1. I MPLEMENTATION OF VMMC EFFICIENCY ELEMENTS IN 4 S UB -S AHARAN C OUNTRIES : SERVICE DELIVERY & PROVIDER ATTITUDES JT Bertrand (Tulane), D Rech (CHAPS), E Njeuhmeli (USAID), D Castor (USAID), S Frade (CHAPS), M Loolpapit (FHI360), M Machaku (Jhpiego), W Mavhu (ZAPP-UZ), and L Perry (Tulane)

2. Methodology Kenya South Africa Tan- zania Zim- babwe # sites visited 301514 Types of sites: --Fixed --Outreach --Mobile 15 12 3 13 2 0 13 1 0 590 590 # providers interviewed 861059374 # VMMC procedures observed 151122133140 Kenya, South Africa, Tanzania, Zimbabwe Study design: observational “natural experiment”: –Process evaluation: 2011 & 2012 Data collection: –Observation of VMMC facilities –Observation of up to 10 VMMC procedures per site –Interviews with VMMC providers –Compilation of monthly service statistics & other data Sampling: –Kenya: 30 (of 235) randomly selected sites in Nyanza province –S Africa, Tanzania, Zimbabwe: All known sites in operation: Jan 2011 Addition of new sites that become operational in 2011 Data collection in each country:

3. KenyaSouth Africa Tan- zania Zim- babwe Multiple bed rotation XXX Purchases pre- bundled kits with disposable instruments XX Task-shiftingXX Task-sharingXXXX Surgical method: forceps-guided XXXX Electrocautery to stop bleeding Xx Quality and safety - positive results: Providers in all countries adhered to the VMMC surgical protocols –One exception: tying of surgical knot HIV testing and counseling is near 100% in Tanzania and Zimbabwe –Increasing in Kenya and South Africa. VMMC sites in all four countries scored high on the provision of group education for HIV prevention. Areas for improvement (in 2+ countries) Inadequate system for registering adverse events Lack of post exposure prophylaxis (PEP) and guidelines for administering it in the operation theatre Occasional lapses in maintaining sterile operating field Failure among providers to conduct a post- operative review of vital signs and to use protective eye gear. Absence of WHO service delivery guidelines near operating theatre in VMMC sites. Results Adoption of efficiency elements: Providers generally favored introduction of efficiency elements not yet in use.

4. 4 The USAID | Project SEARCH, Task Order No.2, is funded by the U.S. Agency for International Development under Contract No. GHH-I-00-07-00032-00, beginning September 30, 2008, and supported by the President’s Emergency Plan for AIDS Relief. The Research to Prevention (R2P) Project is led by the Johns Hopkins Center for Global Health and managed by the Johns Hopkins Bloomberg School of Public Health Center for Communication Programs (CCP).