Background: Modeling shows that scaling-up voluntary medical male circumcision (VMMC) services in sub-Saharan Africa to reach 20 million men will avert 3.4 million HIV infections by 2025. As countries scale up VMMC services, patterns and predictors of Adverse Events (AEs) remain unclear. Factors associated with AEs during six years of program implementation in Iringa, Njombe and Tabora, Tanzania are described.
Methods: A retrospective review of moderate/severe AEs was conducted using client-level data to analyze age of clients, types/severity of AEs, service modalities and surgical techniques. Chi-square test was used for statistical significance and mhodds test to adjust for age. Mild AEs were excluded.
Results: A total of 497,871 clients were circumcised from 2009-2015. There were 274/497,871 (0.06%) clients with intra-operative AE(s); out of 365,957 clients who returned for at least one visit, 1182 (0.33%) were reported to have post-operative AE(s). Across all age groups, the most common intraoperative AEs was excessive bleeding; among clients 10-14 years, the most common was glans injury (18/30=67%). All clients with glans injuries had been circumcised using the forceps-guided (FG) method. Across all age groups, the most common postoperative AEs were infections (58%), hematomas (21%) and excessive bleeding (11%).
AE rates were higher during campaigns (1,192/368,590=0.33%) compared to routine services (139/48,799=0.29%) (p < 0.001). AEs were highest in 15-29 year old clients (193/218,272=0.09% for intra AE; 686/152,950=0.45% for post AE and lower in older and younger age groups (p< 0.001). AE rates were higher amongst clients who were circumcised using the FG technique (271/437,927=0.06% for intra AE; 1,115/316,960 = 0.36% for post AE) compared to dorsal slit (DS) (3/58,364= 0.01% for intra AE; 66/48,232=0.14% for post AE. (p< 0.001). Clients were less likely to have an AE when circumcised with DS compared to FG, even after adjusting for age (AOR = 0.50 p value< 0.001).
Conclusions: Although overall AE rates were low, higher rates during the campaigns need to be addressed. Higher rate of glans injuries among 10-14 year-olds when using the FG method, coupled with lower intraoperative AE rate for DS compared to FG underscores the need to adhere to PEPFAR policy guidelines on age appropriate-methods for VMMC.

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