SYMMACS: Systematic Monitoring of the Voluntary Medical Male Circumcision Scale-up in

Eastern and Southern Africa

Jane T. Bertrand, PhD, MBA Jan. 13, 2014

Overview of presentation

• Background • Methodology • Selected results • Limitations • Dissemination

Source: 2006 Report on the global AIDS epidemic (UNAIDS, May 2006)

Rakai, Uganda Gray et. al. (2007) Lancet; 369: 657 – 66

Kisumu, Kenya Bailey et. al. (2007) Lancet; 369: 643 – 56

Orange Farm, South Africa Auvert et. al. (2005) PLoS Med; 2 (11): e298

Randomised controlled trials of male circumcision to reduce HIV infection

345,244

40,000 377,788

376,795

2,101,566

1,059,104

330,218

1,746,052

4,333,134

183,450

1,373,271

4,245,184

1,949,292 1,912,595

-

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

4,000,000

4,500,000

5,000,000

Number of Adult 15-49 years male circumcision needed to reach 80% coverage in 5years

20,373,693M adult 15-49 years men to be circumcised across all 14 countries

WHO guidance (2010)

WHO convened a panel of experts to develop considerations for optimizing the volume and efficiency of VMMC services

Models for Optimizing the Volume and Efficiency of MC Services (2010)

“Considerations” to be adapted to local context Practitioners working on scale-up identified 6 elements of surgical efficiency that SYMMACS would monitor:

•Rotation among multiple bays in operating theatre •Pre-bundling of surgical supplies with disposable instruments •Task-shifting (use of non-medical providers to perform entire procedure) •Task-sharing (allowing non-medical providers to assist in certain aspects of the procedure) •Use of electrocautery/diathermy •Use of forceps-guided surgical method

6

Objectives of SYMMACS

1. Efficiency – Extent of adoption of 6 elements of efficiency – Factors that improve surgical efficiency

2. Quality – Assessment of VMMC facilities – Assessment of surgical technique during procedure – Effect of scale-up on quality of services (South Africa)

3. Provider perspectives on VMMC scale-up – Provider profile, experience, job satisfaction, burnout – Provider attitudes toward VMMC scale-up

7

SYMMACS methodology

• Process evaluation in four countries in southern and eastern Africa active in VMMC scale-up

– Kenya, South Africa, Tanzania, and Zimbabwe

• Two serial cross-sectional samples of VMMC service

delivery sites – Data collected in 2011 and 2012 using same instruments

• Included fixed, outreach and mobile sites (where they

existed) – Kenya: only country that had mobile sites

8

9

Kenya South Africa

Tanzania Zimbabwe

# sites visited 30 29

15 40

14 29

14 24

Types of sites: Fixed/outreach/ mobile

15/12/3 15/12/2

13/2/0

26/14/0

13/1/0 24/5/0

5/9/0

6/18/0

# providers interviewed

86 82

105 209

93 206

74 94

# VMMC procedures observed

151 218

120 361

133 251

140 204

Number of sites visited: 2011, 2012

KEY FINDINGS: one illustrative result per ojbective

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Efficiency elements and correlates of efficiency

Kenya South Africa Tanzania Zimbabwe

2011-2012 2011-2012 2011-2012 2011-2012

Multiple bays in operating theatre

X / X X / X X / X

Purchase of pre-bundled kits with disposable instruments

X / X X / X

Task-shifting X / X X / X

Task-sharing X / X X / X X / X X / X

Surgical method: forceps-guided X / X X / X X / X X / X

Electrocautery to stop bleeding X / X (x)* / X

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* Indicates partial adoption of efficiency element

Summary of adoption of 6 efficiency elements 2011-2012

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KEY FINDINGS

Quality of services

Quality of VMMC Services during Rapid Scale-up in Four Countries

13

• 29 aspects related to conditions, equipment, supplies at VMMC site

– Service delivery guidelines onsite (3)

– Equipment, supplies (9)

– Life support items (4) – Hygiene/safety (4) – Supervision, info

system, education (9)

• 29 items related to provider technique:

– Pre-op procedures (1) – Surgical techniques

during operation (13) – Hygiene/safety (8) – Post-op procedures (7)

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Kenya South Africa Tanzania Zimbabwe 2011

(T0) 2012 (T1)

∆ = T1- T0

2011 (T0)

2012 (T1)

∆ = T1- T0

2011 (T0)

2012 (T1)

∆ = T1- T0

2011 (T0)

2012 (T1)

∆ = T1- T0

Number of facilities 30 29 15 40 14 29 14 24

Guidelines n=28 n=29 n=15 n=40 n=13 n=29 n=14 n=24

% facilities with all 3 guidelines

34.5 53.6 +19.1 33.3 12.5 -20.8 7.7 27.6 +19.9 7.1 41.7 +34.5 *

Equipment/Supplies n=28 n=28 n=15 n=39 n=13 n=29 n=14 n=24

% facilities with all 9 equipment and supplies

25.0 10.7 -14.3 50.0 2.6 -47.4 * 23.1 6.9 -16.2 28.6 45.8 +17.3

Basic Life Support n=29 n=29 n=15 n=40 n=12 n=29 n=14 n=24

% facilities with all 4 basic life support items

0 3.4 +3.4 64.3 27.5 -36.8 * 7.7 17.2 +9.5 35.7 58.3 +22.6

Hygiene and Safety n=29 n=29 n=15 n=40 n=12 n=29 n=14 n=24

% facilities with all 4 hygiene and safety items

75.9 86.2 +10.3 53.3 12.5 -40.8 * 33.3 17.2 -16.1 28.6 83.3 +54.8*

* denotes statistically significant at p < 0.05

Summary of scores on “Readiness”: Availability of protocols, equipment & supplies

Summary scores: availability of VMMC service package from 2011-2012

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Kenya South Africa Tanzania Zimbabwe

2011 (T0)

2012 (T1)

∆ = T1- T0

2011 (T0)

2012 (T1)

∆ = T1- T0

2011 (T0)

2012 (T1)

∆ = T1- T0

2011 (T0)

2012 (T1)

∆ = T1- T0

Service Package n=28 n=29 n=15 n=40 n=14 n=29 n=14 n=24

% facilities with all 5 package services

32.1 58.6 +26.5* 86.7 22.5 -64.2 * 85.7 58.6 -27.1 85.7 100 +14.3

Mean number (%) package services*

4.3 86%

4.5 90%

+0.2 +4%

4.8 96%

3.5 70%

-1.3 * -26% *

4.9 98%

4.6 92%

-0.3 -6%

4.9 98%

5.0 100%

+0.1 +2%

[*] Includes percent of facilities that scored “satisfactory” on this item; excludes “partially satisfactory.” * Denotes statistically significant at p < 0.05

VMMC service package includes: medical male circumcision, VMMC group education, VMMC individual counseling, HCT, and referrals

Summary of changes – quality of services

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Country specific QA trends (2011 versus 2012):

• South Africa: rapid expansion of sites led to decreased quality of services

• Zimbabwe showed improvement on multiple items

• Kenya and Tanzania – no significant change

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KEY FINDINGS

Provider perspectives

Provider attitudes toward scale-up

• National policy dictates adoption (or not) of 6 elements of efficiency

• Compliance with practices and morale – related to provider attitudes toward these practices

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• Findings: providers generally accepted the use of these 6 practices:

– Objected to lack of task shifting in South Africa and Zimbabwe

– Wanted training in methods other than forceps guided

– Wanted training in electrocautery (in Kenya – where not widespread)

KEY FINDINGS across 4 countries

Overall strengths of program • Group education on HIV prevention widely

available • Generally high marks on quality of surgical

procedure • Improvements in information systems by 2012

General areas for improvement • Inadequate recording of adverse events • Lack of emergency equipment on sites • Absence of guidelines on site

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Limitations of the study

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• Sampling: impossible to know the “universe” of sites at start of data collection

• Timing of data collection: did not correspond to “high volume” periods (except Zimbabwe, 2011; South Africa, 2012)

• Observations of sites and VMMC procedures were by definition subjective

– But based on pre-established written criteria

• Provider data were self reported

Dissemination of findings

• Presented at international conferences – IAS, Malaysia, 2012 – ICASA, Cape Town, 2013

• Dissemination of SYMMACS Final report

– Posted on the R2P website (www.jhsph.edu/r2p) and announced via social media

– Posted on front page of Clearinghouse on Male Circumcision for HIV Prevention (http://www.malecircumcision.org/)

• Publication of VMMC journal supplement in PLoS One – Six papers on SYMMACS, publication dates starting in December 2013

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Acknowledgment to country teams

Kenya South Africa Tanzania Zimbabwe Implementing Agency

FHI360/Kenya CHAPS MCHIP Jhpiego/Tanzania PSI/Zimbabwe, with ZAPP-UZ as subcontractor

Co-investigator Dr. Nicholas Muraguri, Dr. Peter Cherutich, Dr. Kawango Agot, Dr. Walter Obiero, Dr. Jackson Kioko

Dr. Dirk Taljaard,

Dr. James McIntyre

Dr. Bennet Fimbo, Dr. Eleuter Samky

Dr. Karin Hatzold, Christopher Samkange

Country Coordinator

Dr. Mores Loolpapit, Mathews Onyango Sasha Frade Michael D. Machaku Webster Mavhu

Clinician (data collection)

Omondi Dickens,

Nicolas Pule

Mulashi Biola, Daniel Shabangu, Sindiswe Zwane, Sindiswe Maseko

Dr. Sifuni Koshuma, Milton Kabiligi

Dr. Tendai Mutwirah Dr. Eric Nyazika Dr. Kelvin Nemayire

Social Scientist for data collection

Rosemary Owigar, Dr. Violet Naanyu n/a n/a n/a

Data Manager Omondi Dickens Alexandra Spyrelis Flora Hezwa, Dr. Obadia Venance Nyongole Dudzai Mureyi

USAID Mission Anne Murphy Wendy Benzerga, Rebecca Fertziger

Duncan Onditi, Seth Greenberg,

Eric Mlanga

William Jansen

Technical assistance and/or sampling

Dr. Kate McIntyre, Zebedee Mwandi

Carlos Toledo, Lisa Mulwenga Koku Kasaura n/a

Manuscript review n/a n/a Hally Mahler Dr Karin Hatzold 22

Principal investigators Jane T. Bertrand (PI), Dino Rech (co-PI)

Co-investigators Emmanuel Njeuhmeli, Delivette Castor, Jason Reed

Technical Advisory Group to the R2P Project for VMMC (convened in 2010)

Bertran Auvert, Stella Babalola, Robert Bailey, Kelly Curran, Kim Eva Dickson, Timothy Farley, Ron Gray, Jason Reed, Caroline Ryan; also present from USAID: Benny Kottiri, David Stanton, Alison Cheng, Timothy Mah, Emmanuel Njeuhmeli.

USAID/Washington: Emmanuel Njeuhmeli, Delivette Castor, Alison Cheng, Benny Kottiri, Sarah Sandison, Timothy Mah

PEPFAR/CDC/Atlanta: Jason Reed (at the time of initiation of the study)

Center for Communication Programs (CCP), Johns Hopkins Bloomberg School of Public Health:

Susan Krenn, William Glass, and Mark Beisser; and from R2P staff (CCP): Deanna Kerrigan, Caitlin Kennedy, Brandon Howard, Emily Hurley, Heena Brahmbhatt, Andrea Vazzano,‘Kuor Kumoji, Erica Layer, Jessica Spielman and Margie Wild

Technical and administrative support / Tulane SPTHM

Alan Czaplicki, Bobbie Garner-Coffie, Frances Mather, Christopher Swalm.

Research support / Tulane SPTHM

Linnea Perry, Margaret Farrell, Nicholas Thomas

Acknowledgement - other collaborators

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The USAID | Project SEARCH, Task Order No.2, is funded by the U.S. Agency for International Development under Contract No. GHH-I-00-07-00032-00, beginning September 30, 2008, and supported by the President’s Emergency Plan for AIDS Relief. The Research to Prevention (R2P) Project is led by the Johns Hopkins Center for Global Health and managed by the Johns Hopkins Bloomberg School of Public Health Center for Communication Programs (CCP).