Rolling out male circumcision requires community engagement, task shifting and streamlined procedures

It’s feasible and safe for a team of five to circumcise ten men in an hour, researchers told the Eighteenth International AIDS Conference in Vienna on Tuesday. To achieve this, tasks are shared between doctors and nurses, and the procedures have been refined to use time as efficiently as possible.

The conference heard the experiences of people working in Orange Farm, South Africa (where the first randomised controlled trial demonstrating circumcision’s impact on HIV infection was carried out); Kenya (including the city of Kisumu, where a circumcision trial took place); and in Zimbabwe.

Speakers from Orange Farm and Kenya emphasised the importance of community engagement and communication. Much of this had already begun as part of the research trials, but roll-out in Orange Farm has been supported by visits to each household in the area, radio shows, and separate meetings for men and women. In the Kenyan experience, women play an influential role in men’s decisions about circumcision and should be a priority audience for communications.

Teenagers have been much keener to take up the offer than men over the age of 25

Kenya has rolled circumcision out nationally (the largest programme in Africa), requiring engagement with a large number of political, community and social leaders. There has been high-level political support and the involvement of a wide range of government departments and professional bodies.

The Kenyan programme aims to achieve significant population coverage quickly in order to reduce HIV incidence. Starting in October 2008, over 130,000 have been circumcised, with the aim of reaching 860,000 by 2013. Teenagers have been much keener to take up the offer than men over the age of 25.

Circumcision is not a national priority for South Africa, but the clinic in the township of Orange Farm offers free medical circumcision to all male residents aged 15 or over. Between January 2008 and November 2009, 14,011 men took up the offer, which is equivalent to 39% of men in the community.

There were no permanent injuries or deaths, but 1.8% had some adverse events (for example, bleeding). A satisfaction survey of over 1000 men found that 92% rated the service as good or very good.

Although the researchers say that up to 150 men can be circumcised in a day, the monthly average is in fact 740. These high rates were achieved by working in three teams, each composed of one medical circumciser and five nurses.

The practical details of this kind of team working were described in more detail by Karin Hatzold, based on her experience in Zimbabwe. The goal there is to circumcise 80% of men aged 15 to 29 – in other words, 1.3 million men.

In an open-plan operating room, divided by curtains, a team of five works on the circumcisions of four men at a time. This reduces idle time between procedures (for example, while the local anaesthetic is taking effect) and allows staff to move quickly from one patient to another and communicate easily with each other.

As many tasks as possible are delegated to nurses. However, under Zimbabwean law the circumcision itself must be performed by a doctor, so the team is made up of two doctors and three nurses.

The forceps-guided method is used, which the researchers say is the quickest and easiest to learn and use. Wounds are sealed with diathermy (a procedure using electrical heat) rather than stitches. Most of the equipment used is disposable.

One team can now perform between eight and ten circumcisions an hour, rather than one or two before the new systems were introduced. The time the doctor spends on a man has reduced from 25 to 30 minutes to 7 to 10 minutes.

Hatzold was asked if there are any downsides to these procedures. She said that the number of side effects has not increased. On the other hand, the work can be tiring and repetitive. Moreover, to return to the issue of community engagement, the system can only work efficiently if there are enough men who want to be circumcised.

Cherutich P et al. Rollout of voluntary medical male circumcision for HIV prevention in Kenya: two years and counting. Eighteenth International AIDS Conference, abstract TUPDC204, Vienna, 2010.

Auvert B et al. A model for the roll-out of comprehensive adult male circumcision services in African low-income settings of high HIV incidence: the Bophelo Pele project (ANRS-12126). Eighteenth International AIDS Conference, abstract TUPDC206, Vienna, 2010.

Hatzold K et al. Models to increase volumes and efficiency (MOVE) in Zimbabwe's male circumcision program. Eighteenth International AIDS Conference, abstract TUPDC203, Vienna, 2010.

Presentations by the speakers and their related abstracts are available on the official conference website.