XIX International AIDS Conference

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MOPDE0103 - Poster Discussion Session


Implementation of VMMC efficiency elements in four sub-Saharan countries: service delivery methods and provider attitudes

Presented by Jane Bertrand (United States).

J. Bertrand1, D. Rech2, E. Njeuhmeli3, D. Castor3, S. Frade2, M. Loolpapit4, M. Machaku5, W. Mavhu6, L. Perry1


1Tulane School of Public Health and Tropical Medicine, Tulane SPHTM, New Orleans, United States, 2CHAPS, Johannesburg, South Africa, 3USAID, Washington, United States, 4FHI360/Kenya, Nairobi, Kenya, 5Jhpiego/Tanzania, Dar es Salaam, United Republic of Tanzania, 6ZAPP, Harare, Zimbabwe

Background: The Systematic Monitoring of the Male Circumcision Scale-up (SYMMACS) is designed to track voluntary male circumcision (VMMC) service delivery in Kenya, South Africa, Tanzania, and Zimbabwe. The study measured adoption of six elements to increase efficiency in the delivery of clinical VMMC services, including:
  • Surgical method
  • Task shifting (allowing non-physicians to perform VMMC)
  • Task-sharing (allowing non-physicians to conduct aspects of VMMC)
  • Rotation among multiple bays in the operating theater
  • Bundling of supplies and tools
  • Use of electrocautery instead of ligating sutures

Methods: Data collection took place at 14-30 VMMC sites per country (73 sites total) from April-December 2011. It included observation of the clinical facilities, observation of VMMC procedures, interviews with VMMC providers and the in-charge officer, and compilation of service statistics.
Results: The results are useful for monitoring service delivery in each country and conducting cross country comparisons. The data shows considerable variation by country on 5 of the 6 elements, the exception being nearly universal use of the forceps-guided method (see table 1). The study revealed stark differences on task-shifting, both in terms of actual practice and provider attitudes toward it. For example, in Zimbabwe, while no providers report using task-shifting, 86.5% say they would implement the practice given the choice. Countries also differed in the use of multiple beds per provider (rotation) during VMMC, with100% of providers in Zimbabwe reported using multiple beds, compared to 38% percent in Kenya, reflecting a different service delivery model. Provider reported use of electrocautery ranged from 5.4% in Tanzania to 88.6% in South Africa.

If given the choice, providers reported that they would apply the following efficiency measures at their MC clinic:Kenya (n=85)South Africa (n=95)Tanzania (n=93)Zimbabwe (n=74)
 Already do (%)Yes (%)Already do (%)Yes (%)Already do (%)Yes (%)Already do (%)Yes (%)
1. Multiple beds per provider36.727.182.914.373.125.8100.00.0
2. Bundled surgical supplies (purchased as a kit)0.040.088.69.524.732.3100.00.0
Bundling of surgical instruments and supplies by clinic staff97.60.07.619.073.120.40.09.5
3. Task shifting : allowing adequately trained nurses and or clinical officers to perform the entire MC procedure98.81.213.357.173.124.70.086.5
4. Task sharing: allowing secondary providers to administer local anesthesia38.821.285.713.373.123.768.927.0
Task sharing : allowing secondary providers to complete interrupted sutures41.217.681.916.273.123.759.532.4
5. Use of forceps guided surgical method100.00.091.48.674.224.798.61.4
6. Electrocautery/diathermy14.141.288.611.45.415.178.416.2
[Implementation of efficiency measures in VMMC: act]


Conclusions: The decision to adopt these elements is generally based on national policies. However, the review of these practices across four countries demonstrates alternative methods of service delivery, and is intended to incite potential changes to these policies in the name of increasing efficiency.

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