Abstract
Voluntary medical male circumcision (VMMC) reduces risk of HIV acquisition in heterosexual men by approximately 60%. As some countries approach targets for proportions of adolescents and adults circumcised, some are considering early infant male circumcision (EIMC) as a means to achieve sustainability of VMMC for long term reduction of HIV incidence. Evaluations of specialized devices for EIMC are important to provide programs with information required to make informed decisions about how to design safe, effective EIMC programs. We provide assessments by 11 providers with experience in Kenya employing all three of the devices most likely to be considered by various EIMC programs in east and Southern Africa. There was no one device that was seen to be clearly superior to the others. Each had its own advantages and disadvantages. Provider preferences were situation-specific. Most preferred the Mogen Clamp if they themselves were performing the procedure. However, most were concerned that not everyone will have the skills necessary for optimal safety. If someone else were circumcising their son, most would opt for the AccuCirc because of the risk of severing the glans when using the Mogen. A minority preferred the PrePex, but only if the baby received local anesthesia, not EMLA cream (a eutectic mixture of lidocaine 2.5% and prilocaine 2.5%), as presently prescribed by the manufacturer. In the context of a national EIMC program, all participants agreed that AccuCirc would be the device they would recommend due to protection of the glans from laceration and to the provision of a pre-assembled sterile kit that overcomes the need for additional supplies or autoclaving. All agreed that scaling up EIMC, integrating it with existing maternal child health services, will face significant challenges, not least of which is persuading already over-burdened providers to take on additional workload. These results will be useful to programmers considering introduction of EIMC services in sub-Saharan African settings.
Highlights
Male circumcision (MC) is a proven HIV prevention intervention, reducing the risk of heterosexual acquisition of HIV in men by 57–67% in three randomized controlled trials and in long-term follow-up studies [1,2,3,4,5,6]
We provide assessments by 11 providers with experience in Kenya employing all three of the devices most likely to be considered by various early infant male circumcision (EIMC) programs in east and Southern Africa
In the context of a national EIMC program, all participants agreed that AccuCirc would be the device they would recommend due to protection of the glans from laceration and to the provision of a pre-assembled sterile kit that overcomes the need for additional supplies or autoclaving
Summary
Male circumcision (MC) is a proven HIV prevention intervention, reducing the risk of heterosexual acquisition of HIV in men by 57–67% in three randomized controlled trials and in long-term follow-up studies [1,2,3,4,5,6]. The World Health Organization (WHO) and UNAIDS approved scale-up of adolescent and adult voluntary medical male circumcision (VMMC) as part of comprehensive HIV prevention programs, and approximately 11.7 million circumcisions have been achieved in 14 east and Southern African countries through 2015 [7]. As a few countries, including Kenya, have achieved their original targets for total VMMCs and as others are expecting to do so in the few years, governments and donor agencies are considering whether and how best to transition from focusing on adolescent and adult circumcision to early infant male circumcision (EIMC) [8,9,10]. The Mogen is made of stainless steel and appropriate for repeated uses It has two flat blades approximately 2.5mm apart through which the foreskin is placed following the angle of the corona, ensuring the glans is not trapped. The device is left in situ, the foreskin necrotizes, and is sloughed, while the device detaches spontaneously after a mean of 6 days [23]
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