Objective:To measure the effects of information, a challenge, and a conditional cash transfer on take-up of voluntary medical male circumcision (VMMC).Design:A randomized, controlled experiment with 4000 postcard recipients in Soweto (Johannesburg), South Africa.Methods:We examined differences in take-up of several decisions in the VMMC cascade between the control arm and each of several intervention arms using logistic regression.Results:Logistic regression analysis indicated that the group offered US $10 as compensation and the group challenged with “Are you tough enough?” had significantly higher take-up of the VMMC procedure than did the control group [odds ratios, respectively, 5.30 (CI: 2.20 to 12.76) and 2.70 (CI: 1.05 to 6.91)]. Similarly, the compensation group had significantly higher take-up of the VMMC counseling session than did the control group [odds ratio 3.76 (CI: 1.79 to 7.89)]. The analysis did not reveal significantly different take-up of either the VMMC counseling session or the procedure in the partner preference information group compared with the control group [odds ratios, respectively, 1.23 (CI: 0.51 to 2.97) and 1.67 (CI: 0.61 to 4.62)]. The analysis did not reveal significantly higher take-up of the VMMC nurse hotline in any intervention group compared with the control group [odds ratios for US $10, information, and challenge, respectively, 1.17 (CI: 0.67 to 2.07), 0.69 (CI: 0.36 to 1.32), and 0.60 (0.31 to 1.18)].Conclusions:Among adult males in Soweto, South Africa, compensation of US $10 provided conditional on completing the VMMC counseling session compared with no compensation offer and a postcard with a challenge, “Are you tough enough?” compared with no challenge, resulted in moderate increases in take-up of circumcision.

BackgroundSYMMACS, the Systematic Monitoring of the Voluntary Medical Male Circumcision Scale-up, tracked the implementation and adoption of six elements of surgical efficiency— use of multiple surgical beds, pre-bundled kits, task shifting, task sharing, forceps-guided surgical method, and electrocautery—as standards of surgical efficiency in Kenya, South Africa, Tanzania, and Zimbabwe.Methods and FindingsThis multi-country study used two-staged sampling. The first stage sampled VMMC sites: 73 in 2011, 122 in 2012. The second stage involved sampling providers (358 in 2011, 591 in 2012) and VMMC procedures for observation (594 in 2011, 1034 in 2012). The number of VMMC sites increased significantly between 2011 and 2012; marked seasonal variation occurred in peak periods for VMMC. Countries adopted between three and five of the six elements; forceps-guided surgery was the only element adopted by all countries. Kenya and Tanzania routinely practiced task-shifting. South Africa and Zimbabwe used pre-bundled kits with disposable instruments and electrocautery. South Africa, Tanzania, and Zimbabwe routinely employed multiple surgical bays.ConclusionsSYMMACS is the first study to provide data on the implementation of VMMC programs and adoption of elements of surgical efficiency. Findings have contributed to policy change on task-shifting in Zimbabwe, a review of the monitoring system for adverse events in South Africa, an increased use of commercially bundled VMMC kits in Tanzania, and policy dialogue on improving VMMC service delivery in Kenya. This article serves as an overview for five other articles following this supplement.

This study assessed the acceptability of, as well as the facilitators of and barriers to the HIV self-testing kit in the Gauteng province, South Africa. An exploratory qualitative cross-sectional study was conducted using focus group discussions (FGDs) among a sample of 118 respondents selected from the Braamfontein and Soweto areas of Johannesburg. Sixteen FGDs were conducted in order to assess the acceptability of the HIV self-testing kit. Respondent groups were segmented according to area (Soweto or Braamfontein), gender (male or female), age (20-34 and 35-49 years of age) and HIV testing status (have previously tested for HIV or have never tested for HIV) in order to achieve maximum variability. The main advantage identified was that the self-testing kit allows for privacy and confidentiality with regard to HIV status, and does not require a visit to a health facility - two of the main barriers to current HIV counselling and testing uptake. However, respondents, predominantly males, were concerned about the lack of counselling involved, which they thought could lead to suicide ideation among testers. The HIV self-testing kit was found to be acceptable among the majority of respondents. However, there is still a need for follow-up services for self-testers. The idea of a hotline for telephonic counselling within the self-testing model seemed to be favourable among many respondents and is an alternative to traditional face-to-face counselling, although some respondents felt that this was not sufficient.

BackgroundThe scale-up of voluntary medical male circumcision (VMMC) services in South Africa has been rapid, in an attempt to achieve the national government target of 4.3 million adult male circumcisions for HIV prevention by 2016. This study assesses the effect of the scale-up on the quality of the VMMC program.Methods and FindingsThis analysis compares the quality of services at 15 sites operational in 2011 to (1) the same 15 sites in 2012 and (2) to a set of 40 sites representing the expanded program in 2012. Trained clinicians scored each site on 29 items measuring readiness to provide quality services (abbreviated version of the WHO Quality Assessment [QA] Guide) and 29 items to assess quality of surgical care provided (pre-op, surgical technique and post-op) based on the observation of VMMC procedures at each site. Declines in quality far outnumbered improvements. The negative effects in terms of readiness to provide quality services were most evident in expanded sites, whereas the declines in provision of quality services tended to affect both repeat sites and expanded sites equally. Areas of notable concern included the monitoring of adverse events, external supervision, post-operative counselling, and some infection control issues. Scores on quality of surgical technique tended to be among the highest across the 58 items observed, and the South Africa program has clearly institutionalized three “best practices” for surgical efficiency.ConclusionsThese findings demonstrate the challenges of rapidly developing large numbers of new VMMC sites with the necessary equipment, supplies, and protocols. The scale-up in South Africa has diluted human resources, with negative effects for both the original sites and the expanded program.

IntroductionThis analysis explores the association between elements of surgical efficiency in voluntary medical male circumcision (VMMC), quality of surgical technique, and the amount of time required to conduct VMMC procedures in actual field settings. Efficiency outcomes are defined in terms of the primary provider’s time with the client (PPTC) and total elapsed operating time (TEOT).MethodsTwo serial cross-sectional surveys of VMMC sites were conducted in Kenya, Republic of South Africa, Tanzania and Zimbabwe in 2011 and 2012. Trained clinicians observed quality of surgical technique and timed 9 steps in the VMMC procedure. Four elements of efficiency (task-shifting, task-sharing [of suturing], rotation among multiple surgical beds, and use of electrocautery) and quality of surgical technique were assessed as explanatory variables. Mann Whitney and Kruskal Wallis tests were used in the bivariate analysis and linear regression models for the multivariate analyses to test the relationship between these five explanatory variables and two outcomes: PPTC and TEOT. The VMMC procedure TEOT and PPTC averaged 23–25 minutes and 6–15 minutes, respectively, across the four countries and two years. The data showed time savings from task-sharing in suturing and use of electrocautery in South Africa and Zimbabwe (where task-shifting is not authorized). After adjusting for confounders, results demonstrated that having a secondary provider complete suturing and use of electrocautery reduced PPTC. Factors related to TEOT varied by country and year, but task-sharing of suturing and/or electrocautery were significant in two countries. Quality of surgical technique was not significantly related to PPTC or TEOT, except for South Africa in 2012 where higher quality was associated with lower TEOT.ConclusionsSYMMACS data confirm the efficiency benefits of task-sharing of suturing and use of electrocautery for decreasing TEOT. Reduced TEOT and PPTC in high volume setting did not result in decreased quality of surgical care.