Feasibility and validity of telephone triage for adverse events during a voluntary medical male circumcision campaign in Swaziland.

Tigistu Adamu Ashengo,Emmanuel Njeuhmeli,Jonathan Grund,George Bicego,Masitsela Mhlanga,Rhoy Shoshore,Thabo Hlophe,Naomi Bock,Kelly Curran,Munamato Mirira,Laura Fitzgerald,Khumbulani Moyo,Elizabeth Mallas

doi:10.1186/1471-2458-14-858

Abstract

BackgroundVoluntary 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.MethodsWe 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.ResultsA 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.ConclusionsThe use of a telephone-based triage system may be an appropriate first step to identify life-threatening and urgent complications following VMMC surgery.

Highlights

Voluntary medical male circumcision (VMMC) reduces HIV acquisition among heterosexual men by approximately 60%
Description of telephone triage The nurses who provided telephone triage for VMMC completed a full course of competency-based clinical training on male circumcision under local anesthesia, which is the same training required of surgical nurses in VMMC facilities
We retrospectively reviewed a dataset of telephone calls logged by the triage nurses during the Soka Uncobe VMMC campaign

Summary

Introduction

Voluntary medical male circumcision (VMMC) reduces HIV acquisition among heterosexual men by approximately 60%. More than 40 observational studies and three randomized controlled trials have demonstrated that voluntary medical male circumcision (VMMC) reduces HIV acquisition among heterosexual men by approximately 60% [1,2,3,4]. Given the potential impact of VMMC on HIV incidence, the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommended that VMMC should be part of comprehensive HIV prevention programming in regions with generalized HIV epidemics and low levels of male circumcision [8]. Modeling projections suggest that approximately 3.36 million new HIV infections and 386,000 AIDS deaths would be averted through 2025 if 80% coverage with VMMC in 14 priority countries in Eastern and Southern Africa were achieved within five years [9]. In order to achieve this level of coverage, an estimated 20 million VMMC procedures would need to be performed [9]

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