To give voluntary medical male circumcision (VMMC) service providers the required competencies to provide a full package of VMMC services, according to national, World Health Organization/Joint United Nations Programme on HIV/AIDS (WHO/UNAIDS) and U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) standards. These competencies include the following:
- Group education and individual counseling on VMMC and human immunodeficiency virus (HIV) risk reduction
- Pre-procedure clinical eligibility screening
- Pain control using appropriate weight-based dosing of local anesthetic agents
- Povidone iodine skin preparation with two-minute drying time before circumcision
- Immediate post-procedure clinical monitoring
- Clinical follow-up including diagnosis, management and referral of adverse events
- Training and use of emergency commodities to handle any potentially severe/life threatening adverse events, and/or having developed in advance and able to utilize a rapid referral plan for more advanced levels of medical care, as needed
- Referral and active linkage of VMMC clients identified as HIV-positive at VMMC sites to HIV care and treatment services as well as other services, such as STI treatment
- Use of safe injection techniques
- (For supervisors) Provide supportive supervision for other service providers.
WHAT USERS NEED TO KNOW
To maintain the highest level of quality and safety required of an elective surgical/clinical program, all those providing services at the site must have completed and been deemed competent by a recognized in-service training program in providing the full minimum package of VMMC services, including clinical circumcision services, as well as HIV testing, risks/benefits of circumcision, risks of complications, post-procedure hygiene, wound care, and abstinence counseling. [See Chapter 6—Providing the VMMC Minimum Package of Services (Tables 6.1 and 6.2)].
Providers should be specifically trained in eligibility screening, including medical history, physical examination, screening for sexually transmitted infections (STIs), tetanus vaccination history, and tetanus risk. The actual circumcision procedure must be by a WHO-recognized method, including forceps-guided (for males older than 14 years), dorsal slit, sleeve resection, or a WHO-prequalified medical device for adolescent or adult VMMC. Programs using electrocautery for hemostasis must provide adequate training in both electrocautery and placement of ligating sutures (Table 5.1). Special attention during training is given to weight-based dosing of local anesthetic for pain control, with particular emphasis on the correct technique for injection of local anesthetic (aspiration before EVERY injection of anesthetic agent to ensure the needle is not in a blood vessel or the corpus cavernosum). Safe injection training also addresses the problem of “double-dipping” and reuse of anesthetic vials, needles, or syringes between patients [See Chapter 9].
Providers are trained on clinical follow-up, including screening, documentation, diagnosis, management, and reporting of adverse events. While numerous VMMC for HIV prevention curricula exist throughout the sub- Saharan region, all must be based on core knowledge and skills outlined by WHO [See WHO Manual for Male Circumcision Under Local Anaesthesia, 1st edition]. Supplemental training information has also been developed that sites should use to ensure providers are up to date on the current standard of practice, such as identification and management of adverse events [See COSECSA/PSI VMMC AE Action Guide] and correct use of electrocautery [See Manual for Use of Electrocautery in VMMC]. Training material specific to VMMC counseling should also be used [See VMMC Counseling Training Package].
Site-level refresher training in best practices [See VMMC Video: Implementing Best Practices] and basic VMMC science [See Global Health e-Learning Course—Male Circumcision: Policy and Programming] may be useful for identifying opportunities for innovation and ensuring retention of basic knowledge. For sustainability of the program, existing supervision systems should also be strengthened; those responsible for supervising VMMC service providers may benefit from supportive supervision training [See Supervising Healthcare Services: Improving the Performance of People] and tools for assessing providers to ensure ongoing competency or to identify needs for refresher training [See Quality Assessment Toolkit].
TOOLS, INSTRUMENTS & GUIDANCE DOCUMENTS
The following documents, which are available online and in the accompanying external media (included with the hard copy version of this Guide), provide the background information or procedural guidance used for development of this chapter.
- WHO Manual for Male Circumcision Under Local Anaesthesia, 1st edition
- COSECSA/PSI VMMC AE Action Guide
- Manual for Use of Electrocautery in VMMC (PDF, 344 KB)
- VMMC Counseling Training Package
- VMMC Video: Implementing Best Practices
- Global Health e-Learning Course—Male Circumcision: Policy & Programming
- Supervising Healthcare Services: Improving the Performance of People
- VMMC Standardized Job Descriptions
- Training Information Management System Form
- Quality Assessment Toolkit
To see charts, graphs, and read additional information, download the chapter PDF.