Search

Background: The government of the Kingdom of Swaziland recognizes that it must urgently scale up HIV prevention interventions, such as voluntary medical male circumcision (VMMC). Swaziland has adopted a 2-phase approach to male circumcision scale-up. The catch-up phase prioritizes VMMC services for adolescents and adults, while the sustainability phase involves the establishment of early infant male circumcision (EIMC). Swaziland does not have a modern-day tradition of circumcision, and the VMMC program has met with client demand challenges. However, since the launch of the EIMC program in 2010, Swaziland now leads the Eastern and Southern Africa region in the scale-up of EIMC. Here we review Swaziland's program and its successes and challenges., Methods: From February to May 2014, we collected data while preparing Swaziland's "Male Circumcision Strategic and Operational Plan for HIV Prevention 2014-2018." We conducted structured stakeholder focus group discussions and in-depth interviews, and we collected EIMC service delivery data from an implementing partner responsible for VMMC and EIMC service delivery. Data were summarized in consolidated narratives., Results: Between 2010 and 2014, trained providers performed more than 5,000 EIMCs in 11 health care facilities in Swaziland, and they reported no moderate or severe adverse events. According to a broad group of EIMC program stakeholders, an EIMC program needs robust support from facility, regional, and national leadership, both within and outside of HIV prevention coordination bodies, to promote institutionalization and ownership. Providers and health care managers in 3 of Swaziland's 4 regional hospitals suggest that when EIMC is introduced into reproductive, maternal, newborn, and child health platforms, dedicated staff attention can help ensure that EIMC is performed amid competing priorities. Creating informed demand from communities also supports EIMC as a service delivery priority. Formative research shows that EIMC programs should address the fears and anxieties of parents so that they, especially fathers, understand the health benefits of EIMC before the birth of their babies., Conclusion: The vast majority of public-sector facilities in Swaziland are led by nurses, and nurses and midwives have borne the brunt of caring for patients with HIV/AIDS in Swaziland. Like prevention of mother-to-child transmission, EIMC provides an opportunity for nurses and midwives to stand at the forefront of HIV prevention efforts. Rapid scale-up of VMMC and EIMC in Swaziland has the potential to avert more than 56,000 HIV infections and save US$370 million in the next 20 years., (© Fitzgerald et al.)

Background: Voluntary medical male circumcision (VMMC) reduces HIV acquisition among heterosexual men by approximately 60%. VMMC is a surgical procedure and some adverse events (AEs) are expected. Swaziland's Ministry of Health established a toll-free hotline to provide general information about VMMC and to manage post-operative clinical AEs through telephone triage., Methods: We retrospectively analyzed a dataset of telephone calls logged by the VMMC hotline during a VMMC campaign. The objectives were to determine reasons clients called the VMMC hotline and to ascertain the accuracy of telephone-based triage for VMMC AEs. We then analyzed VMMC service delivery data that included date of surgery, AE type and severity, as diagnosed by a VMMC clinician as part of routine post-operative follow-up. Both datasets were de-identified and did not contain any personal identifiers. Proportions of AEs were calculated from the call data and from VMMC service delivery data recorded by health facilities. Sensitivity analyses were performed to assess the accuracy of phone-based triage compared to clinically confirmed AEs., Results: A total of 17,059 calls were registered by the triage nurses from April to December 2011. Calls requesting VMMC education and counseling totaled 12,492 (73.2%) and were most common. Triage nurses diagnosed 384 clients with 420 (2.5%) AEs. According to the predefined clinical algorithms, all moderate and severe AEs (153) diagnosed through telephone-triage were referred for clinical management at a health facility. Clinicians at the VMMC sites diagnosed 341 (4.1%) total clients as having a mild (46.0%), moderate (47.8%), or severe (6.2%) AE. Eighty-nine (26%) of the 341 clients who were diagnosed with AEs by clinicians at a VMMC site had initially called the VMMC hotline. The telephone-based triage system had a sensitivity of 69%, a positive predictive value of 83%, and a negative predictive value of 48% for screening moderate or severe AEs of all the AEs., Conclusions: The use of a telephone-based triage system may be an appropriate first step to identify life-threatening and urgent complications following VMMC surgery.