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Building the capacity to Deliver Early Infant Male Circumcision

services in Rwanda: Lessons learnt

Presenter: Placidie Mugwaneza

Prevention Unit/HIV Division Rwanda Biomedical Center

Outline

§  Introduction

§  Objectives

§  Description

§  Lessons learnt, Conclusion and Recommendations

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§  Rwanda is a traditionally a non circumcising society §  The prevalence of MC is 13% while the HIV prevalence is

3% §  VMMC was integrated in the HIV prevention

interventions package since 2009 (2009-2012 National Strategic Plan)

§  National scale up started in 2010

Introduction Adult Male Circumcision (MC)

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Voluntary Medical Male Circumcision (VMMC)

§  Scale up of VMMC is through various approaches: v Service provision :

– Health facilities : Routine services and weekend campaigns

– Outreaches: Mass campaigns in collaboration with IPs

–  Combined method: Surgical and no surgical methods using prepex

device

v Quality services: –  Capacity building of Health care providers

– Mentorship and Supervision of health facilities

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As a result, majority of the males that received VMMC are aged between 15 and 24 years.

VMMC data July 2013- June 2014

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VMMC access to younger children is limited - HENCE the need for EIMC

   

Introduction to Early Infant Male Circumcision(EIMC)

§  EIMC is circumcision performed less than 60 days

following child birth (WHO).

§  EIMC was introduced in national HIV strategic plan in 2013

-2018 as is:

v a more sustainable strategy than adult MC

v  less expensive to perform than adult circumcision

v associated with fewer complications

v a simpler procedure for most health care workers to perform

after a short training

Goal and Objectives  

§  Goal – To implement EIMC services as a long term and sustainable strategy for male circumcision as a HIV prevention intervention

§  Objectives:

v  To assess the feasibility of implementing a safe EIMC program

v  To deliver EIMC services as a component of maternal

newborn and child health package of services v  Gather lessons to inform national roll out of EIMC

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§  EIMC Task Force (RBC, WHO, UNICEF, UNAIDS, CDC) established:

v  Review of VMMC KAP study on acceptability of parents for EIMC v  79% of men in the study would accept circumcision for their sons

§  Procurement of equipment and supplies:

v  50 Mogen clamps, v  10 circumstraints and basic surgical supplies

§  Selection of six District Hospitals based on their high number of deliveries to start in the 1st phase

v  Orientation of managers on EIMC program v  Facility readiness assessment was conducted

Implementation – How did we go about it

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Implementation cont’d §  After the orientation, the Hospital mangers:

v  Conducted awareness among the staff to educate parents with boys below 60 days on EIMC (Maternity & Immunization services)

v  Selected doctors and nurses for the first training session v  Experience in surgical procedure and working in maternity were criteria

for selection of the trainees

§  A collaborative agreement was established with Rwanda Surgical Society (RSS) to conduct training of health care workers

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How did we conduct the training §  Theoretical training:

v  Adaptation of WHO training manual for EIMC v  Inclusion of existing training tools ( pictures,.. ) v  The training was conducted by an experienced team of surgeons

( members of RSS) from King Faisal hospital, the only hospital in the country with capacity to offer EIMC service at a cost

–  Details on the anatomy of the penis was covered

–  Discussion on exclusion criteria from EIMC and different congenital

malformations previously noted among Rwanda infants were shown v  Introduction to EIMC device:

•  The theoretical component took a whole morning 11  

Training cont’d § Practical session

v  The component of the practical training took 2 days v  After training, trainees were mentors at their hospital for additional 2 days

§ Practical session during training: v  Demonstration of EIMC procedure using models:

-  Adult Penile models and condoms were used to demonstrate the technique for EIMC

-  Application of the local anaesthetize, freeing the foreskin from the glans and application of the Morgan clamp to excision

-  This component of the training took the whole afternoon.

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Training cont’d v  EIMC Practical session on babies: -  The 1st step was to observe surgeons performing 4 EIMC procedure

(setting of the tables, preparation of infants and performing circumcision)

-  The 2nd step was for the trainees to alternate in assisting the surgeons. (3 trainees were able to assist at a time as there were 3 surgeons while the others observed)

-  The 3rd step was for the trainees to perform the procedure under the assistance of the surgeon.

-  The 4th step was for the trainees to perform the procedure in pairs (one as a surgeon and the other as assistant) under the supervison of the surgeons.

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EIMC Results §  4 doctors and 4 nurses were trained on EIMC over three days and

were mentored for two days

§  Parents in maternity and immunization services were educated on risks and benefits of EIMC before they decided to circumcise their children

§  In total, 85 parents accepted circumcision for their infants v  37 infants were circumcised during the training period and 48 were

circumcised during mentorship

v  The average birth weight was 3.3 kilos and age was 41 days

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EIMC Results

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§  74 out 85 of all circumcised infants came for follow up: v  Physical examination of the penis was performed to assess quality of

circumcision v  History on adverse events and their management taken

v  Questionnaires on parent satisfaction with the procedure were completed

§  Trainees were asked to provide information on how the training was

organized and to propose areas of improvement

EIMC Results

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§  Findings on satisfaction: v  Most of parents were happy that their children were

circumcised §  Findings on adverse events:

v  Among all children circumcised no one developed infection

v  5/85 experienced bleeding (1 immediately and 4 within 48h) which were corrected by surgery

v  One infant experienced serious adverse event. A small piece of

the corpora cavernous of the glans was cut in the process

   

Management of Incident case §  Emergency care was done by the trainers on training site

§  The infant and the excised tissue of the glans were transferred to the plastic surgeon at the referral hospital for specialized care

§  The tissue was put in the normal saline and ice to keep frozen and

viable during the transport to referral hospital §  Follow up of infant was done in the hospital until successful healing

§  Following this incident, the trainings were temporally suspended and the EIMC TWG reviewed the whole training process and came up with recommendations for future trainings. 17  

Lessons learnt

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§  Integration of infant male circumcision in MNCH setting is feasible

§  Parents would prefer their infants to be circumcised at early age

§  It is important to involve both parents in education and procedure itself

§  Health workers with surgical experience and mentorship after training are key factors to minimize adverse events during EIMC

§  The Mogen Clamp does not allow pre-verification of the glans inside the foreskin before cutting and this may lead to accident

Conclusion and recommendations

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§  Meticulous preparations of program implementation is required for successful implementation of EIMC

v  Modify technique to visualize the glans before cutting v  Duration of training v  Selection of trainees (Surgical experience,…) v  Certification of trainees before doing EIMC independantly v  Material to be used v  Infant models for practices

§  Program should be prepared on potential adverse events for management in case they happen.

   

                           

                       THANK YOU

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