Building the capacity to Deliver Early Infant Male Circumcision services in Rwanda: Lessons learnt Presenter: Placidie Mugwaneza Prevention Unit/HIV Division Rwanda Biomedical Center 1
Outline Introduction Objectives Description Lessons learnt, Conclusion and Recommendations 2
Introduction Adult Male Circumcision (MC) 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 3
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 4
As a result, majority of the males that received VMMC are aged between 15 and 24 years. 5
VMMC data July 2013- June 2014 VMMC access to younger children is limited - HENCE the need for EIMC 6
after a short training 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
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 program EIMC 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 8
Implementation How did we go about it EIMC Task Force (RBC, WHO, UNICEF, UNAIDS, CDC) established: v v Review of VMMC KAP study on acceptability of parents for EIMC 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 1 st phase v v Orientation of managers on EIMC program Facility readiness assessment was conducted 9
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 10
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 v 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 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. 12
Training cont d v EIMC Practical session on babies: - The 1 st step was to observe surgeons performing 4 EIMC procedure (setting of the tables, preparation of infants and performing circumcision) - The 2 nd 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 3 rd step was for the trainees to perform the procedure under the assistance of the surgeon. - The 4 th 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. 13
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 14
EIMC Results 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 15
Findings on satisfaction: EIMC Results 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 16
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 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 18
Conclusion and recommendations 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. 19
THANK YOU 20