1. 1 5 th World Conference on Virology, December 07 -09th 2015, Atlanta,USA Chaste KARANGWA 1, Eugene RUGIRA 1, Placidie MUGWANEZA 1, Helene Badini 3, Fabian MWANYUMBA 2 Modeling implementation of Early Infant Male Circumcision in Rwanda: Lessons learnt RBC₁, UNICEF₂, UNAIDS₃ Prevention Unit/HIV Division Rwanda Biomedical Center

2. Outline of the Presentation Introduction Objectives Description Lessons learnt 2

3. Rwanda is a traditionally a non circumcising society Prevalence of MC is 24% while the HIV prevalence is 3%(DHS 2015) Male circumcision is an effective intervention to reduce HIV infections risks among males up to 60% Rwandan Ministry of Health adopted Male Circumcision as HIV prevention strategy since 2007 Introduction Adult Male Circumcision (MC) 3

4. Introduction to Early Infant Male Circumcision (EIMC) EIMC is a male circumcision performed between 7 and 60 days of life(WHO) EIMC has a number of advantages over adult MC: – Involves a simpler procedure that most health care providers can perform after a short training – Associated with fewer complications – Less expensive to perform than adult circumcision – More sustainable strategy than adult MC We report Rwanda’s first experience in implementation of EIMC 4

5. Objectives Test the feasibility of implementing a safe EIMC program in selected District Hospitals To integrate EIMC as a component of newborn and child health package of services within maternal newborn and child health system 5

6. A steering committee was established for management and supervision: – Rwanda Biomedical Centre HIV Division, Rwanda Surgical society and UN Agencies:UNICEF and UNAIDS Purchase of Mogen clamp, infant circumstraint and other consumable surgical supplies Two District Hospitals with high number volume if deliveries were selected to implement EIMC 4 MD and 4 nurses from 2 District were trained on EIMC by experienced surgeons from referral hospital Process Description 6

7. Awareness campaign for parents with boys bellow 60 days were conducted at MNCH points: –Maternity for new mothers and immunization clinics for infants. Parents were educated on risks and benefits of EIMC Written Consent form were signed by parents Training (theoretical and practical) was conducted by experienced surgeons from referral hospital 7 Process

8. Infant Selection Criteria All infants were offered circumcision services according to the guidelines and protocols: – Exclusion criteria : Parent had not consented Was premature Had one or more of the following conditions: –congenital malformations such as hypospadias –history of bleeding tendencies, –birth weight of less than 2500 grams –Had conditions requiring admission to new born care unit 8

9. Performing the procedure /technique 9 Procedure was performed under local anaesthesia A trained doctor/Nurse with assistance of a trained staff performed the procedure in a health care setting(clean room) Mogen clamp devices were preferred to other devices such as (Gomco) because it a one size for all sizes of the new-born glans penis

10. Outcome of the training 10 A total of 8 health care providers were trained and mentored. 85 infants were circumcised over the training period. The average birth weight was 3.3 kilos and age was 41 days 5/85 of infants experienced minor bleeding which was arrested immediately by surgery One of the infants experienced severe adverse event that required the intervention of a plastic surgeon

11. Monitoring and Evaluation 11 With support of community health care workers All circumcised children came back at the facility for evaluation session Objectives : –To asses all infants circumcised during EIMC training –To document any adverse events and other data related to EIMC and the outcome the procedure –To use findings of the review to improve on future trainings of health care workers Data on NMC, circumcisions performed and adverse events was collected and analysed using stata

12. Results of monitoring and Evaluation All parents agreed to be educated on risks and benefits of EIMC before they decide to circumcise their children 98% of these parents declared to be happy that their children are circumcised at an early age All parents were committed to recommend EIMC to others parents (neighbours and friends) No post-operative infection observed 12

13. Lessons learnt 13 Need of health care providers with experience in surgical procedures There is a need to increase the duration of training from 3 to 5 days All health care providers selected for EIMC will be certified by the team of trainers before starting to provide EIMC services Facilitate skill acquisition infant models will be required for trainees to have more practice on models before applying on clients

14. Conclusion and recommendations 14 Integration of newborn male circumcision in MNCH setting is feasible Parents would prefer their infants to be circumcised at early age Continuous quality improvement strategies such as reaching pregnant women and their partners are critical for increasing uptake of EIMC services Surgical experienced health providers,use of penis model and supervision are key factors to minimize adverse events during EIMC

15. Acknowledgement  I would like to acknowledge the Government of Rwanda for initiating EIMC program.  My deep appreciations go to the parents of circumcised children, Community Health Workers, health care providers and colleagues who gave their support to make this first implementation of EIMC successful in Rwanda. 15

16. THANK YOU 16