Background: Mozambique MOH introduced VMMC as part of HIV prevention strategies in 2009. The surgical circumcision method originally chosen was forceps guided (FG). Glans injuries were reported to WHO among younger adolescents circumcised using FG method throughout 14 VMMC priority countries. In August 2014, MOH recommended that dorsal slit (DS) be used in VMMC clients aged 10-14 years, consistent with WHO guidance. Since then, VMMC clinical providers have been trained to attain proficiency in both methods.
The authors assessed the frequency and characteristics of adverse events (AEs) among VMMC clients aged 10-14 years by circumcision method (FG&DS), including glans injuries.
Methods: AE data were abstracted from circumcised clients aged 10-14 from November 2009 to December 2015 in 40 facilities in six provinces. By convention, only moderate and severe AEs/rates were included. Analysis was done to characterize AEs diagnosed and quantify AE rates, and compared by FG vs. DS method for statistical significance using Chi-square.
Results: Total of 447,289 VMMC procedures were conducted in the period, 235,527 (52.7%) among males aged 10-14 years. Of these, 198,242 (84.1%) through FG and 37,285 (15.8%) by DS. With FG the AE rate was 0.3% (341/112,997) and 0.14% (30/21,252) with DS. Chi-square revealed statistical differences between frequencies of AE in FG and DS (p=0.001), though 43% of clients failed to follow-up on day 7, and AEs are unknown among these. Only clients returning for follow-up visit were considered. No glans injuries occurred with DS, while with FG, there were 6 (5.9%). For both methods, bleeding/hematoma was the most frequently diagnosed AE, 23% with FG and 43% with DS, a difference of proportions t test revealed statistical differences (p=0.000). Infection and pain were similar across both methods.
Conclusions: The DS VMMC method reduced the risk of glans injuries among clients aged 10-14 years. Overall rate of AE was lower with DS than FG, with statically significant differences, except for bleeding/hematoma. Ongoing training in FG and DS surgical techniques should continue to ensure proficiency in both methods and further expand availability of appropriate VMMC methods to meet demand for VMMC, which is particularly high among adolescents.

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