PhD Explores Voluntary Medical Male Circumcision

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The feasibility of integrating Voluntary Medical Male Circumcision (VMMC) with other HIV and sexual reproductive health programmes was evaluated in the thesis of PhD graduate, Dr Roger Phili.

The study titled: “Feasibility of Implementation of Medical Male Circumcision (MMC) in Public Sector Health Facilities Users in KwaZulu-Natal as Part of a Comprehensive HIV Risk Reduction Package”, examined the implementation of VMMC both as an entry and exit strategy for men who use health services for other reasons and were offered VMMC during their visit.

‘This was a field-based operational research study to establish and evaluate the real-world implementation constraints of an integrated HIV prevention strategy following the introduction of VMMC in KwaZulu-Natal,’ said Phili.

The study used three levels of public health care in KwaZulu-Natal to establish the feasibility of implementation and scale-up of MMC - Public Health Care (PHC) level, district level and private health level.  ‘The research included comparisons of the operational efficiencies of different patient entry points within health institutions in order to determine the optimal levels of access to and service delivery at public health institutions.’

The research revealed some limitations and opportunities for service improvements particularly regarding effective expansion of VMMC services and highlighted the implementation challenges and lessons for operationalising new research findings into routine health services.

Amongst the major findings of the study was that the integration of VMMC with existing HIV services as an ‘add-on’ strategy to an existing package of prevention services may not be feasible at the health care facilities currently and that a vertical approach through the male-only facilities may be a more feasible strategy to introduce VMMC services in public sector health facilities in KwaZulu-Natal.

Phili said offering of MMC as an exit strategy for men who present for other services may be more feasible as a medium to long term strategy as the operational barriers are resolved over time.

‘It may be argued that the vertical implementation of VMMC at standalone male-only facilities would invariably attract more clients for VMMC as such clients are already motivated to present for VMMC. However, the study showed that client motivation alone may not necessarily result in the higher uptake of services as several other barriers may restrict access to services.

‘It is further observed that despite higher uptake of HCT and VMMC using the vertical approach, the offering and integration of VMMC with other prevention programmes tends to be compromised. There may be a need to strengthen the offering and/or referral of other prevention programmes through multi-skilling of health providers when using this approach,’ said Phili.

He said his findings were important to inform planning of new prevention services and highlight several areas that pose barriers to effective integration of prevention programmes.

According to Phili, his research was largely based on the rapidly evolving implementation science field. ‘The support and guidance from my supervisor, Professor Quarraisha Abdool Karim, proved invaluable,’ he said.

He said MMC was amongst the most effective HIV prevention interventions recently recommended by the World Health Organization (WHO) and Joint United Nations Programme on AIDS following the three randomised controlled trials conducted in Africa that showed its effectiveness in preventing female-to-male HIV transmission by up to 60%.

He said it also found no significant change in the uptake of HIV counselling and testing amongst patients presenting at health facilities after the introduction of routine offering of counselling and testing to all patients (PICT) vs when the old VCT strategy was being used.

‘Most men preferred to be circumcised at public sector facilities rather than at private practitioners,’ he added.  

The study also found that there were low rates adverse events related to MMC that were comparable to those observed in the RCTs despite VMMC implementation on a large scale. ‘Younger men (<24 years old) were most likely to return for follow-up visits compared to the older men,’ he added.

The HIV incidence and prevalence of sexually transmitted diseases amongst males post-circumcision were found to be low over a one year period. There was also an increase in sexual activity but accompanied by a significant decline in multiple partners after circumcision, and increasing age group and condom use were significantly associated with a higher number of sexual partners. However, condom use was significantly reduced by 48% at 12 months compared to baseline, and most men observed the six-week sexual abstinence post-circumcision.

Overall the study highlighted the fact that a highly effective intervention in a research setting may require the realignment of systems and resources in order to realise the same effectiveness in real-life settings.

The study used a combination of quantitative and qualitative methods to assess key outcomes depicting the operational realities of MMC implementation, scale-up and integration with other HIV prevention, sexual and reproductive health programmes.

‘Despite competing priorities of a demanding full-time job and family responsibilities, Dr Phili impressively and with tenacity and passion stayed the course to complete his PhD that makes important contributions to HIV prevention, strengthening health care delivery systems and introducing new technologies in the public sector that has immediate local and pan-African relevance,’ said Professor Abdool Karim.

Nombuso Dlamini