/ 6 May 2014

Quick expansion of medical circumcision brings challenges – study

As South Africa vastly expanded male medical circumcision services since 2010, surgical efficiency and record-keeping improved but the quality of surgical care, such as tracking complications, declined, a study released on Tuesday found.

The study, by the Centre for HIV and Aids Prevention Studies (Chaps) and the Johns Hopkins School of Public Health, was published in the open access journal of PLOS Medicine journal.

Researchers assessed 40 government medical male circumcision sites in six South African provinces in 2012, following a first assessment in 2011.

Previous studies have shown that medical male circumcision – the full removal of the foreskin of a penis – can reduce a heterosexual man’s risk of contracting HIV through sex by about 60%.

The national health department aims to medically circumcise 4.3-million men by 2016. Health department figures show about 1.3-million circumcisions have been performed since April 2010 and sites have expanded from one in 2010 to 80 in 2012.

According to World Health Organisation figures, South Africa has the fastest scale-up among African countries offering medical male circumcision services to prevent HIV.

Declines vs improvements 
But the PLOS study found that the scaleup of medical male circumcision services had “diluted human resources”, as experienced staff was redeployed to train staff in new clinics. “Declines in quality far outnumbered improvements,” study authors reported.

These included a quality decline in the monitoring of complications, post-operative counselling and some infection control issues, such as hand washing between clients, using sterile gloves and protective eyewear, disposal of medical waste and disinfection of surgical beds between clients.

“Medical male circumcision is a complex mass medical intervention involving many elements in the service chain,” co-author Dino Rech from the Chaps told Bhekisisa. “Initially South Africa’s focus was on making the surgery safe. It then shifted to post-operative care and counselling on which we’re still working.”

Rech pointed out that the quality of surgical care has started to improve since the collection of the study’s data. “Throughout the research period, we regularly met with the South African government to plug the gaps and found them to be open to improvement.”

On the plus side, South Africa has adopted three best practices for surgical efficiency – use of multiple surgical bays, electrocautery (the process of heating tissue with electricity to stop bleeding) instead of sutures, and ready-made kits with disposable instruments.

Manual or computerised record-keeping of circumcisions performed was also excellent but the South Africa system failed in tracking adverse events. 

According to the study, the rapid scaling up of medical male circumcision services should go hand in hand with a plan to maintain quality.

“We must ensure that the urgency of scaling up does not hinder the quality of existing services,” said Larissa Jennings, from the Johns Hopkins Bloomberg School of Public Health.