1. Rebeca M Plank, MD Botswana-Harvard Partnership 10 June 2010
Infant Male Circumcision in Botswana as Part of Public HIV-Prevention Efforts
Rebeca M Plank, MD
Botswana-Harvard Partnership
10 June 2010

2. World Health Organization
WHO recommends neonatal circumcision should be a component of prevention campaigns since “neonatal circumcision is a less complicated and risky procedure than circumcision performed in young boys, adolescents or adults [and] countries should consider how to promote neonatal circumcision in a safe, culturally acceptable and sustainable manner (WHO / UNAIDS, 2007).”

3. Neonatal Circumcision: Safety
100,157 circumcised
62 local infection
8 bacteremias
83 bleeding (3 transfusions)
20 surgical trauma
20 UTIs
No deaths
35,929 uncircumcised
88 UTIs
32 bacteremia
3 meningitis
2 renal failure
2 deaths
Wiswell et al. Pediatrics 1989;83(6):1011-5

4. Neonatal Circumcision: Safety and Sustainability
Virtually bloodless
No sutures
Fast healing ~ 7-10 days
Low complication rate
No risk of sex before healing
By the time an adult decides, he may be infected
No loss of time from school or work
Infant circumcision about 1/10th cost and time
Cost versus discounted savings:
Binagwaho PLoS Med ;7:e

5. Cultural Acceptability: Botswana
Traditional until ~ 1900 in Mochudi, others
Revived in
Circumcisions done in hospital but expensive
July 2009: 1300 initiates circumcised medically in 10 days
MOH helped with costs
Will be repeated this year

6. Table 1 Married 10 (17%) Single 50 (83%) Religious Affiliation -
Christian
49 (82%)
None
11 (18%)
Highest Educational Level
No education
3 (5%)
At least some primary education
6 (10%)
At least some secondary schooling
44 (73%)
At least some tertiary education

7. Results
Fifty-seven (95%) women reported being tested for HIV within the last year
Twenty-one (35%) reported being HIV+
Forty-six (77%) had previously heard that male circumcision could affect a man’s chances of becoming infected with HIV
Thirty-one (52%) said they thought male circumcision partially protected a man from being heterosexually infected with HIV
Twenty-six (43%) thought male circumcision completely protected a man from being heterosexually infected with HIV

8. If it were available, would you be interested in having your new son circumcised at this hospital by a trained doctor?
Yes (91.7%)
No (6.7%)
“Unsure” (1.7%)

9. Top 3 Reasons for Circ
Protect him from future infections such as HIV (98%)
Protect him from bladder infections as an infant (82%)
Hygiene (71%)
Cultural, traditional or religious reasons (36%)
Personal preference (9%)

10. Conclusions / Discussion
Male infant circumcision appears to be highly acceptable in Botswana
Protection from HIV / other infections appears to be a major motivation
The exaggerated perception of the protective benefit of MC and concerns about comfort and safety must be carefully addressed
Assessment of the actual uptake, safety and sustainability of expanded infant MC services deserves urgent attention

11. Aims of Current Study
Determine the acceptability by actual uptake of infant male circumcision and identify barriers
Estimate the feasibility and safety
Primary outcomes will be rate of significant complications such as bleeding, infection or need for repeat procedure
Estimate what, if any, advantages would exist for sustainable scale up of Mogen Clamp versus Plastibell
Human resources, equipment needs, adverse events and acceptability to parents and providers in Botswana

13. Gomco Clamp

14. Plastibell

18. Plastibell Standard surgical instruments
Visualize the glans prior to procedure
Little risk of bleeding
Retained ring
Infection (tissue)
Infection (bladder)
Supply chain must be reliable

19. Mogen Clamp No retained ring Higher theoretical risk of bleeding
Could amputate part of glans
Need sterilization or high level disinfection including water and limited by number of clamps

20. A view of the glans penis after the excess foreskin and clamp have been removed. The whitish color is from a thin layer of cells adherent from the inner prepuce,which will disintegrate within a day. the true color of the infant glans is more reddish-purple.

25. Aim 1: Actual Acceptability
191/300 babies randomized
In Mochudi 100 mothers brought baby for circumcision (85% of those interviewed and 71% of ALL mothers approached)
In Gaborone 70 have brought baby for circumcision (42% of those interviewed and 19% of ALL mothers approached)
100% follow-up

26. Aim 2: Safety (100)
Three cases of minor bleeding immediately following the procedure, all controlled with local pressure
No local infections
No case of damage to urethra or glans
Study physician subjectively dissatisfied with 19 cases
All photos to be reviewed by two pediatric urologists
One case of retained Plastibell removed at day 17 without sequelae

28. Aim 3: Sustainability One infant death day of life 3
Reviewed by 5 regulatory bodies
Thought due to neonatal sepsis NOT related to circumcision
Infant health and implications for scale-up
< 28 days  risk neonatal death
> 28 days  risk bleeding
> day 1 risk of not returning
< 4 weeks exclude those observing confinement
< day ? exclude out of hospital births

29. Future Directions: Arm 3
Like the Plastibell, there is a “bell” that protects the glans.
There is also an adjustable foreskin holder that allows positioning and repositioning PRN
The device acts as the clamp and blade
The blade is retained within the device (self-destructs) and prevents reuse

30. Future Directions: Arm 3 +
The AccuCirc comes in a self-contained kit
Simplifies supply chain
No parts are retained
All items are one-time use (no sterilizing)
These design advantages make it an excellent candidate for task shifting as midwives, nurses and clinical officers could easily learn to perform the procedure safely

31. Take Home Points Neonatal circumcision is acceptable
Acceptability can increase with education
Begin active process in ANC
Neonatal circumcision is safe
Plastibell will require active follow-up and well prepared primary providers
Sustainability will depend on timing of procedure with regard to local infant mortality and increased likelihood of follow-up
UNAIDS / WHO Review completed

32. The best time to plant a tree is 20 years ago
The best time to plant a tree is 20 years ago. The next best time is now.
Thank you

33. Thank you Jane Magetse Magdeline Mabuse Maggie Ngkau Max Essex
Roger Shapiro
David Bangsberg
Ron Bosch
Daniel Halperin
Barbara Bassil
Shahin Lockman
Nnamdi Ndubuka
Joseph Makhema
Janet Mwambona
Fatima Hussein
Ali Ali
Poloko Kebaabetswe
Chiapo Lesetedi
Mompati Mmalane
HUPA
CFAR
PEPFAR / BOTUSA / CDC
NIH K23-AI
ASTMH / Burroughs Wellcome