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Title
Switching from the forceps-guided to the dorsal slit technique in a Voluntary Medical Male Circumcision (VMMC) program: Experience from Tanzania
Presenter
Augustino Hellar
Authors
A. Hellar1, A. Christensen1, J. Reed2, A. Kapula1, S. Mkungume1, M. Machaku1, K. Curran2, P. Luvanda3, G. Lija4, E. Mlanga5
Institutions
1Jhpiego, AIDSFree/VMMC, Dar es Salaam, Tanzania, United Republic of, 2Jhpiego, HIV ID Unit, Washington DC, United States, 3President's Office Regional Authority and Local Goverment, Iringa RHMT, Iringa, Tanzania, United Republic of, 4Ministry of Health Community Development Gender Elderly and Children, National AIDS Control Program (NACP), Dar es Salaam, Tanzania, United Republic of, 5USAID, USAID/Tanzania, Dar es Salaam, Tanzania, United Republic of

Background: Prior to 2014, forceps-guided (FG) technique was the main method used in the scale-up of VMMC due to its time efficiency compared to sleeve resection (SR) or dorsal slit (DS) circumcision techniques. In July 2014, WHO recommended discontinuation of the FG technique among young adolescents due to an associated inherent risk of glans injury. Beginning in August 2014, the Strengthening High Impact Interventions for an AIDS-Free Generation (AIDSFree) Project, funded by PEPFAR and USAID, stopped using FG among those under 15 years and gradually phased out the FG technique among all VMMC clients. This action necessitated refresher training for all VMMC providers to ensure they had adequate skills to perform DS or SR techniques. We analyzed the impact of this change on client numbers and trends in reported adverse events (AEs).
Methods: De-identified VMMC client-level data were examined from October 2013 until September 2016. We analyzed the data according to the circumcision technique performed by age group each fiscal year and any adverse events during or following the procedure.
Results: There was a progressive switch to the DS technique, with a gradually higher proportion of clients circumcised by the DS technique at the end of fiscal year 2016 (Table 1). While FG was the most common technique used earlier in the program, DS became the method of choice for those under 15 beginning in 2014-2015, and the most frequently performed technique among all clients in 2015-2016. The moderate and severe AE rate per 100,000 procedures also declined across the analysis period from 5.3 in 2013-2014, 2 in 2014-2015, and 1.3 in 2015-2016. There were 2, 1, and zero instances of glans injuries in 2013-2014, 2014-2015, and 2015-2016, respectively.

Table 1: Analysis of VMMC techniques by Client Age from October 2013 to September 2016 in Tanzania
[Table 1: Analysis of VMMC techniques by Client Age from October 2013 to September 2016 in Tanzania]


Conclusions: The VMMC program in Tanzania has successfully transitioned from using the FG to the DS circumcision technique since the 2014 WHO recommendations. The data demonstrate that, with proper training, it is possible to completely change the surgical technique to enhance safety of the VMMC procedure. The reported number of AEs continued to decline over time, demonstrating increasing safety and quality of VMMC services.

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