington, United States of America
| | | | - Lewis Masimba
- Zimbabwe Technical Training and Education Centre for Health (Zim-TTECH), Harare, Zimbabwe
| | - Marrianne Holec
- Department of Global Health, International Training and Education Center for Health, University of Washington, Seattle, Washington, United States of America
| | - Scott Barnhart
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, International Training and Education Center for Health, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Sulemana Matinu
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | | | - Caryl Feldacker
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, International Training and Education Center for Health, University of Washington, Seattle, Washington, United States of America
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Su Y, Mukora R, Ndebele F, Pienaar J, Khumalo C, Xu X, Tweya H, Sardini M, Day S, Sherr K, Setswe G, Feldacker C. Cost savings in male circumcision post-operative care using two-way text-based follow-up in rural and urban South Africa. PLoS One 2023; 18:e0294449. [PMID: 37972009 PMCID: PMC10653449 DOI: 10.1371/journal.pone.0294449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023] Open
Abstract
INTRODUCTION Voluntary medical male circumcision (VMMC) clients are required to attend multiple post-operative follow-up visits in South Africa. However, with demonstrated VMMC safety, stretched clinic staff in SA may conduct more than 400,000 unnecessary reviews for males without complications, annually. Embedded into a randomized controlled trial (RCT) to test safety of two-way, text-based (2wT) follow-up as compared to routine in-person visits among adult clients, the objective of this study was to compare 2wT and routine post-VMMC care costs in rural and urban South African settings. METHODS Activity-based costing (ABC) estimated the costs of post-VMMC care, including counselling, follow-ups, and tracing in $US dollars. Transportation for VMMC and follow-up was provided for rural clients in outreach settings but not for urban clients in static sites. Data were collected from National Department of Health VMMC forms, RCT databases, and time-and-motion surveys. Sensitivity analysis presents different follow-up scenarios. We hypothesized that 2wT would save per-client costs overall, with higher savings in rural settings. RESULTS VMMC program costs were estimated from 1,084 RCT clients: 537 in routine care and 547 in 2wT. On average, 2wT saved $3.56 per client as compared to routine care. By location, 2wT saved $7.73 per rural client and increased urban costs by $0.59 per client. 2wT would save $2.16 and $7.02 in follow-up program costs if men attended one or two post-VMMC visits, respectively. CONCLUSION Quality 2wT follow-up care reduces overall post-VMMC care costs by supporting most men to heal at home while triaging clients with potential complications to timely, in-person care. 2wT saves more in rural areas where 2wT offsets transportation costs. Minimal additional 2wT costs in urban areas reflect high care quality and client engagement, a worthy investment for improved VMMC service delivery. 2wT scale-up in South Africa could significantly reduce overall VMMC costs while maintaining service quality.
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Affiliation(s)
- Yanfang Su
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | | | | | - Jacqueline Pienaar
- The Aurum Institute, Johannesburg, South Africa
- Centre for HIV-AIDS Prevention Studies (CHAPS), Johannesburg, South Africa
| | | | - Xinpeng Xu
- School of Public Health, Nanjing Medical University, Nanjing, China
| | - Hannock Tweya
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
| | - Maria Sardini
- Centre for HIV-AIDS Prevention Studies (CHAPS), Johannesburg, South Africa
| | - Sarah Day
- Centre for HIV-AIDS Prevention Studies (CHAPS), Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Geoffrey Setswe
- The Aurum Institute, Johannesburg, South Africa
- Department of Health Studies, University of South Africa (UNISA), Pretoria, South Africa
| | - Caryl Feldacker
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
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Su Y, Mukora R, Ndebele F, Pienaar J, Khumalo C, Xu X, Tweya H, Sardini M, Day S, Sherr K, Setswe G, Feldacker C. Cost savings in male circumcision post-operative care using two-way text-based follow-up in rural and urban South Africa. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.02.08.23284877. [PMID: 36798405 PMCID: PMC9934777 DOI: 10.1101/2023.02.08.23284877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Introduction Voluntary medical male circumcision (VMMC) clients are required to attend multiple post-operative follow-up visits in South Africa. However, with demonstrated VMMC safety, stretched clinic staff in SA may conduct more than 400,000 unnecessary reviews for males without complications, annually. Embedded into a randomized controlled trial (RCT) to test safety of two-way, text-based (2wT) follow-up as compared to routine in-person visits among adult clients, the objective of this study was to compare 2wT and routine post-VMMC care costs in rural and urban South African settings. Methods Activity-based costing (ABC) estimated the costs of post-VMMC care, including counselling, follow-ups, and tracing in $US dollars. Transportation for VMMC and follow-up was provided for rural clients in outreach settings but not for urban clients in static sites. Data were collected from National Department of Health VMMC forms, RCT databases, and time-and-motion surveys. Sensitivity analysis presents different follow-up scenarios. We hypothesized that 2wT would save per-client costs overall, with higher savings in rural settings. Results VMMC program costs were estimated from 1,084 RCT clients: 537 in routine care and 547 in 2wT. On average, 2wT saved $3.56 per client as compared to routine care. By location, 2wT saved $7.73 per rural client and increased urban costs by $0.59 per client. 2wT would save $2.16 and $7.02 in follow-up program costs if men attended one or two post-VMMC visits, respectively. Conclusion Quality 2wT follow-up care reduces overall post-VMMC care costs by supporting most men to heal at home while triaging clients with potential complications to timely, in-person care. 2wT saves more in rural areas where 2wT offsets transportation costs. Minimal additional 2wT costs in urban areas reflect high care quality and client engagement, a worthy investment for improved VMMC service delivery. 2wT scale-up in South Africa could significantly reduce overall VMMC costs while maintaining service quality.
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Affiliation(s)
- Yanfang Su
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | | | - Jacqueline Pienaar
- The Aurum Institute, Johannesburg, South Africa
- Centre for HIV-AIDS Prevention Studies (CHAPS), Johannesburg, South Africa
| | | | - Xinpeng Xu
- School of Public Health, Nanjing Medical University, Nanjing, China
| | - Hannock Tweya
- Department of Global Health, University of Washington, Seattle, WA, USA
- International Training and Education Center for Health (I-TECH), Seattle, WA, USA
| | - Maria Sardini
- Centre for HIV-AIDS Prevention Studies (CHAPS), Johannesburg, South Africa
| | - Sarah Day
- Centre for HIV-AIDS Prevention Studies (CHAPS), Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Geoffrey Setswe
- The Aurum Institute, Johannesburg, South Africa
- Department of Health Studies, University of South Africa (UNISA), Pretoria, South Africa
| | - 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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O'Bryan G, Ensminger A, Billah I, Sithole E, Nghatanga M, Brandt L, Shepard M, Aupokolo M, Mengistu AT, Forster N, Zemburuka B, Mutandi G, Barnhart S, O'Malley G, Feldacker C. Implementing quality management strategies improves clinical quality as a voluntary medical male circumcision program in Namibia matures: a process analysis. BMC Health Serv Res 2023; 23:1044. [PMID: 37773121 PMCID: PMC10543846 DOI: 10.1186/s12913-023-10016-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 09/11/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND Surgical voluntary medical male circumcision (VMMC) is a safe procedure; however, maintaining quality standards at scale, particularly during scale-up, is a challenge making ongoing quality management (QM) efforts essential. This study describes program quality measured by rates of adverse events (AEs) over four years of VMMC implementation in Namibia, compares AE rates over time, and discusses QM processes that contextualize AE trends and illustrate improvements in quality as the program matured. The International Training and Education Center for Health (I-TECH) assisted the Namibian Ministry of Health and Social Services (MoHSS) in expanding VMMC in three regions among boys and men over 10 years of age between January 2015 and September 2019. METHODS A comprehensive package of QM strategies was implemented by multi-disciplinary onsite teams with support from national and international technical advisors. Retrospective routine MoHSS data from the VMMC register, client forms, and monthly AE reports were collected during implementation in the three regions to assess the impact of QM interventions on AEs and to calculate the proportion of clients who experienced AEs over time. The proportion of clients who experienced an AE over time was compared using a Cochran-Armitage test for trend. RESULTS Between January 2015 and September 2019, 40,336 clients underwent VMMC and 593 (1.5%) clients experienced a post-operative AE in the three supported regions. The AE rate was highest in the first quarter of clinical service delivery in each region (January-March 2015 in Oshana and Zambezi, October-December 2017 in //Kharas) but declined over the implementation period as the program matured. This observed trend between program maturity and declining AE rates over time was significant (p < 0.001) when compared using a Cochran-Armitage test for trend. CONCLUSIONS As the I-TECH-supported VMMC program matured, QM measures were introduced and routinized, and clinical quality improved over time with the rate of AEs decreasing significantly over the implementation period. Applying systematic and continuous QM processes and approaches across the continuum of VMMC services and considering local context can contribute to increased clinical safety. QM measures that are established in more mature program sites can be quickly adopted to respond to quality issues in program expansion sites.
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Affiliation(s)
- Gillian O'Bryan
- International Training and Education Center for Health (I-TECH), Seattle, WA, USA.
- Department of Global Health, University of Washington, Seattle, WA, USA.
| | - Alison Ensminger
- International Training and Education Center for Health (I-TECH), Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Idel Billah
- International Training and Education Center for Health (I-TECH), Windhoek, Namibia
| | - Edwin Sithole
- Centers for Disease Control and Prevention (CDC/DDPHSIS/CGH/DGHT), Windhoek, Namibia
| | - Magdaleena Nghatanga
- International Training and Education Center for Health (I-TECH), Windhoek, Namibia
| | - Laura Brandt
- Department of Global Health, University of Washington, Seattle, WA, USA
- International Training and Education Center for Health (I-TECH), Windhoek, Namibia
| | - Mark Shepard
- Department of Global Health, University of Washington, Seattle, WA, USA
- International Training and Education Center for Health (I-TECH), Windhoek, Namibia
| | - Mekondjo Aupokolo
- Directorate of Special Programmes-Ministry of Health and Social Services, Windhoek, Namibia
| | | | - Norbert Forster
- Department of Global Health, University of Washington, Seattle, WA, USA
- International Training and Education Center for Health (I-TECH), Windhoek, Namibia
| | - Brigitte Zemburuka
- Centers for Disease Control and Prevention (CDC/DDPHSIS/CGH/DGHT), Windhoek, Namibia
| | - Gram Mutandi
- Centers for Disease Control and Prevention (CDC/DDPHSIS/CGH/DGHT), Windhoek, Namibia
| | - Scott Barnhart
- International Training and Education Center for Health (I-TECH), Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Gabrielle O'Malley
- International Training and Education Center for Health (I-TECH), Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Caryl Feldacker
- International Training and Education Center for Health (I-TECH), Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
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Feldacker C, Pienaar J, Wasunna B, Ndebele F, Khumalo C, Day S, Tweya H, Oni F, Sardini M, Adhikary B, Waweru E, Wafula MB, Dixon A, Jafa K, Su Y, Sherr K, Setswe G. Expanding the Evidence on the Safety and Efficiency of 2-Way Text Messaging-Based Telehealth for Voluntary Medical Male Circumcision Follow-up Compared With In-Person Reviews: Randomized Controlled Trial in Rural and Urban South Africa. J Med Internet Res 2023; 25:e42111. [PMID: 37159245 DOI: 10.2196/42111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 12/22/2022] [Accepted: 02/24/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND There is a dearth of high-quality evidence from digital health interventions in routine program settings in low- and middle-income countries. We previously conducted a randomized controlled trial (RCT) in Zimbabwe, demonstrating that 2-way texting (2wT) was safe and effective for follow-up after adult voluntary medical male circumcision (VMMC). OBJECTIVE To demonstrate the replicability of 2wT, we conducted a larger RCT in both urban and rural VMMC settings in South Africa to determine whether 2wT improves adverse event (AE) ascertainment and, therefore, the quality of follow-up after VMMC while reducing health care workers' workload. METHODS A prospective, unblinded, noninferiority RCT was conducted among adult participants who underwent VMMC with cell phones randomized in a 1:1 ratio between 2wT and control (routine care) in North West and Gauteng provinces. The 2wT participants responded to a daily SMS text message with in-person follow-up only if desired or an AE was suspected. The control group was requested to make in-person visits on postoperative days 2 and 7 as per national VMMC guidelines. All participants were asked to return on postoperative day 14 for study-specific review. Safety (cumulative AEs ≤day 14 visit) and workload (number of in-person follow-up visits) were compared. Differences in cumulative AEs were calculated between groups. Noninferiority was prespecified with a margin of -0.25%. The Manning score method was used to calculate 95% CIs. RESULTS The study was conducted between June 7, 2021, and February 21, 2022. In total, 1084 men were enrolled (2wT: n=547, 50.5%, control: n=537, 49.5%), with near-equal proportions of rural and urban participants. Cumulative AEs were identified in 2.3% (95% CI 1.3-4.1) of 2wT participants and 1.0% (95% CI 0.4-2.3) of control participants, demonstrating noninferiority (1-sided 95% CI -0.09 to ∞). Among the 2wT participants, 11 AEs (9 moderate and 2 severe) were identified, compared with 5 AEs (all moderate) among the control participants-a nonsignificant difference in AE rates (P=.13). The 2wT participants attended 0.22 visits, and the control participants attended 1.34 visits-a significant reduction in follow-up visit workload (P<.001). The 2wT approach reduced unnecessary postoperative visits by 84.8%. Daily response rates ranged from 86% on day 3 to 74% on day 13. Among the 2wT participants, 94% (514/547) responded to ≥1 daily SMS text messages over 13 days. CONCLUSIONS Across rural and urban contexts in South Africa, 2wT was noninferior to routine in-person visits for AE ascertainment, demonstrating 2wT safety. The 2wT approach also significantly reduced the follow-up visit workload, improving efficiency. These results strongly suggest that 2wT provides quality VMMC follow-up and should be adopted at scale. Adaptation of the 2wT telehealth approach to other acute follow-up care contexts could extend these gains beyond VMMC. TRIAL REGISTRATION ClinicalTrials.gov NCT04327271; https://www.clinicaltrials.gov/ct2/show/NCT04327271.
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Affiliation(s)
- Caryl Feldacker
- Department of Global Health, University of Washington, Seattle, WA, United States
- International Training and Education Center for Health, Department of Global Health, University of Washington, Seattle, WA, United States
| | | | | | | | | | - Sarah Day
- Centre for HIV-AIDS Prevention Studies (CHAPS), Johannesburg, South Africa
- Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Hannock Tweya
- Department of Global Health, University of Washington, Seattle, WA, United States
| | | | | | | | | | | | | | | | - Yanfang Su
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Geoffrey Setswe
- Aurum Institute, Johannesburg, South Africa
- Department of Health Studies, University of South Africa (UNISA), Pretoria, South Africa
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Bershteyn A, Mudimu E, Platais I, Mwalili S, Zulu JE, Mwanza WN, Kripke K. Understanding the Evolving Role of Voluntary Medical Male Circumcision as a Public Health Strategy in Eastern and Southern Africa: Opportunities and Challenges. Curr HIV/AIDS Rep 2022; 19:526-536. [PMID: 36459306 PMCID: PMC9759505 DOI: 10.1007/s11904-022-00639-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 12/05/2022]
Abstract
PURPOSE OF REVIEW Voluntary male medical circumcision (VMMC) has been a cornerstone of HIV prevention in Eastern and Southern Africa (ESA) and is credited in part for declines in HIV incidence seen in recent years. However, these HIV incidence declines change VMMC cost-effectiveness and how it varies across populations. RECENT FINDINGS Mathematical models project continued cost-effectiveness of VMMC in much of ESA despite HIV incidence declines. A key data gap is how demand generation cost differs across age groups and over time as VMMC coverage increases. Additionally, VMMC models usually neglect non-HIV effects of VMMC, such as prevention of other sexually transmitted infections and medical adverse events. While small compared to HIV effects in the short term, these could become important as HIV incidence declines. Evidence to date supports prioritizing VMMC in ESA despite falling HIV incidence. Updated modeling methodologies will become necessary if HIV incidence reaches low levels.
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Affiliation(s)
- Anna Bershteyn
- Department of Population Health, New York University Grossman School of Medicine, 227 East 30th Street, New York, NY 10016 USA
| | - Edinah Mudimu
- Department of Decision Sciences, College of Economic and Management Sciences, University of South Africa, Pretoria, Gauteng South Africa
| | - Ingrida Platais
- Department of Population Health, New York University Grossman School of Medicine, 227 East 30th Street, New York, NY 10016 USA
| | - Samuel Mwalili
- Strathmore Institute of Mathematical Sciences, Strathmore University, Nairobi, Kenya
| | - James E. Zulu
- Zambia Field Epidemiology Training Program, Workforce Development Cluster, Zambia National Public Health Institute, Lusaka, Zambia
| | - Wiza N. Mwanza
- Directorate of Public Health and Research, Ministry of Health, Lusaka, Zambia
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Lucas T, Cooney C, Prainito A, Godfrey C, Kiggundu V, Thomas AG, Ridzon R, Toledo C. Consolidated Overview of Notifiable Adverse Events in the U.S. President's Emergency Plan for AIDS Relief's Voluntary Medical Male Circumcision Program Through 2020. Curr HIV/AIDS Rep 2022; 19:508-515. [PMID: 36348185 PMCID: PMC9643893 DOI: 10.1007/s11904-022-00636-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2022] [Indexed: 11/11/2022]
Abstract
PURPOSE OF REVIEW Through December 2020, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) supported more than 25 million voluntary medical male circumcisions (VMMC) as part of the combined HIV prevention strategy in 15 African countries. PEPFAR monitors defined adverse events (AEs) occurring within 30 days of VMMC through its notifiable adverse event reporting system (NAERS). All NAERS reports through December 2020 were reviewed to quantify AE type, severity, and relation to the VMMC procedure. Interventions to improve client safety based on NAERS findings are described. RECENT FINDINGS Fourteen countries reported 446 clients with notifiable adverse events (NAEs); 394/446 (88%) were determined VMMC-related, representing approximately 18 NAE reports per million circumcisions. Fatalities comprised 56/446 (13%) with 24/56 (43%) of fatalities determined VMMC-related, representing 0.96 VMMC-related fatalities per million circumcisions. The remaining 390 NAEs were non-fatal with 370/390 (95%) VMMC-related. Multiple programmatic changes have been made based on NAERS data to improve client safety. Client safety is paramount in this surgical program designed for individual and population-level benefit. Surveillance of rare but severe complications following circumcision has identified pre-existing or new safety concerns and guided continuous programmatic improvement.
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Affiliation(s)
- Todd Lucas
- U.S. Centers for Disease Control and Prevention, Division of Global HIV and TB, HIV Prevention Branch, Atlanta, GA, USA.
| | - Caroline Cooney
- U.S. Department of State, Office of the U.S. Global AIDS Coordinator and Health Diplomacy, Washington, DC, USA
| | - Amber Prainito
- U.S. Department of State, Office of the U.S. Global AIDS Coordinator and Health Diplomacy, Washington, DC, USA
| | - Catherine Godfrey
- U.S. Department of State, Office of the U.S. Global AIDS Coordinator and Health Diplomacy, Washington, DC, USA
| | - Valerian Kiggundu
- U.S. Agency for International Development, Global Health, Office of HIV/AIDS, Washington, DC, USA
| | - Anne Goldzier Thomas
- U.S. Department of Defense HIV/AIDS Prevention Program, Defense Health Agency, San Diego, CA, USA
| | - Renee Ridzon
- U.S. Department of State, Office of the U.S. Global AIDS Coordinator and Health Diplomacy, Washington, DC, USA
| | - Carlos Toledo
- U.S. Centers for Disease Control and Prevention, Division of Global HIV and TB, HIV Prevention Branch, Atlanta, GA, USA
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