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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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