HIV This Week

Kiggundu V, Watya S, Kigozi G, Serwadda D, Nalugoda F, Buwembo D, Settuba A, Anyokorit M, Nkale J, Kighoma N, Ssempijja V, Wawer M, Gray RH. The number of procedures required to achieve optimal competency with male circumcision: findings from a randomized trial in Rakai, Uganda. BJU Int. 2009 Apr 17. [Epub ahead of print]

Kiggundu and colleagues set out to assess the number of procedures required to achieve optimal competency (time required for surgery with minimal adverse events) in Rakai, Uganda, and thus facilitate the development of guidelines for training providers, as male circumcision reduces the acquisition of human immunodeficiency virus (HIV) in men and is recommended for HIV prevention. In a randomized trial, 3011 men were circumcised, using the sleeve method, by six physicians who had completed training, which included 15-20 supervised procedures. The duration of surgery from local anaesthesia to wound closure, moderate or severe surgery-related adverse events, and wound healing were assessed in relation to the number of procedures done by each physician. The median age of the patients was 24 years. The number of procedures per surgeon was 20-981. The mean time required to complete surgery was approximately 40 min for the first 100 procedures and declined to 25 min for the subsequent 100 circumcisions. After controlling for the number of procedures there was no significant difference in duration of the surgery by patient HIV status or age. The rate of moderate and severe adverse events was 8.8% (10/114) for the first 19 unsupervised procedures after training, 4.0% for the next 20-99 (13/328) and 2.0% for the last 100 (P for trend, 0.003). All adverse events resolved with management. The completion of more than 100 circumcisions was required before newly trained physicians achieved the optimum duration of surgery. Adverse events were higher immediately after training and additional supervision is needed for at least the first 20 procedures after completing training.

Editors’ note: This is the kind of operational research that will improve service outcomes if its results are now taken on board. They strongly suggest that time pressure should not be placed on newly trained surgeons, who will become more efficient with time in any case, and that they should be supervised for the first 20 circumcisions they perform after training, in addition to periodic supervision for the next 80. This surgical procedure, described in male circumcision circles as ‘minor surgery on a major organ’, warrants the strong emphasis being placed on safety and quality assurance.

Kline MW, Ferris MG, Jones DC, Calles NR, Mizwa MB, Schwarzwald HL, Wanless RS, Schutze GE. The Paeditric AIDS Corps: responding to the African HIV/AIDS health professional resource crisis. Paediatrics. 2009 Jan;123(1):134-6.

Health professional capacity for delivery of HIV care and treatment is severely constrained across sub-Saharan Africa. African health professional expertise in paediatrics is in particularly short supply. Here Kline et al describe a Paediatric AIDS Corps program that was designed to place paediatricians and other physicians in Africa on a long-term basis to expand existing health professional capacity for paediatric and family HIV care and treatment. In the first 2 years of this program, 76 physicians were placed in 5 African countries that have been hit hard by AIDS. Enrolment of HIV-infected children in care more than quadrupled over a 24-month period, to 26 590. The authors believe that this pilot program can serve as a model for larger-scale efforts to immediately expand access for African children and families to life-saving HIV care and treatment.

Editors’ notes: With health professional capacity for delivering HIV treatment and care severely constrained across sub-Saharan Africa, attention has turned to task-shifting to other health cadres, task-sharing which involves parts of procedures or tasks being taken on by different health care providers, recruiting and retaining new health caregivers, and hosting short-term volunteer projects. This programme, responding to the fact that children are underrepresented among patients on antiretroviral treatment in virtually every setting in sub-Saharan Africa, mobilised US graduates of residency training programmes in paediatrics, family medicine, and internal medicine for assignments of a year or longer in Botswana, Lesotho, Swaziland, Malawi, and Burkina Faso. They receive a living stipend, full benefits, a housing allowance, and student loan debt relief. The programme plans its own obsolescence by training local health professionals. Its success in improving paediatric treatment coverage while being locally acceptable will be of interest to many worldwide who would like to contribute in some way to improve the dire situation of the vast majority of the 2 million children living with HIV in Africa.

Kim JC, Askew I, Muvhango L, Dwane N, Abramsky T, Jan S, Ntlemo E, Chege J, Watts C. RADAR, School of Public Health, University of the Witwatersrand, Acornhoek, South Africa. Comprehensive care and HIV prophylaxis after sexual assault in rural South Africa: the Refentse intervention study. BMJ. 2009 Mar 13;338:b515.

Although international guidelines specify the central role of the health sector in providing comprehensive care, including HIV post-exposure prophylaxis (PEP), after sexual assault, in both industrialised and developing countries there are many challenges to providing timely and comprehensive services. A nurse-driven model of post-rape care was integrated into existing hospital services; the before and after study design evaluated impacts on quality of care, reviewing 334 hospital charts and conducting interviews with 16 service providers and 109 patients in a 450-bed district hospital in rural South Africa. The key measures for improvement examined were quality of care after rape (forensic history and examination, provision of emergency contraception, prophylaxis for sexually transmitted infections, referrals); provision of HIV counselling and testing and provision and completion of full 28 day course of PEP; and service utilisation (number of service providers seen on first visit and number of rape cases presenting to hospital per month). After completing baseline research, Kim and colleagues introduced a five-part intervention model, consisting of a sexual violence advisory committee, hospital rape management policy, training workshop for service providers, designated examining room, and community awareness campaigns. Existing services had been fragmented and of poor quality. After the intervention, there were considerable improvements in clinical history and examination, pregnancy testing, emergency contraception, prophylaxis for sexually transmitted infections; HIV counselling and testing, PEP, trauma counselling, and referrals. Completion of the 28-day course of PEP drugs increased from 20% to 58%. The authors conclude that it is possible to improve the quality of care after sexual assault, including HIV prophylaxis, within a rural South African hospital at modest cost, using existing staff. With additional training, nurses can become the primary providers of this care.

Editors’ note: Refentse means ‘we shall overcome’ in Venda, the language of this rural South African area and that is exactly what these investigators aimed to do. Aside from immediate genital and bodily injuries, sexual violence brings risks of HIV and sexually transmitted disease, unwanted pregnancy, urinary tract infections, chronic pelvic pain, miscarriage, depression, substance abuse, post-traumatic stress disorder, and suicide. They used formative research to conduct a baseline assessment with providers and patients to define problems and design a strategy for change. The process and its positive findings are an example for managers and providers of sexual assault care, but also of other services, who are keen to embark on a transparent, participatory process to improve their programme outcomes.