Considerations for implementing models for optimizing the volume and efficiency of male circumcision services Field testing edition February 2010 WHO Library Cataloguing-in-Publication Data Considerations for implementing models for optimizing the volume and efficiency of male circumcision services February 2010 | Field testing edition © World Health Organization 2010 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; email: [email protected]). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; email: [email protected]). 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Printed in Considerations for implementing models for optimizing the volume and efficiency of male circumcision services Field testing edition February 2010 Contents Acknowledgements ...............................................................................................................................5 Abbreviations ..........................................................................................................................................6 Background ..............................................................................................................................................7 Purpose .....................................................................................................................................................9 1. Clinical considerations .................................................................................................................10 1.1 Surgical techniques .............................................................................................................10 1.2 Haemostasis by diathermy................................................................................................10 2. Staff considerations for optimizing efficiency .......................................................................12 2.1 Task-shifting and task-sharing ...........................................................................................12 2.2 Staff time ................................................................................................................................ 14 2.3 Staff ratios .............................................................................................................................. 18 3. Optimizing the use of facility space .......................................................................................... 19 4. Client considerations ................................................................................................................... 21 4.1 Client flow .............................................................................................................................. 21 4.2 Client scheduling .................................................................................................................. 21 5. Supply chain management ..........................................................................................................23 5.1 Bundling of commodities (sets, packs, kits, modules) ..............................................23 5.2 Forecasting supply needs ..................................................................................................27 5.3 Procurement ..........................................................................................................................27 5.4 Distribution ............................................................................................................................28 6. Cost efficiencies .............................................................................................................................29 7. Quality assurance ......................................................................................................................... 30 7.1 Service standards ............................................................................................................... 30 7.2 Clinical protocols and guidelines ......................................................................................31 7.3 Infection prevention .............................................................................................................31 7.4 Monitoring and evaluation .................................................................................................31 8. Annexes ...........................................................................................................................................32 References ............................................................................................................................................ 50 4 CONSIDERATIONS FOR IMPLEMENTING MODELS FOR OPTIMIZING THE VOLUME AND EFFICIENCY OF MALE CIRCUMCISION SERVICES Acknowledgements This document was produced by Kim Eva Dickson (WHO), Jason Reed (CDC, USA) and Dino Rech (PSI/WHO Consultant). WHO would like to thank the following people: Jim Kahn (University of California, San Francisco, USA) and Elliot Marseilles (University of California, San Francisco, USA), Emmanuel Njeuhmeli (USAID, USA) for contributing to the writing and review of the document. Special thanks go to the international experts who reviewed the document: Bertran Auvert (Agence Nationale de Recherche sur le SIDA et les Hépatites virales, France), Robert Bailey (University of Illinois at Chicago, USA), Naomi Bock (CDC, USA), Kasonde Bowa (University of Zambia School of Medicine, Zambia), Agnes Chidanyika (WHO Consultant, Zimbabwe), Ladislous Chonzi (Family Life Association of Swaziland, Swaziland), Kristin Chrouser (Jhpiego, USA), Sean Doyle (University of California, San Francisco, USA),Jessica Fast (Clinton Foundation, USA), Adam Groeneveld (Ministry of Health and Social Welfare, Swaziland), Timothy Hargreave (Consultant Surgeon, United Kingdom), Palesa Mohaleroe (Surgeon, Lesotho), Jabbin Mulwanda (Jhpiego, Zambia), Ira Sharlip (American Urological Association, USA), Stephen Watya (Mulago Hospital, Uganda). WHO would also like to thank members of the WHO/UNAIDS Male Circumcision Working Group: WHO: Tim Farley, George Schmid, Bruce Dick and Julie Samuelson. UNAIDS: Catherine Hankins and Nicolai Lohse. 5 Abbreviations ANRS Agence nationale de recherches sur le sida et les hepatites virales COBAN cohesive bandage DHS demographic and health survey EtO ethylene oxide HIV human immunodeficiency virus HQHV high-quality, high-volume IV intravenous MC male circumcision MOVE models for optimizing volume and efficiency (of services) NGO nongovernmental organization OT operating theatre PSI Population Services International STI sexually transmitted infection UNAIDS Joint United Nations Programme on HIV/AIDS WHO World Health Organization 6 CONSIDERATIONS FOR IMPLEMENTING MODELS FOR OPTIMIZING THE VOLUME AND EFFICIENCY OF MALE CIRCUMCISION SERVICES Background In the light of the conclusive evidence that male circumcision provides partial protection against HIV acquisition by men, WHO/UNAIDS recommended that male circumcision be considered as an additional HIV prevention intervention and added to existing comprehensive HIV prevention packages in countries with predominantly heterosexual epidemics.1 Mathematical models that have been developed to estimate the potential impact at the popula- tion level of male circumcision on HIV incidence in high-prevalence settings have produced similar findings.2 The models indicate large benefits of circumcision among heterosexual men in settings of low male circumcision and high HIV prevalence, with one HIV infection averted for every 5 to 15 male circumcisions performed. The public health impact could be enhanced, depending on the scale and pace of service delivery, sexual risk compensation and the uptake of complimentary prevention, care and treatment services. All the models show that rapid expansion of male circumcision coverage will result in earlier and larger effects on HIV incidence. An expert review group concluded that rapid initial scale-up produces direct and indirect effects earlier and is considerably more cost-effective, with fewer circumcisions required