Attachment 7_VMMC Service Assessment Report of USAID-Supported Sites.pdf

Attachment 7: VMMC Service Assessment Report of USAID-Supported Sites in South Africa, June 27-July

13, 2011

Prepared by: Olga Mashia, Rebecca Fertziger, Tigitsu Adamu, Pamala, Abubakary and

Njeuhmeli, Emmanuel

U. S. President’s Emergency Plan for AIDS Relief

09/05/2011

VMMC Service Assessment Report of USAID-Supported Sites in South Africa June 27- July 13, 2011

Annexure 7: VMMC Service Assessment Report of USAID-Supported Sites in South Africa, June 27-July

Table of Contents Introduction

Availability of SOPs, Guidelines, Policies and Records:

Adequacy of Facilities, Supplies and Equipment

Completeness of Clinical Record Keeping and Monitoring and Evaluation:

Comprehensiveness of services and linkages

Adequacy of Staffing

Adequacy of Clinical/Surgical Practices

Communication to Clients

Waste Management

Conclusions

Frequently Used Abbreviations and Terms:

AE Adverse event ART Antiretroviral therapy CD4 CD4 lymphocyte count, in cells/µL CDC Centers for Disease Control and Prevention CHAPS Center for HIV and AIDS Prevention Studies Diathermy (electrocautery) Electrically-induced heat to cauterize a wound or vessel DS Dorsal sleeve resection, a male circumcision technique EQA External quality assurance FG Forceps guided, a male circumcision technique FIFO “First In, First Out,” indicating that materials received first should be distributed first F/U Follow-up H&P History and physical HTC HIV testing and counseling IEC Information Education and Communication IP Infection Prevention KZN Kwa Zulu Natal MC Voluntary medical male circumcision MOH Ministry of Health NDOH National Department of Health OT Operating theatre PEP Post-exposure prophylaxis for HIV PEPFAR U.S. President’s Emergency Plan for AIDS Relief QA Quality assurance QC Quality Control QI Quality Improvement RH Reproductive health SA South Africa SOP Standard operating procedure SR Sleeve resection, a male circumcision technique STI Sexually transmitted infection UNAIDS The Joint United Nations Program on AIDS

USAID United States Agency for International Development

VS Vital signs (i.e., pulse, blood pressure, temperature, respirations)

WHO World Health Organization

Introduction

The United States Agency for International Development (USAID)conducted quality and ‘preparation to scale’ of 14 government- and partner-operated VMMC facilities in Gauteng, Free state, KZN and

Mpumalanga Provinces in South Africa (SA).

Quality assurance (QA) is the process of assessing and evaluating program activities against defined standards so as to identify strengths and gaps and provides guidance for program (and policy) improvement. The overarching goals of quality in VMMC are clinical safety and the provision of a minimum package of services defined by PEPFAR and the World Health Organization (WHO) in standardized manner. PEPFAR’s external quality assurance (EQA) assessments are conducted using a toolkit that is derived from the one published by the WHO/UNAIDS for the normative standards developed for MC self-assessments.i PEPFAR, as a major funder of VMMC activities, places additional emphasis on program efficiency and productivity; ability to meet impact targets; communication and promotional activities; and any issues specific to a country (e.g., standardization of service deliver in SA).

Thus, PEPFAR’s EQA process strongly complements sites’ self-assessment activities. Provides objective assessment to guide improvements and aims at creating incentives for clinics to align services with national standards and donor guidelines, facilitates achievement of VMMC service targets, complements

WHO’s QA self-assessment tool, and promotes public recognition and confidence in the VMMC services provided.

The overarching goals of the EQA assessments were to: a) to ensure that the PEPFAR-funded VMMC programs in SA are conducted according to the best clinical and programmatic evidences and practices, and b) provide regular, standardized feedback regarding service volume and client characteristics. To achieve these goals the following objectives were developed.

Objective: To assess components of the comprehensive VMMC service in order to highlight strengths, identify gaps and suggest possible interventions.

Specific objectives: To assess:

Availability of SOPs, Guidelines, Policies Pertinent to MC Provision

Adequacy of Facilities, Supplies and Equipment

Completeness of Clinical Record Keeping and Monitoring and Evaluation

Comprehensiveness of Non-Surgical Services and Referrals

Adequacy of Staffing

Adequacy of Clinical/Surgical Practices

Communication to Clients

Efficiency and Public Health Impact

Waste management

The methods used to collect this information included document and chart reviews, observations of facilities, MC and HIV counseling sessions and surgeries, interviews and discussions with key personnel.

This assessment was completed for 14 VMMC Sites supported by USAID (5 in Gauteng, 1 Free State, 2 in

KwaZulu-Natal, 6 in Mpumalanga).

Availability of SOPs, Guidelines, Policies and Records:

TOOLS A&B

Across all the facilities we observed a comprehensive list of guidelines, forms and SOPs. However no site had all the SOPs, Guidelines, Policies and records in place (Patient rights policies, staff job description, personnel files, Inform Consent process guidelines, HIV/AIDS Counseling and Testing guidelines, STI guidelines, Supplies and equipment inventory reports, medication inventory, emergency guidelines, waste management guideline and SOPs, quality control register for HIV tests, Infection prevention guidelines, MC procedure checklists, complications and AE management guidelines). Some partner-supported sites didn’t have the documents at site level but rather at partners’ office. A few sites developed their own SOP and guideline documents because of the lack of a standard SOP. Some of these documents do not articulate the NDOH’s stand in scaling up VMMC.

Challenges

• Lack of specific National Guidelines that sites can use or refer to; this forces each partner to develop its own guidelines hence multiple versions of documentation that makes service continuity outside the service provision site difficult.

• Adverse events reporting and management guidelines are not consistent with WHO recommendations.

– National guidelines are not placed in VMMC clinics to guide service providers. Although national guidelines on STI, HTC and Waste management exist, most VMMC sites don’t have all or some of them.

Recommendations

• Partners work with NDOH and national task force for VMMC to adapt and use standardized guidelines.

• Partners work with PEPFAR and the NDOH to fill the gaps on guidelines that are key for service quality and efficiency, but not available in SA.

Adequacy of Facilities, Supplies and Equipment

TOOL B

Findings

Most of the facilities have adequate and dedicated space for male circumcision and are using existing supply chain management for supplies and equipment. Although it was not possible to assess the facilities supply chain management system, the supplies are adequately distributed to the sites.

Generally, facilities keep only limited stock of supplies (i.e. a week supply) and there have been reports of stock outs. The visit identified some shortages/absence of supplies, such as chairs for the waiting room and group education sessions, audiovisuals for group education, waiting room and recovery room.

Recommendations

Site space needs to be designed in such a way that client flow is as described by WHO MOVE document.

Sites need to increase the amount of stock especially during high circumcision seasons and use FIFO.

Also storage of supplies needs to be revisited in some sites.

Completeness of Clinical Record Keeping and Monitoring and Evaluation:

TOOL C

Findings:

All clinics keep records of the VMMC services provided and reports compiled by the implementing partner that support the program and are shared with USAID at different intervals. A majority of the clients (>88% on average) are above the age of 15. In VMMC clinics, on average 5% of clients test positive for HIV. Completeness of records ranges from 70% for client history and physical examination to 100% for clients demographic information.

The type of procedures performed in all the clinics is not recorded, however clinic managers reported that forceps guided is the only surgical method used. All sites also use diathermy for hemostasis but this isn’t recorded anywhere in the clients charts that were reviewed.

Consent forms are missing in 10% of clients files. 50% of the files documented at least one follow up post circumcision. A majority of these follow ups (75%) were for clients who return to the clinic after 2 days for their first post op reviews; the remaining 25% of clients returned to the clinic at the second day post MC.

Discussion

It is encouraging to see that recording and reporting is given due emphasis in the VMMC program in SA.

However, the recording and reporting tools and systems vary significantly between sites. There are no standardized client record forms, HTC forms, consent forms, referrals, adverse event reporting and management forms and post-operative care forms. Therefore different sites/partners use different forms which capture information with varying degrees of clarity and detail. The Systems for filing client records and tracking follow-up appointments were also highly variable. At two sites, clients’ files were not available onsite as the implementing partner keeps them in its office for the purpose of research.

Most importantly, completeness of records is lacking in all the VMMC sites visited. There are multiple pages of papers that are required to complete for every clients and pages from these files get lost often.

Promising practices One site uses ONE recording format that has most of the information necessary for one client. This approach of having one standardized recording format that has provisions for recording demographics of the client, counseling and testing, consent, history and physical examination, surgical procedure note, post procedure follow up, adverse events recording and management, and referral notes will help reduce paper work, reduce the chance of missing pages from client files, and provide an opportunity to have all documents in one record rather than multiple pages.

Challenges The absence of comprehensive monitoring and evaluation system for VMMC is pushing partners to develop their own system and tools. This makes standardized reporting and experience sharing a challenge. In addition, the presence of multiple recording formats that are not properly introduced to service providers caused the quality of the records to be low.

The monitoring information isn’t changed into electronic formats as expected, but everything is done manually. This proves to be cumbersome and affects the completeness as well as quality of data and reports.

Issues:

Standards recording and reporting tools for the national VMMC program are not available. Client files kept outside clinics.

Recommendations

- One monitoring and evaluation system for the VMMC program in SA is critical to effectively monitor progress, assure safety and plan for expansion.

- Recording and reporting can and should be computerized and data should be accessible for NDOH for decision making real time

- Standardized recording and reporting tools needs to be developed as part of the monitoring system

- Consensus amongst partners and donors on one monitoring system, orientation and training of providers on standardized tools are important considerations for the VMMC programs in SA supported BY PEPFAR

Comprehensiveness of services and linkages

TOOL D

Findings

Generally, sites visited provide the minimum package of services: included are HIV testing and counseling, risk reduction counseling, screening and treatment of STIs. Only few sites, 2 out of 8, refer clients for STI services outside VMMC. Clinic linkages to care and treatment are also implemented in different facilities at different levels. VMMC clinics provide little or no information to women and partners about the services. No couple counseling services are provided.

Discussion

As per the recommendation of WHO, almost all of the sites ‘refer’ and majority of them link clients with care and treatment services. All sites provide HCT services and a majority provides symptomatic screening for STIs. The provision of comprehensive services through referrals and linkages are an accepted standard.

Promising practices o At one site, clients who test positive and have a CD4 count below 350 are ‘escorted’ to care and treatment clinics to be enrolled. Such active linkage between MC and other services need to be strengthened

Challenges

Follow up of clients after referral, according to most of the sites, has proved challenging. There is no mechanism to confirm if clients actually accessed services at the receiving end of the referrals. In particular, referrals to care and treatment are not receiving feedback about clients. In addition, the

VMMC service has little to offer to women in the form of access to information, opportunity to access couple counseling and testing and risk reduction. Although a couple of sites reported efforts to educate women, in general there is a lack of IEC materials that target women and families. Providers are not trained to provide couples counseling in the VMMC clinic.

Issues

Clinics make decisions to circumcise clients who test positive and have a CD4 count of >200 and < 350.

While this cut off for CD4 count along with clinical assessment works well in all the clinics, clients who, according the national guidelines, need to be enrolled for care and treatment as a priority are lost in favor of performing circumcision. The linkage to care and treatment after circumcision is weaker than the linkage before circumcision. Clinics need to prioritize enrollment to care and treatment over circumcision.

Recommendation

A mechanism need to be put in place to track clients referred to other services, mainly care and treatment.

Possible utilization of dedicated personnel (case manager, peer educator, expert client) to provide active referral and linkage

A recording and reporting mechanism to track and document where clients went, when they accessed services. A simple SMS system to provide and or exchange feedbacks between referring and receiving clinics can be helpful.

Adequacy of Staffing

TOOL E

Findings

Most of the sites have highly motivated staffs that are knowledgeable about services provided.

However, the lack of standardized composition of staff and the challenges of getting full time dedicated personnel forced many sites to rely on part-time service providers, especially doctors. This has significantly affected the capacity of sites to provide timely as well as high volume circumcision services.

This will have a huge impact on how clients perceive service provision and how they communicate to potential clients.

• Most sites have staffs working 5 days a week but with variation of time per day

• Physicians’ time is variable from part time to full time

• Some of the staff do not provide MC counseling. They were not trained.

Best Practices

Motivated, hardworking and competent staff were found in ¾ of the sites visited. The number of nurses providing services is much better than that of doctors, but the lack of task shifting prevents nurses from performing the procedure.

Two sites have a dedicated data manager whose main duty is data management and preparation of monthly statistics. Moreover, these two sites have other personnel who do the data quality checks.

About 36% of the sites visited, have dedicated quite a number of recruiters (health promotion officers) who go around the community to advertise and recruit clients for VMMC.

One site has a very important collaboration with another NGO which does HCT for VMMC clients. This reduces the workload for VMMC staff in providing HCT.

Challenges

Each site has a different composition of the MOVE team which makes it difficult to standardize the human resource needed to provide high quality, high volume services without affecting other health services. The fact that service provision is planned based on the availability of doctors makes it inconvenient for clients and will have potential negative consequences when clients share their experience with future clients or community members.

Recommendations

Sites need to develop a standard composition of the MC team that matches with the demand for services. This matching of supply and demand will also improve the quality of services provided at any given time. Most importantly, the presence of a dedicated circumcision providers (i.e. doctors) is critical not only for the actual services but for the management of any adverse event that can occur anytime of the day or night. Each site should also have a data clerk or data manager to help improve the data recording and timely data flow between service provision and program planning.

Adequacy of Clinical/Surgical Practices

TOOL F

Findings:

In all sites most of the standards are fairly adequately met (>80%). Since SA is the pioneer in implementing the MOVE model for efficient service provision in clinics, most providers are aware and practice the principle. Although surgical procedure checklists are not always available in all the sites, most of the steps in the standard checklist are completed/observed by the providers. The local anesthesia of choice is a mixture of Lignocaine and Marcaine and a standard dose is used for all clients.

While the WHO manual document a per kg calculation of anesthesia usage, almost all providers use a predefined amount. Clinics use pre-packaged disposable kits and unlike other places providers do not complain about the number and variety of instruments in the kits. However, a few providers expressed concerns regarding the quality of instruments (one artery forceps broke during the visit and we were told that this is common). The majority of the sites exhibit a reasonable infection prevention and control techniques during the procedure.

Best Practices:

Effective use of MOVE model is applied.

Challenges:

Using the standard dose for local anesthesia instead of weight based dosage. While no major problem occurred to date as per the report of clinic managers, the clinical rationale hasn’t been explained by any of the providers.

No marking of the intended point of incision is done prior to the placement of forceps. While some proficient providers will have the level of proficiency that allows them to not rely on clinical protocols, in such programs where large number of circumcisions are provided for public health benefit, following an internationally agreed upon and locally endorsed protocol is critical.

The recommended vertical mattresses for 3, 9 and 12 o’ clock positions are often replaced with simple interrupted sutures. This also needs to either follow the WHO guide or be informed by documented local evidence. The current practice doesn’t follow both.

Many sites do not record duration of surgery.

The diathermy machine’s ground plate/rod is hand held. The safety of such rods is not well established in VMMC services; therefore the technical implementer need to provide clear guidance and evidence based recommendation when using surgical instruments and devices.

Recommendations:

Since the WHO protocol based on studies recommended the use of weight base calculation, a ground plate very close to the surgical site is something that providers need to re-visit.

It is also recommended that the intended incision line is marked prior to placement of forceps.

This reduces the chance of cutting too much or too little of the foreskin.

Communication to Clients

TOOL G

Best Practices:

Several best practices were observed and these standards should be celebrated and continued. First, many of the clinics have strong outreach and demand for VMMC services is strong overall. The majority of the clinics display signs and posters on VMMC, HIV prevention, risk reduction, etc. Most of the clinics exhibit signage outside of the VMMC facility. Eleven of the twelve clinics display ‘Brothers for Life’ posters inside their clinics. Most of these facilities also offered ‘Brothers for Life’ pamphlets/flyers and/or other take-away IEC materials on VMMC and HIV prevention.

Secondly, several components of the group session and the individual pre- and post- HIV testing and counseling sessions were excellent overall. In all group counseling sessions, counselors made clients feel comfortable, managed group dynamics effectively, and encouraged group interaction. Most group counselors used teaching aids, such as pictures and props, and the vast majority demonstrated correct usage of male condoms and offered complimentary male condoms to clients. All group counselors observed discussed the required six weeks of abstinence following VMMC.

Lastly, all sites offering HCT services insured privacy by providing private rooms for individual HIV testing and counseling.

Challenges:

There are a few challenges regarding IEC materials. First, although many clinics display signs outside of the clinic facility, most fail to mention VMMC’s effect on HIV prevention. Furthermore, many signs are not visible from the street. Therefore, clients need to enter the facility grounds to realize that VMMC services are offered on-site. Also, though most facilities do have some type of IEC materials, flyers and pamphlets seemed in short supply in many clinics, especially when taking supplies of all relevant local languages into account, and these materials were not always being provided to clients. Lastly, none of the sites were taking the opportunity to play video messages on VMMC, HIV prevention, and risk reduction, even though clients were frequently waiting at facilities for several hours or even the better part of the day. Not utilizing a TV fails to take advantage of a valuable messaging opportunity.

There are also many formidable challenges with group and individual counseling sessions. In general, most counseling sessions fail to repeat and re-emphasize key HIV prevention and risk reduction messages, such the importance of partner testing, the partially protective nature of VMMC, the required

6-weeks of abstinence including abstinence from masturbation, and the importance of combining

VMMC with other HIV prevention strategies in order to stay negative. It seems that individual counselors tend to assume that clients previously receive the required messages in the group session and therefore miss out on the chance to reinforce key taking points and promote a deeper understanding.

Group counseling sessions experienced several challenges as well. First, only a minority of group counselors discussed the need to abstain from masturbation. Those that did discuss masturbation were usually prompted due to a question from a client. Including a discussion about masturbation is critical, as clients may not understand that masturbation will delay healing. Secondly, only a few group counselors demonstrated female condoms or offered free samples. Many group counselors failed to explain that STI screening was a key criterion for determining eligibility for VMMC. Furthermore, group counselors failed to explain that VMMC does not directly protect clients’ partners from acquiring HIV.

In certain sites, the space for group counseling is inadequate. A few clinics offer group settings in the lobby – a space that is extremely busy, with doctors, nurses, and clients going in and out. Therefore, privacy and client attention span are major concerns. Many clients were distracted by movement in the hallway, and several were even called out of initial group sessions to fill out admissions paperwork. This is troubling, because it makes it easy for individuals to miss out on certain key messages. Moreover, clients who come late are not always offered group counseling sessions, thus they miss out completely on this experience. Given that risk reduction messages need to be repeated to have an impact on behavior, allowing a client to skip a group session is inappropriate.

Many of the individual post-op counseling sessions were also inadequate. While counselors did tend to discuss general wound care, many failed to talk about potential adverse events or the warning signs requiring immediate attention. Additionally, most post-op counselors failed to explore knowledge about HIV transmission and prevention, discuss information about HIV/AIDS, provide prevention counseling, stress the importance of partner testing, repeat that VMMC is only partially protective against HIV, or discuss a personal prevention strategy.

There are also challenges with counseling supervision in many sites. The VMMC and HIV counseling supervisor is frequently shared by other clinics and/or only available on select days of the week.

Additionally, several challenges with correct messaging were observed, and the lack of counseling supervision could be exacerbating this problem.

Lastly, at several clinics, clients receive counseling services on the other side of the hospital rather than at the VMMC clinic. Therefore, it is difficult to assess whether or not the quality standards are being adhered to and if the messaging if consistent and appropriate.

Recommendations

There are many recommendations that will improve the overall communications practices of local clinics and the following details specify suggestions for each section of Tool G:

a. Male Circumcision Promotion Efforts

Each clinic should have a sign outside which is visible from the street, not just inside of the hospital or facility, which mentions VMMC’s proven effect on HIV prevention.

Each clinic should increase the availability of IEC materials on VMMC, HIV prevention, and risk reduction overall and insure that each pamphlet/flyer is available in all relevant local languages.

If possible, each clinic should add a TV and DVD player so that VMMC and/or HIV prevention messages may be broadcasted during the client waiting period.

o In the long run, standardized videos should be produced for VMMC to ensure consistent messaging going forward.

o For now, the mission should consider looking into MTV’s PEPFAR-sponsored ‘Shuga’ series or other pre-prepared material so as to not miss out on this valuable messaging opportunity.

More effort needs to be put into matching site-specific supply with demand. While certain sites were booked until September and/or sending away clients on a daily basis, others will need to put far more effort into outreach to match supply with demand as their capacity for VMMC increases.

b. Education and Counseling Resources and Procedures

The overall VMMC messaging protocol for all counseling sessions should be reviewed, and

USAID should provide a comprehensive guide that details specific key messages for each step of client communication.

o All counselors should incorporate more risk reduction and HIV prevention messages into group and individual sessions. These key messages should be repeated and reinforced during each step of client communication.

o All counselors must communicate that VMMC is only partially protective and discuss the importance of combining VMMC with other prevention strategies in order to stay negative.

o All counseling sessions should emphasize the importance of partner testing.

o All counselors should be reminded to practice active listening and check for the clients’ understanding throughout the session.

o If necessary, counselors at partner clinics should receive refresher training on correct messages for VMMC and HIV prevention.

The lack of supervision and technical support for VMMC and HIV counseling should be addressed. In-person supervision and technical support should be increased where possible.

Phone check-ins and remote supervision and technical support to address potential issues should be instituted on days when on-site supervision is not possible.

c. Initial VMMC Education and Counseling

All clients should participate in the full group sessions without distraction, so the space and client flow at certain sites must be re-examined.

o Staff must ensure that clients are not pulled out of the initial group counseling sessions for record-keeping or allowed to wonder in and out of the sessions.

o Privacy should be insured so that the group feels comfortable to ask questions in a safe and secure environment.

Group counseling should incorporate specific VMMC teaching aids, including illustrative photos and props such as dildos, demonstration vulvas, etc.

Group counselors must demonstrate correct and consistent condom use for male and female condoms. A full demo of a female condom with a demonstration vulva where possible will improve the condom presentation overall.

Group counselors must:

o Explain the 60% protective effect of VMMC, o Discuss that VMMC does not directly protect clients’ partners from acquiring HIV, o Communicate that STI screening is part of evaluation for VMMC, and o Clarify the importance of abstaining from all form of sexual activity, including masturbation, for six-week post-op.

d. Individual HIV Testing and counseling

Individual counselors need to:

o Explore knowledge about HIV transmission and prevention, o Discuss information about HIV/AIDS, o Provide prevention counseling, o Stress the importance of partner testing, o Prepare the client mentally for his HIV test results before the test, o Reiterate that VMMC is only partially protective against HIV, and o Discuss a personal prevention strategy with each and every client.

Counselors should highly encourage, though not mandate, clients to test for HIV prior to VMMC.

e. Post-operative VMMC Counseling

Post-operative counselors need to:

o Provide information on the warning signs that require immediate attention and how to address any potential adverse events, o Re-emphasize the six-week period of abstinence including masturbation, and o Remind the client that VMMC should be combined with other strategies to prevent HIV transmission.

There should be a private room for post-operative exams and counseling sessions.

f. Routine Follow-up Appointment

The routine follow-up counselors must:

o Discuss the partially-protective nature of VMMC and o Remind clients of the required 6-weeks of abstinence, including abstinence from masturbation

Issues:

More attention needs to be put into targeting women with relevant messaging regarding VMMC and HIV prevention.

o All of the information sessions, from the initial group session to the post-operative follow-up session, need to include messaging which promotes respect for women and female partner(s).

o IEC materials need to target women with the benefits of VMMC and allow them to become informed in order to support and encourage male partners to pursue VMMC for

HIV prevention.

o A comprehensive set of IEC materials needs to be compiled to ensure that all facilities are using a comprehensive, 360 degree, standardized communications approach targeting both men and women.

Although testing should be highly encouraged, prohibiting VMMC for those that choose not to test is unethical, so human rights considerations must be taken into account.

One additional consideration is the CD4 count at which circumcision is allowed. Certain sites only allow VMMC to clients with CD4 counts above 350 while other sites allow VMMC to men who have a CD4 count above 200.

There are inconsistent guidelines for post-operative wound care. While each facility says to mix water with salt, the recommended allocation of salt to water varies from one teaspoon of salt in one liter of water to three teaspoons of salt in one cup of water.

o One facility said to mix one tablespoon of salt with one coffee mug of water and use it to wash the penis three times per day for six weeks.

o Other facilities had different suggestions. However, there should be a national guideline that recommends a standard dosage.

Certain sites are circumcising boys who are younger than 15 years old, but PEPFAR funds should be focused on VMMC for HIV prevention and thereby utilized to circumcise men between the ages of 15-49 only.

o One partner asked for more funding to circumcise boys who were as young as 8 for medical reasons.

Waste Management

TOOL Z

Findings

In the procedure and counseling are, there are appropriately labeled temporary waste containers: sharp containers, non-contaminated office waste containers and contaminated medical waste segregation happens at point of use in the majority of sites and almost all facilities (with the exception of those in

Mpumalanga) rely on external companies for the final disposal of waste. In those using facility

Incinerators, we were able to see that incinerators were secure and kept clean. In two sites, the incinerators are installed close to public roads.

Best Practices

One site has a dedicated infection control nurse who does the supervision, technical assistance and mentorship (to other nurses working at VMMC Clinic) on infection control procedures.

Challenges

Interim waste storage bins are card boxes. While this might be the standard in SA, because of the nature of the waste i.e. contaminated medical waste – leak proof container with cover is a requirement

Practice of hand washing and maintenance of strict surgical sterility isn’t always considered and hence need frequent reminder and follow up.

In some sites sharp containers are kept until they are full

Recommendation

It is recommended that sharp containers are disposed when they are ¾ full.

Consider using leak proof hard plastic containers with appropriate color coded bin liners.

Conclusions The goal of this EQA assessment was to ensure that the USAID-supported VMMC programs for HIV prevention were conducted according to the best clinical practices, in high volume and high quality. The assessment also sought to ascertain that USAID’s VMMC investments were directed to high public health impact programs.

While SA is a pioneer in the area of VMMC and creating HIV prevention evidence, the translation of evidence to practice will need to live up to that high standard. The visit showed that the programs currently running are staffed by highly motivated and competent providers at all facilities. The involvement of the provincial health offices needs to continue and should be encouraged. Given the large number of circumcisions required in South Africa, improving the pace, scale, and quality of the program is of a priority. The potential to achieve the necessary pace, scale, and quality exists in the country which is very encouraging. During the visit, we identified key areas that need closer review and planning in order for the program to head fast in the right direction, we would like to highlight a couple of these observations again here.

1. Human resources – The availability of human resources for service provision is NOT matching with the demand for services (at least during the assessment visit). This is urgent and needs to be considered through either task shifting or making dedicated doctors available for the

VMMC program.

2. Monitoring and Evaluation – The NDOH is responsible for the overall lead and guidance of the

VMMC program in SA. In the current situation, where each partner and/or site has its own recording and reporting form and channel, coordinating the program and provision of informed leadership decision is a challenge. The partners need to look for opportunities to get everyone involved and standardize the tools used for VMMC. Moreover, data transfer will be efficient and timely if a web-based real time data entry recording and reporting is initiated.