The quality of voluntary medical male circumcision done by mid-level workers in Tshwane District, South Africa: A retrospective analysis

BACKGROUND: Voluntary medical male circumcision (VMMC) reduces the acquisition of human immunodeficiency virus (HIV) in heterosexual men by up to 60%. One HIV infection is averted for every 5 to 15 VMMCs. To conduct VMMCs in large populations, large numbers of trained healthcare professionals are needed. Countries in Sub-Saharan Africa have a high burden of HIV and a shortage of healthcare professionals, creating a healthcare conundrum. To bridge this gap, South Africa launched a new cadre of mid-level medical worker called Clinical Associates (CA). We assessed the ability of CAs to perform circumcisions of adequate quality and their subsequent usefulness to meet the demands of VMMCs in a population with a high HIV burden. METHODS: We conducted a retrospective analysis, reviewing patient files (n = 4850) of surgical VMMCs conducted over a 16-month period. Patient files were sourced from clinics and hospitals that provided free VMMCs in Tshwane district in South Africa. FINDINGS: Clinical associates performed 88.66% of the circumcisions and doctors performed the remaining 11.34% (p < 0.001). The number of adverse events did not differ between the two groups. Data on intra-operative adverse events were available for 4 738 patients. Of these, 341 (7.2%) experienced intra-operative adverse events. For the whole sample, 44 (8.1%, n = 543) adverse events occurred during circumcisions done by doctors and 297 (7.1%, n = 4195) occurred during circumcisions done by CAs (p = 0.385). Clinical associates performed circumcisions in shorter times (duration: 14.63 minutes) compared to doctors (duration: 15.25 minutes, t = -7.46; p < 0.001). Recorded pain, bleeding, swelling, infection and wound destruction did not differ between clients circumcised by CAs and doctors. This study is limited by the use of data from a single district. CONCLUSIONS: Clinical associates contribute to the demands for high numbers of VMMCs in Tshwane district, South Africa. Clinical associates perform VMMCs at a clinical standard that is comparable to circumcisions performed by doctors.