Differences in Adverse Events Related to Voluntary Male Medical Circumcision Between Civilian and Military Health Facilities in Uganda

Abstract Background: Voluntary medical male circumcision (VMMC) significantly reduces the risk of acquiring HIV in men. Despite the percentage of circumcised men (15-49 years) in Uganda increasing over time, some populations are not taking up the surgical procedure. The government of Uganda and implementing partners have responded to this lack of VMMC coverage among key populations by intensifying introducing innovative strategies that increase demand particularly among military personnel using the WHO’s MOVE strategy. As a surgical intervention, it is critical that VMMC services are safe for clients and that adverse events or complications are minimized. This paper describes the prevalence and trends of adverse events reported among military mobile camps in comparison to civilian sites in Uganda. Methods: A prospective study conducted in eighteen (18) public health facilities between March and August 2019. Of these nine (9) were providing care to civilian populations while nine (9) served the military population and catchment areas. Descriptive statistics, Chi-square test and trends analysis were carried out to describe profile of advance events among civilian and military facilities over the study period. Results: The highest proportions of VMMC were done among persons aged 15 to 19 years whereas among military camps the highest proportions of circumcision among males aged 20 to 24 years. Regarding site of circumcision, the highest proportions of VMMC were done at outreaches, with higher levels in military camps compared to civilian camps. For the proportions of adverse events reported, higher proportions were reported in civilian camps compared to military camps (Total – 1.3% vs 0.2%; p- value<0.05). For trends analysis, results indicate that there was no statistically significant trend for both civilian and military number of adverse events reported for the four quarters in 2020 (P-value =0.315 for civilian and P=0.094 for the military). Conclusions: The MOVE model is great for scaling up VMMC in specialized populations such as military. Can also be adapted in other populations if contextual bottlenecks are identified and collectively addressed by key stakeholders – leadership, community engagement and using a largely horizontal approach offer promising possibilities and outcomes.

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Adapting “MOVE” to Accelerate VMMC Coverage for HIV Prevention in Priority Populations: Implementation Experiences from Uganda’s Military Settings

International STD Research & Reviews ◽

10.9734/isrr/2021/v10i130122 ◽

2021 ◽

pp. 39-52

Author(s):

A. Nyanzi ◽

E. Lugada ◽

D. Bwayo ◽

V. Kasujja ◽

C. Wamundu ◽

...

Keyword(s):

Scale Up ◽

Cost Effective ◽

Integrated Approach ◽

Health Facilities ◽

Health System Strengthening ◽

Voluntary Medical Male Circumcision ◽

Intervention Package ◽

Medical Male Circumcision ◽

Military Health ◽

Performance Trends

This paper describes the WHO’s Model of Optimizing Volumes and Efficiencies (MOVE), adapted by the University Research Council (URC) - Department of Defense HIV/AIDS Prevention Program (DHAPP) to rapidly scale up Voluntary Medical Male Circumcision (VMMC) within Uganda’s military health facilities. First, we examine the MOVE model and then present the URC-DHAPP adapted intervention package comprising of: a) a Command-driven approach, b) Mobile theatres c) Quality assurance d) Data strengthening and reflection. To expand VMMC, URC-DHAPP worked with army commanders to create awareness, mobilize their troops and surgeons were assigned daily targets. The mobile theatre involved regular visits to hard-to-reach outposts and placing several mobile camps at health facilities close to deployment sites. All stakeholders were briefed on performance trends of previous medical camps and the program was monitored through VMMC camp reports. URC-DHAPP registered an exponential increase in VMMC coverage from 13% performance at Q2 to over 140% in Q4. The integrated approach led to circumcision of over 22,000 men (15-49 years) in a record four months. Our approach also contributed to health system strengthening and national HIV preventiontargets. We conclude that the MOVE is cost-effective and can be successfully scaled up in resource-limited settings with a high HIV burden when implemented with cognizance of contextual specificities.

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Accelerated Scale up of Voluntary Medical Male Circumcision within the Military Health Services in Uganda: The Race towards 2020 HIV Epidemic Control

International STD Research & Reviews ◽

10.9734/isrr/2021/v10i230127 ◽

2021 ◽

pp. 1-15

Author(s):

E. Lugada ◽

G. Seruwagi ◽

A. Nyanzi ◽

S. Lawoko ◽

D. Bwayo ◽

...

Keyword(s):

Male Circumcision ◽

Unit Cost ◽

Scale Up ◽

Voluntary Medical Male Circumcision ◽

Epidemic Control ◽

Medical Male Circumcision ◽

Military Health ◽

Multiple Stakeholder ◽

Hiv Epidemic ◽

The Military

Background: Scaling up Voluntary Medical Male Circumcision (VMMC) is a critical intervention in achieving HIV epidemic control by 2020. However, documentation of programmatic interventions to improve VMMC uptake among military populations, a population that is at high risk of HIV, is lacking. URC-Department of Defense HIV/AIDS Prevention Program (DHAPP) implemented a novel approach to accelerate VMMC uptake in the Ugandan military. We describe trends in VMMC uptake and associated operational costs following the intervention. We also contrast between military and civilian facilities. Program Description: We implemented monthly mobile VMMC services throughout the country targeting soldiers, their families and surrounding communities. Records gathered during implementation were used to describe the intervention. Quantitative methods were applied to compare VMMC post intervention rates with set targets and monthly VMMC trends country-wide between military and civilian facilities over a five months period. An operational VMMC service cost analysis was applied to determine per male circumcision unit cost, excluding cost of consumables. Lessons Learnt: Command-driven mobilization, multiple stakeholder engagement, use of mobile VMMC teams and data-driven planning increased demand for and uptake of VMMC services among the military. By the first month of intervention, VMMC performance had surpassed set monthly targets of 1,474 by 1457 circumcisions, accounting for a 99% increase (n=2,931 circumcisions) from 31% to 62% uptake. Overall VMMC performance achieved within the military was 132% in excess of set targets (n=7,408) at six months. The scaled-up operational VMMC cost per circumcision performed dropped from $15 to $7, a 47% unit cost saving within six months. While a positive trend in VMMC uptake was observed in the military facilities, the opposite was exhibited in civilian facilities over the observation period. Conclusion: It is feasible to rapidly scale up circumcision coverage in populations served by military health facilities through mobile short term episodic VMMC services which optimize volume and efficiency. Invoking command-led mobilization and multiple stakeholder involvement is critical in demand creation and overcoming the mobile nature of the military.

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Diagnostic Evaluation of Hypoglycemia Due To an Insulinoma in a Deployed Infantryman: Significance of Neuroglycopenia and the Role of the Military Health System

Military Medicine ◽

10.1093/milmed/usab261 ◽

2021 ◽

Author(s):

Samuel T Olatunbosun ◽

Ayodeji F Alaketu ◽

Joseph H McDermott ◽

Al M Elsayed von Bayreuth

Keyword(s):

Health System ◽

Rare Condition ◽

Service Member ◽

Hyperinsulinemic Hypoglycemia ◽

Suspected Case ◽

Military Health System ◽

Military Population ◽

Military Health ◽

The Military

ABSTRACT Insulinoma, the prototype of endogenous hyperinsulinemic hypoglycemia, is a very rare condition, with an incidence of four cases per million person-years. Its rate of occurrence in the U.S. military population is unknown. Two cases of insulinomas involving active duty service members have been published. However, there has been no reported case of an insulinoma in a deployed service member. We report the case of a 21-year-old infantryman with clinical hypoglycemia of insidious onset, manifesting with overt neuroglycopenic symptoms during his deployment as a combatant soldier, and the ultimate diagnosis of an insulinoma as the underlying cause. The series of multiple clinical evaluations and the unique circumstances leading to the formal evaluation of the patient’s hypoglycemia and treatment are chronicled. The significance of neuroglycopenia and the diagnostic approach to any suspected case of hypoglycemia, the potential challenges and opportunities, and educational aspects of evaluation and management of the insulinoma are elaborated. The potential role of the Military Health System in facilitating the detection and treatment of this rare condition in the service member is discussed as well.

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Incidental diagnosis of haemophilia: A case report of three cases following voluntary medical male circumcision in South Africa

Journal of Clinical Images and Medical Case Reports ◽

10.52768/2766-7820/1078 ◽

2021 ◽

Vol 2 (2) ◽

Author(s):

Donna Jacobs ◽

◽

Carla Visser ◽

Freck Dikgale ◽

Ngoanamathiba Molepo ◽

...

Keyword(s):

South Africa ◽

Adverse Events ◽

Wound Management ◽

Voluntary Medical Male Circumcision ◽

Haemophilia A ◽

Bleeding Disorders ◽

African Countries ◽

Medical Male Circumcision ◽

Incidental Diagnosis ◽

Prolonged Bleeding

Introduction: Since 2007, over 15.2 million Voluntary Medical Male Circumcisions (VMMCs) have been performed in 14 sub-Saharan African countries for partial prevention of transmission of HIV. In South Africa, close to 4 million VMMCs have been conducted since the onset of the national VMMC program in 2010. Within this context, the occurrence of notifiable adverse events related to peri-operative bleeding occurs commonly. The ability to screen, diagnose, and manage these cases appropriately will mitigate associated adverse events. Aim: In this paper, we describe three cases of prolonged bleeding after VMMC procedure and propose program measures. Methods: Descriptive haemophilia case accrual at three sites implementing a PEPFAR- funded VMMC program. The cases were recruited consecutively over a 17-month period (May 2017 to September 2018). Standard laboratory tests were used to confirm diagnosis. Written assent and informed consent were obtained from each subject and their respective guardians. Results: A total number of 31 severe or moderate adverse events were reported of whom three 16-year-old clients from three different provinces in South Africa were diagnosed with Haemophilia post VMMC services during July 2018. Two clients were diagnosed with Haemophilia A and one client was diagnosed with Haemophilia B. Conclusions: Greater emphasis on training and placement of qualified health care workers for peri-operative screening as well as a high index of suspicion for pre-operative diagnosis and appropriate referral for bleeding disorders is highly recommended. Clinical VMMC protocols guiding post-operative wound management, adverse event management, active client follow-up and care need to be reinforced, with rigorous reporting. Keywords: Prolonged bleeding; Adverse events; Haemophilia; Screening; Bleeding disorders; Incidental diagnosis.

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rs11670527 Upstream of ZNF264 Associated with Body Mass Index in the Coriell Personalized Medicine Collaborative

Military Medicine ◽

10.1093/milmed/usz216 ◽

2019 ◽

Vol 185 (Supplement_1) ◽

pp. 649-655

Author(s):

Dara M Kusic ◽

Wendy N Roberts ◽

Joseph P Jarvis ◽

Pan Zhang ◽

Laura B Scheinfeldt ◽

...

Keyword(s):

Body Mass Index ◽

Personalized Medicine ◽

Body Mass ◽

P Value ◽

Healthy Weight ◽

Military Health ◽

Complex Genetics ◽

Genome Wide ◽

A Genome ◽

The Military

Abstract Introduction: the effects of obesity on health are a concern for the military as they affect the fitness to serve of active service members, increase costs to the Military Health System, and reduce quality of life for veterans and beneficiaries. Although obesity can be influenced by behavioral and environmental factors, it has also been shown to be associated with genetic risk factors that are not fully understood. Materials and Methods: we performed a genome-wide association study of 5,251 participants in the Coriell Personalized Medicine Collaborative, which includes 2,111 Air Force participants. We applied a generalized linear model, using principal component analysis to account for population structure, and analyzed single-variant associations with body mass index (BMI) as a continuous variable, using a Bonferroni-corrected P-value threshold to account for multiplicity. Results: we identified one genome-wide significant locus, rs11670527, upstream of the ZNF264 gene on chromosome 19, associated with BMI. Conclusions: the finding of an association between rs11670527 and BMI adds to the growing body of literature characterizing the complex genetics of obesity. These efforts may eventually inform personalized interventions aimed at achieving and maintaining healthy weight.

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Prevalence and correlates of voluntary medical male circumcision adverse events among adult males in the Copperbelt Province of Zambia: A cross-sectional study

PLoS ONE ◽

10.1371/journal.pone.0256955 ◽

2021 ◽

Vol 16 (9) ◽

pp. e0256955

Author(s):

Imukusi Mutanekelwa ◽

Seter Siziya ◽

Victor Daka ◽

Elijah Kabelenga ◽

Ruth L. Mfune ◽

...

Keyword(s):

Adverse Events ◽

Male Circumcision ◽

Associated Factors ◽

Cross Sectional Study ◽

World Health ◽

Voluntary Medical Male Circumcision ◽

Adult Males ◽

Sectional Study ◽

Cross Sectional ◽

Medical Male Circumcision

Background Voluntary Medical Male Circumcision (VMMC) is a key intervention in HIV/AIDS. Improving VMMC program uptake in Zambia requires careful monitoring of adverse events (AE) to inform program quality and safety. We investigate the prevalence of VMMC AE and their associated factors among adult males in Ndola, Copperbelt Province, Zambia. Methods We performed a cross-sectional study using secondary clinical data collected in 2015 using two validated World Health Organisation/Ministry of Health reporting forms. We reviewed demographics and VMMC surgical details from 391 randomly sampled adult males aged ≥18 years at Ndola Teaching Hospital, a specialised VMMC fixed site in Zambia. Non-parametric tests (Fisher’s exact test or Chi-square depending on assumptions being met) and logistic regression were conducted to determine the relationships between associated factors and VMMC AE. Results The overall VMMC AE prevalence was 3.1% (95% CI 1.60%– 5.30%) and most AEs occurred postoperatively. In decreasing order, the commonly reported VMMC AE included; bleeding (47.1%), swelling (29.4%), haematoma (17.6%), and delayed wound healing (5.9%). There was an inversely proportional relationship between VMMC volume (as measured by the number of surgeries conducted per VMMC provider) and AEs. Compared to the highest VMMC volume of 63.2% (247/391) as reference, as VMMC volume reduced to 35.0% (137/391) and then 1.8% (7/391), the likelihood of AEs increased by five times (aOR 5.08; 95% CI 1.33–19.49; p = 0.018) and then sixteen times (aOR 16.13; 95% CI 1.42–183.30; p = 0.025) respectively. Conclusions Our study found a low prevalence of VMMC AEs in Ndola city, Copperbelt Province of Zambia guaranteeing the safety of the VMMC program. We recommend more surgically proficient staff to continue rendering this service. There is a need to explore other high priority national/regional areas of VMMC program safety/quality, such as adherence to follow-up visits.

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Vitamin D Deficiency in the Military: It’s Time to Act!

Military Medicine ◽

10.1093/milmed/usab402 ◽

2021 ◽

Author(s):

Sarah A Fogleman ◽

Cory Janney ◽

Lynn Cialdella-Kam ◽

James H Flint

Keyword(s):

Vitamin D ◽

Vitamin D Deficiency ◽

Musculoskeletal Injury ◽

Current Status ◽

Vitamin D Status ◽

Military Health System ◽

Military Population ◽

Military Health ◽

The Military ◽

Practical Recommendations

ABSTRACT Vitamin D is critically important to numerous physiologic functions, including bone health. Poor vitamin D status is a common but underrecognized problem that predisposes the military population to stress fracture and completed fracture. This has significant implications for force health protection, warfighter readiness, attrition, and cost. Despite this, vitamin D deficiency is still underdiagnosed and undertreated in the military. This is a major hindrance to military readiness and one that could easily be modified with awareness, prevention, and early treatment. In this commentary, we review the literature on vitamin D deficiency and critically examine the current status of policies and clinical practice related to vitamin D in the military health system. We offer several practical recommendations to increase awareness and readiness while decreasing musculoskeletal injury and the associated costs.

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Prevalence of male circumcision in four culturally non-circumcising counties in western Kenya after 10 years of program implementation from 2008 to 2019

PLoS ONE ◽

10.1371/journal.pone.0254140 ◽

2021 ◽

Vol 16 (7) ◽

pp. e0254140

Author(s):

Elijah Odoyo-June ◽

Stephanie Davis ◽

Nandi Owuor ◽

Catey Laube ◽

Jonesmus Wambua ◽

...

Keyword(s):

Male Circumcision ◽

Program Planning ◽

P Value ◽

Voluntary Medical Male Circumcision ◽

Cross Sectional Survey ◽

Cross Sectional ◽

Medical Male Circumcision ◽

Prevalence Estimates ◽

Kappa Agreement ◽

The Impact

Introduction Kenya started implementing voluntary medical male circumcision (VMMC) for HIV prevention in 2008 and adopted the use of decision makers program planning tool version 2 (DMPPT2) in 2016, to model the impact of circumcisions performed annually on the population prevalence of male circumcision (MC) in the subsequent years. Results of initial DMPPT2 modeling included implausible MC prevalence estimates, of up to 100%, for age bands whose sustained high uptake of VMMC pointed to unmet needs. Therefore, we conducted a cross-sectional survey among adolescents and men aged 10–29 years to determine the population level MC prevalence, guide target setting for achieving the goal of 80% MC prevalence and for validating DMPPT2 modelled estimates. Methods Beginning July to September 2019, a total of 3,569 adolescents and men aged 10–29 years from households in Siaya, Kisumu, Homa Bay and Migori Counties were interviewed and examined to establish the proportion already circumcised medically or non-medically. We measured agreement between self-reported and physically verified circumcision status and computed circumcision prevalence by age band and County. All statistical were test done at 5% level of significance. Results The observed MC prevalence for 15-29-year-old men was above 75% in all four counties; Homa Bay 75.6% (95% CI [69.0–81.2]), Kisumu 77.9% (95% CI [73.1–82.1]), Siaya 80.3% (95% CI [73.7–85.5]), and Migori 85.3% (95% CI [75.3–91.7]) but were 0.9–12.4% lower than DMPPT2-modelled estimates. For young adolescents 10–14 years, the observed prevalence ranged from 55.3% (95% CI [40.2–69.5]) in Migori to 74.9% (95% CI [68.8–80.2]) in Siaya and were 25.1–32.9% lower than DMMPT 2 estimates. Nearly all respondents (95.5%) consented to physical verification of their circumcision status with an agreement rate of 99.2% between self-reported and physically verified MC status (kappa agreement p-value<0.0001). Conclusion This survey revealed overestimation of MC prevalence from DMPPT2-model compared to the observed population MC prevalence and provided new reference data for setting realistic program targets and re-calibrating inputs into DMPPT2. Periodic population-based MC prevalence surveys, especially for established programs, can help reconcile inconsistencies between VMMC program uptake data and modeled MC prevalence estimates which are based on the number of procedures reported in the program annually.

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