Background: Botswana has the second highest HIV prevalence (18.5%) globally and has been earmarked by WHO and UNAIDS among high priority countries for scaling up voluntary medical male circumcision (VMMC). WHO and UNAIDS recommend early infant male circumcision (EIMC) due to its cost-effectiveness, safety, and reduced risks compared to adult and adolescent circumcision. Countries are considering various devices for EIMC. Although rare, serious potential complications have been associated with some devices. Botswana program is the first to implement EIMC in routine reproductive health services using the AccuCirc device in a successful fully integrated approach, positioning it as a model program.
Description: During pilot services in two referral hospitals, with some technical support from PEPFAR, a small number of midwives and doctors in maternity wards were trained to offer EIMC using the AccuCirc device. Upon reaching proficiency, these providers at the pilot facilities were trained on clinical training skills and capacitated to be EIMC master trainers. The pilot facilities became training hubs for cascading training. Demand creation was conducted in antenatal clinics, outpatient education sessions and at traditional (Kgotla) meetings. To date, 277 providers (majority midwives) have been trained. Overall, twenty five EIMC service delivery points have been established, covering most districts. Nurse midwives have conducted 95% of 3,334 procedures in 24 months through December 2015 in this fully integrated model, managed and financed by government.
Lessons learned: Task shifting to nurses has helped overcome the staff shortage associated with a doctor depended model. Integration has enhanced government ownership. EIMC training using the master trainers has increased program reach. Due to proper scheduling of staff and procedures, providers report no burden from including EIMC in their regular work. The pre-packaged device kits ease the supply chain management. Challenges include loss to follow up and obtaining consents from partners and guardians.
Conclusions/Next steps: Roll out of EIMC to supplement and sustain coverage of VMMC using the AccuCirc device in a fully integrated model was is feasible in this fairly resource constrained setting. Systematic assessment of safety and cost of AccuCirc device based services in this model is recommended.