Medical male circumcision for HIV prevention in Kenya:
a study of service provision and adverse events
A. Herman-Roloff1,2, R. Bailey2, K. Agot3, J. Ndinya-Achola4
1Nyanza Reproductive Health Society, Kisumu, Kenya, 2University of Illinois at Chicago, Chicago, United States, 3Impact Research and Development Organization, Kisumu, Kenya, 4University of Nairobi, Nairobi, Kenya
The Male Circumcision Consortium (MCC) is supporting the Government of Kenya (GoK) to provide medical male circumcision (MMC) in Kenya. Monitoring and evaluation (M&E) is essential to assess service provision.
The M&E system, comprised of clinic-based system and a home-based system, was implemented in 16 GoK facilities to monitor clients from pre-procedure through 40-days post-MMC. Males, aged ≥ 12 years, who are circumcised at a study facility, are eligible to enroll.
3,003 of 3,205 MMC clients enrolled in the study. GoK staff provided 11.8% of the 2,675 MMC procedures; a clinician provided 70.8%. 52.3% of clients returned for a follow-up visit a mean of 8.1 days post-MMC. The clinic-based adverse event (AE) rate was 2.7%. 1,050 clients were interviewed for the home-based system a mean of 36.1 days post-MMC. An examination revealed 9.5% had too little foreskin removed and 11.0% were not healed. 30.9% initiated sexual activity before abstaining for six weeks. 152 clients (14.5%) reported an AE. 90 clients (8.6%) were treated for an AE at a health facility. MMCs provided by GoK staff were more likely to result in an AE than procedures provided by MCC staff (OR=3.4, 2.0-5.9). MMCs performed by clinicians reduced the odds of developing an AE compared to MMCs provided by nurses (OR = 0.6, 0.4-0.9). Frequent bathing was protective against AE development (OR=0.2, 0.0-1.0).
Further exploration of AE rates and ascertainment (e.g., observation versus client report) is needed. Evaluation of clinical technique is advised to reduce AE incidence and to ensure the correct amount of foreskin is removed. Counseling should include female partners and recommend frequent bathing. Research has indicated that performing 100 MMCs is necessary for expertise; this analysis may suggest that nurses and GoK staff have not yet reached this level. Methods to increase capacity among these providers should be explored.
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