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

24 Background: Voluntary medical male circumcision (VMMC) significantly reduces the risk of 25 acquiring HIV in men. Despite the percentage of circumcised men (15-49 years) in Uganda 26 increasing over time, some populations are not taking up the surgical procedure. The 27 government of Uganda and implementing partners have responded to this lack of VMMC 28 coverage among key populations by intensifying introducing innovative strategies that increase 29 demand particularly among military personnel using the WHO’s MOVE strategy. As a surgical 30 intervention, it is critical that VMMC services are safe for clients and that adverse events or 31 complications are minimized. This paper describes the prevalence and trends of adverse events 32 reported among military mobile camps in comparison to civilian sites in Uganda. 33 Methods: A prospective study conducted in eighteen (18) public health facilities between 34 March and August 2019. Of these nine (9) were providing care to civilian populations while 35 nine (9) served the military population and catchment areas. Descriptive statistics, Chi-square 36 test and trends analysis were carried out to describe profile of advance events among civilian 37 and military facilities over the study period. 38 Results: The highest proportions of VMMC were done among persons aged 15 to 19 years 39 whereas among military camps the highest proportions of circumcision among males aged 20 40 to 24 years. Regarding site of circumcision, the highest proportions of VMMC were done at 41 outreaches, with higher levels in military camps compared to civilian camps. For the 42 proportions of adverse events reported, higher proportions were reported in civilian camps 43 compared to military camps (Total – 1.3% vs 0.2%; p- value<0.05). For trends analysis, results 44 indicate that there was no statistically significant trend for both civilian and military number 45 of adverse events reported for the four quarters in 2020 (P-value =0.315 for civilian and 46 P=0.094 for the military). 47 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 49 and collectively addressed by key stakeholders – leadership, community engagement and using 50 a largely horizontal approach offer promising possibilities and outcomes.

Voluntary medical male circumcision (VMMC) significantly reduces the risk of acquiring HIV 55 in men (1-9) and for every circumcision there is a reduction of male to female sexual 56 transmission of HIV by approximately 60% (10,11). VMMC is associated with several health 57 benefits such as reducing the risk of contracting genital ulcers, syphilis, penile cancer, human 58 papillomavirus (HPV), herpes simplex virus (HSV) and cancroid (12,13). 59 Given that the Southern and Eastern African countries have been severely affected by the HIV 60 epidemic, prevention and treatment services remain significant public health priorities [19]. 61 Uganda is a priority country for VMMC scale-up, with HIV prevalence among adults at 6.2%, 62 7.6% among women and 4.7% among men in 2016; corresponding to approximately 1.2 63 million adults living with HIV (14). Despite, the percentage of circumcised men (15-49 years) 64 in Uganda increasing from 24% in 2006 to 27% in 2011 and 46% in 2016 (15, 16); of these, circumcision services (17). The MOVE model advocates for a task-shifting and task-sharing 77 approach; whereby task-shifting refers to the use of non-physician providers to complete all 78 steps of male circumcision surgery. This allows the operator (or surgeon) to focus on the most 79 technically complex components of the surgery. In task-shifting and task-sharing models, 80 surgical activities are reassigned, where appropriate, from those providers qualified for such 81 interventions, e.g. physicians, to other appropriately trained and competent healthcare 82 providers, e.g. clinical officers and nurses (17) events may be managed locally on site of the VMMC service delivery or referred to a higher-104 level health facility or to a specialist for further management for adverse events related to 105 partial or complete amputation of the glans or shaft; resulting in permanent disability; and 106 resulting in permanent anatomic deformity.

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Timely and proper management of VMMC adverse events is very crucial for the attainment of 108 the set goals of VMMC to prevent HIV and STI. There is little is known about adverse rates 109 reported among the various projects implementing VMMC programs in different populations 110 and contexts. This paper describes the prevalence and trends of adverse events reported among 111 military mobile camps in comparison to civilian sites in Uganda.

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Study aim: 114 To describes the prevalence and trends of adverse events reported among military mobile 115 camps in comparison to civilian sites in Uganda.

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The study took place in eighteen (18) public health facilities. Of these nine (9) were providing 118 care to civilian populations while nine (9) served the military population and catchment areas.

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The health facilities are located in all regions of Uganda. These sites were selected for the 120 scale-up because they met the minimum standards for providing safe VMMC including that 121 appropriate VMMC outreach/mobile sites must: be co-located or close to a health facility; have 122 sufficient space for comprehensive VMMC services; have water, electricity, and sewerage   The leaders and VMMC teams systematically targeted areas previously without VMMC 158 services, including locations of recently recruited personnel. The military men were identified 159 systematically through assistance from military commanders who mobilized their teams.

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Military men or clients eligible for VMMC were then mobilized by commanders and 161 voluntarily participated in the circumcision exercises. 162 We implemented a military-centered, persistently high-frequency community mobile VMMC 163 service which catered for soldiers, their families and surrounding communities. We adopted

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Results from Table 1 indicate that there were differences in age by region between civilian and    regarding the number of adverse events reported (Table 2).

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The adverse events reported in facilities were higher compared to outreach (civilian -4.1% vs 295 0.6% and military-0.5% vs 0.1%). In a facility-based setting, field studies in other sub-Saharan

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African settings report low AE rates (< 2%) (35-39), and these low rates could be due to the 297 fact that some AEs may not be identified, in part as clients may seek care outside of routine 298 VMMC settings. Also, it is important to note that the men circumcised from outreaches may 299 find it hard to return to their camps of circumcision for follow up thus the low rates of reporting 300 adverse events in outreaches.

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Although younger boys ages 10-14 represent the majority of program VMMCs, they are not 302 more likely, overall, to have an AE than their older peers (40