This post is by John Byabagambi, who was EnCompass’ Regional Senior Quality Improvement Advisor for AIDSFree, providing programmatic technical support to AIDSFree-supported implementing partners in Lesotho, Malawi, Mozambique, Namibia, Tanzania, and Uganda. Photo at top depicts EnCompass’ VMMC team and VMMC site team in Malawi, c/o of Dr. Byabagambi.

EnCompass is pleased to announce a new resource developed from our work supporting continuous quality improvement (CQI) for voluntary medical male circumcision (VMMC) in Malawi. This new case study details results and lessons from 2 years supporting VMMC CQI under the USAID Strengthening High Impact Interventions for an AIDS-free Generation (AIDSFree) project.

VMMC and HIV Prevention

It is close to 40 years since HIV was first discovered, but we still do not have an effective cure. However, we have made great strides, especially in prevention. Since 2007, the World Health Organization (WHO) and UNAIDS have recommended VMMC as part of comprehensive HIV prevention strategies for countries with high prevalence of HIV and low prevalence of circumcision.

VMMC is a biomedical HIV prevention intervention package that involves educating clients about HIV prevention interventions, such as consistent condom use and screening and treatment for sexually transmitted infections; surgical removal of the foreskin, using WHO-approved methods for circumcision; and post-operative review of circumcised clients.

With support from the President’s Emergency Plan for AIDS Relief (PEPFAR), VMMC is implemented in 14 countries in Sub-Saharan Africa. One PEPFAR partner is AIDSFree, a USAID-funded 5-year project that provides, among other services, direct VMMC service delivery and technical assistance in CQI to PEPFAR implementing partners.

Although circumcision is a relatively minor procedure, it brings the risk of adverse events—from mild pain to life-threatening events—just like any other surgery. And because VMMC is a surgical procedure, it is vital to maintain high quality standards. For this reason, PEPFAR and country ministries of health have invested resources in CQI efforts to assure that standards are maintained all the time and for each and every client.

In healthcare, CQI is “a structured organizational process that involves physicians and other personnel in planning and implementing ongoing proactive improvements.” Following an external quality assessment of the VMMC program in Uganda in 2013, PEPFAR identified the need for technical support to assure the procedure would meet the quality standards prescribed by WHO, country ministries of health, and PEPFAR.

The Value of CQI for VMMC as an HIV Prevention Strategy: Lessons from Malawi

EnCompass began providing VMMC technical assistance as part of the AIDSFree project in October 2017. In Malawi, our CQI team supported four PEPFAR implementing partners working on VMMC—two USAID programs, a CDC-funded program, and a program funded by the Department of Defense.

The work consisted of a series of CQI activities to support VMMC facilities to identify quality gaps and their root causes, develop and test solutions, and measure changes in performance. VMMC provider teams also conducted CQI assessments, training, coaching, mentoring, and peer-to-peer learning sessions.

Here is what we found. As you can see, the lessons extend beyond the VMMC facility, engaging peers to increase uptake of this procedure.

Finding 1: CQI helped improve post-operative reviews to avoid adverse events

After circumcision, clients are expected to return for three follow-up visits (or any other time they have a problem): at 48 hours, at 7 days, and at 6 weeks. VMMC teams in Malawi saw strong improvement at the first follow-up visit, but reviews at 7 days were often poor. In October 2017, at one VMMC site, only about 2 percent of clients were returning for this crucial second visit. By June 2018, following CQI support, this percentage had improved to 72 percent.

Finding 2: CQI helped strengthen referrals to treatment for HIV-positive VMMC clients

VMMC is an HIV prevention service, but HIV-infected individuals are also sometimes identified through the VMMC program, since HIV testing is part of the package of services. Although PEPFAR guidance recommends supporting these individuals to initiate antiretroviral therapy, this is a gap at some health facilities. Before the CQI intervention in Malawi, one team had no complete records regarding what happened to clients identified as HIV positive, and could not follow up to confirm they had started treatment. Following CQI support, the team was linking 100 percent of HIV-positive VMMC clients to antiretroviral treatment.

What’s Next for VMMC and CQI?

This work is a clear manifestation that with the right support, VMMC service providers have the capacity to identify and fill gaps in their programs. We hope this case study will help motivate other VMMC programs and service providers to begin making changes to improve their programs.

Reflecting back, I am amazed by the energy the services providers put into this work to ensure they offer a good-quality service. Without doubt, most of this success is due to the front-line health workers, whose desire is to offer the best care they can with the means available to them. Through CQI, these teams are making a strong contribution to creating an AIDS-free generation—in Malawi and around the world.