Task shifting for male medical circumcision safe: international review

With proper training and supervision task shifting of medical male circumcision to non-physician clinicians in Africa can be done safely, according to researchers in South Africa and North America reporting in the advance online edition of AIDS.

This systematic review and analysis of ten studies (from South Africa, Kenya, Comoros, Nigeria, Zambian and Uganda) with information on over 25,000 circumcisions done by trained non-physician clinicians (nurses, midwives, surgical aides and clinical officers) found adverse events were not serious; and the pooled relative risk in two studies separately reporting outcomes for doctors and non-physicians showed comparable rates of adverse events (1.18: 95% CI: 0.78-1.78).

Evidence from randomised trials and observational studies support the protective effect of male circumcision for men getting HIV. Widespread male circumcision in Africa could prevent up to six million new infections and three million deaths in the next twenty years according to mathematical modelling estimates, note the authors.

With its potential as a high impact and cost-effective intervention both UNAIDS and the World Health Organization (WHO) promote voluntary male medical circumcision, with the latter providing guidelines for scaling-up of services in eastern and southern Africa.

In addition to ethical and acceptability challenges a severe shortage of health care workers in high prevalence countries, notably in Eastern and Southern Africa, is one of the major obstacles to effective scale-up.

Task shifting, the planned delegation of tasks from specialists or doctors to non-physician health care professionals, is a proposed strategy supported by WHO to increase scale-up of HIV treatment and prevention services. Randomised trials have provided evidence of the safety and efficacy of task shifting for ART.

To date evidence of the safety of circumcision by non-physician health care workers has been mixed. Reports of high rates of serious complications, note the authors, have confused those circumcisions undertaken by lay people with little or no training, lack of supervision or supportive equipment with circumcisions undertaken as a result of task shifting.

While there have been systematic reviews looking at the frequency of adverse events after circumcision, none have specifically looked at task shifting, note the authors.

The authors undertook a search of online databases and conference websites up to July 2011 reporting the outcomes of task shifting for circumcision in Africa.

Task shifting was clearly defined as “the planned delegation of the surgical act of male medical circumcision to non-physician clinicians (that is any health workers below the level of doctor).” All unplanned studies (those without training and/or supervision) were excluded. Studies with teams of providers were included as long as more than 70% of the team were non-physician clinicians.

Out of 1,885 citations first identified 33 studies were evaluated and a final ten were included in the analysis, of which six were undertaken in health care settings and four in the community. Two studies described a task-sharing model in which a doctor was part of the team; eight reported on outcomes in adults and two on outcomes in children.

The proportion of adverse events ranged from 0.70% (95% CI:0.44-1.02%) to 37.36% (95% CI:27.54-47.72%) with an overall pooled proportion of 2.31% (95% CI:1.46-3.16%). A high level of heterogeneity was expected. Using an alternative means of confidence interval estimation did not change the proportion (2.33; 95% CI:1.44-3.20).

No differences in the frequency of adverse events were seen when comparing adults and children; or between task shifting and task-sharing models; or when circumcisions were done in the community compared to the health care setting.

Among the six studies reporting on specific complications excessive bleeding ranged from 0.30-24.71% with an overall pooled prevalence of 0.55% (95% CI: 0.13-0.97%); and infection was seen in 0.30-1.85% of cases with an overall pooled proportion of 0.88% (95% CO:0.29-1.47%).

The authors note their findings are comparable to male medical circumcisions undertaken by doctors, urologists and surgeons and cite a systematic review that found the frequency of severe adverse events ranged from 0 to 25% in children and 0 to 33% in adolescents and adults.

Additionally they cite a report from Israel of over 19,000 circumcisions done mostly by trained ritual circumcisers with an adverse event rate of 0.34%.

The authors suggest some of the studies may have underestimated the number of adverse events if only immediate issues were reported. Infection can take a few days and sexual function problems take longer to determine.

While the authors included a broad search category they were aware of much unpublished data from routine programmes where circumcision is part of HIV prevention. Data was not disaggregated by provider so could not be included.

Critical to the safety of male medical circumcision is the quality of training and supervision, availability of safe equipment and the number of circumcisions performed, the authors stress. They cite a Ugandan study that showed the post-training rate of adverse events after circumcisions done by physicians went from 8.8% for the first 20 procedures to 2% after 100 procedures. One study in this review similarly reported complication rates at 3.8% for the first 100 procedures falling to 0.7% after 400 procedures.

Areas for further research, according to the authors, include reporting of all factors contributing to safety including:

• Length and duration of training

• Provision and use of supportive materials

• Relative contribution of team members where a skills mix is used

• Frequency of adverse events depending on the experience of the practitioner

• Standardised approach to the reporting of adverse events.

The authors note that as an HIV prevention intervention circumcision has been found to be cost-effective. However, what is also needed is the assessment of the potential cost savings of task shifting.

Charging for services has led some to turn to informal providers with adverse results.

The authors conclude their “review provides reassurance that task shifting of male medical circumcision to non-physician clinicians can be done safely, with reported rates of adverse events similar to doctors and specialists.”

Reference

Ford N et al Safety of task shifting for male medical circumcision in Africa: a systematic review and meta-analysis. Advance online edition AIDS 25, doi:10.1097/QAD.0b013e32834f3264, 2011.