Abstract
Male circumcision reduces the risk for female-to-male human immunodeficiency virus (HIV) transmission by approximately 60% (1) and has become a key component of global HIV prevention programs in countries in Eastern and Southern Africa where HIV prevalence is high and circumcision coverage is low. Through September 2017, the President's Emergency Plan for AIDS Relief (PEPFAR) had supported 15.2 million voluntary medical male circumcisions (VMMCs) in 14 priority countries in Eastern and Southern Africa (2). Like any surgical intervention, VMMC carries a risk for complications or adverse events. Adverse events during circumcision of males aged ≥10 years occur in 0.5% to 8% of procedures, though the majority of adverse events are mild (3,4). To monitor safety and service quality, PEPFAR tracks and reports qualifying notifiable adverse events. Data reported from eight country VMMC programs during 2015-2016 revealed that bleeding resulting in hospitalization for ≥3 days was the most commonly reported qualifying adverse event. In several cases, the bleeding adverse event revealed a previously undiagnosed or undisclosed bleeding disorder. Bleeding adverse events in men with potential bleeding disorders are serious and can be fatal. Strategies to improve precircumcision screening and performance of circumcisions on clients at risk in settings where blood products are available are recommended to reduce the occurrence of these adverse events or mitigate their effects (5).
Highlights
In resource-limited settings, health facilities might lack the capability to diagnose a bleeding disorder and might lack the blood products necessary for treatment
Strategies to improve precircumcision screening and performance of circumcisions on clients at risk in settings where blood products are available are recommended to reduce the occurrence of these adverse events or mitigate their effects [5]
Mild or moderate bleeding disorders are not contraindications to Voluntary medical male circumcision (VMMC), but in cases where clients are considered or suspected to have a bleeding disorder, the Adverse Event Action Guide advises that the procedure be conducted in a setting where blood products are available
Summary
Bleeding and Blood Disorders in Clients of Voluntary Medical Male Circumcision for HIV Prevention — Eastern and Southern Africa, 2015–2016. MD27; Shirish Balachandra, MD28; John Mandisarisa, PhD28; Sinokuthemba Xaba, MSc29; Stephanie M. Data reported from eight country VMMC programs during 2015–2016 revealed that bleeding resulting in hospitalization for ≥3 days was the most commonly reported qualifying adverse event. Before 2015, two bleeding-related fatalities were reported, one attributable to suspected factor VIII deficiency and one to a hemorrhage of unknown cause These deaths served, in part, as the impetus for broadening the adverse event notification process to include some nonfatal adverse events, including bleeding resulting in hospitalization for. When a qualifying notifiable adverse event occurs, the in-country office is notified and conducts an investigation including a review of the patient’s medical chart for relevant clinical data. Because availability of testing to confirm a bleeding disorder was limited, not all clients had a complete laboratory evaluation, and a diagnosis of a bleeding disorder was frequently based on clinical data only
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