Jhpiego Collaboration on Voluntary Medical Male Circumcision Offers Innovative Response to Health Care Worker Shortage in Mozambique

By Mehebub Kassim Mahomed and Edgar Necochea

Maputo,Mozambique—Health facilities are successfully integrating voluntary medical male circumcision into their minor surgery work as part of a Jhpiego-supported initiative. This partnership is leading to a steady increase in use of this HIV prevention practice, with more than 22,000 men circumcised.

Facing an acute shortage of health care workers in the country, the Mozambique Ministry of Health (MOH) requested Jhpiego’s support to explore an integrated approach that would strengthen minor surgical services, including the provision of medical male circumcision. This approach would capitalize upon the skills of trained personnel (mainly nurses) who are already performing minor surgical procedures. The U.S. Centers for Disease Control and Prevention funded this innovative, collaborative effort that focused on building the capacity of health care workers to provide male circumcision (MC) as part of their health services.

Throughout the 21-month partnership, nurses performed 80 percent of the procedures in seven health facilities. Young men, ages 15‒19, represented about a third of the 22,479 clients who opted for voluntary medical male circumcision. Men who ranged in age from 20‒34—a clientele often more difficult to reach – represented 28.4 percent, an exceedingly successful outcome.

An overwhelming 94 percent of clients were so pleased with the service at their facility that they said they would encourage a friend or family member to attend, and clients reported an overall satisfaction rate of 97.8 percent with their experience.

Experts estimate that for every 13 medical male circumcision procedures conducted in Mozambique, one new HIV infection will be averted by the year 2025. Transferring these calculations to procedures performed through September 2011 means that the Jhpiego-supported demonstration project contributed to averting an estimated 1,729 new HIV infections. Overall, expanding access to MC to reach 80 percent of adult and newborn males in Mozambique by 2015 would avert more than 300,000 adult HIV infections between 2009 and 2025, and yield total net savings of more than $1.5 billion between 2009 and 2025 in treatment costs.

Jhpiego conducted the demonstration program from November 2009 through November 2010, initially at four sites in two provinces and Maputo City, where HIV prevalence rates are greater than the 11.5 percent national average and MC rates are lower than average for the country. Selected facilities included a basic health center, a rural hospital, a general hospital in an urban center and a military hospital. Staff in charge of the program were trained in the forceps-guided MC technique, basic minor surgery practices including local anesthesia, infection prevention measures, quality assurance and management of complications.

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During the pilot, Jhpiego tested service delivery models and collected data on actual and potential productivity of the joint services in the country (including implications for human resources, infrastructure, equipment and materials, and operational systems), as well as on existing demand for such services. An extensive report was submitted to the U.S. Centers for Disease Control and Prevention and the MOH in December 2010, with an initial proposal for expansion. Services continued at the four initial sites, and were then expanded in a second phase to three additional sites in Maputo City and two additional provinces through July 2011.

The monthly complication rate at the facilities declined steadily during the program’s duration, averaging less than 1 percent per month; most complications were mild. On average, facilities complied with 89 percent of quality assurance standards.

As part of the program, clients seeking minor surgery and MC services received HIV counseling and testing. Of the 22,954 men counseled and tested, 997 tested positive for HIV and were referred for treatment. Treatment referrals will continue to be a major focus of the program.

Ministry officials have endorsed the approach and are supporting greater expansion of the program. Among the recommendations for the expansion:

  • Prioritize high-volume units, in areas of high HIV prevalence, to increase efficiency and productivity.
  • Guarantee that the training is competency-based.
  • Form teams of providers (nurses and technicians) who can operate in the facilities under the supervision of surgeons, physicians and/or surgical technicians.
  • Guarantee a referral system for moderate and severe complications.
  • Plan, organize and control the supply chain to avoid stock-outs.

Jhpiego is currently tasked with serving 90,000 additional MC clients by the end of this program year, June 14, 2012. Establishment of services is under way in three new sites, and greater expansion is already planned for the next program year.

Among the beneficiaries of the Jhpiego demonstration project was S. Mutego, 39, of Matola. He is a counselor at the Minor Surgery and Male Circumcision Service of Maputo Military Hospital, one of the initial four project sites. This father of two children is in charge of group counseling for prospective MC clients. He explains the benefits and risks of MC, wound care after surgery, HIV prevention, and individual counseling and testing for HIV.

After working as a counselor at the military hospital for 18 months, Mutego decided to undergo an MC procedure. Through his work, he realized that a traditional circumcision performed on him as a boy had not properly completed the procedure. Mutego was nervous at first, he says, but soon he became relaxed because he did not feel any pain. He recovered quickly and without any complications.

Mutego is very pleased with the outcome of his surgery. The six-week postoperative abstinence period has passed, and he plans to bring his two sons for circumcision at the military hospital during their next school holiday.

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