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Voluntary Medical Male Circumcision (VMMC) is a routine standard of care service offered by the National Department of Health (NDoH) as a proven biomedical prevention modality.

Due to the large-scale efforts in SA to provide VMMC, the NDoH has mandated that all practitioners undertake an accredited training programme to ensure their competency. This is to ensure full knowledge of MMC, approved surgical techniques, operational requirements, adverse event mitigation and management.

The Aurum Institute provided classroom-based theory and practice training to 36 Clinical Associate (CA) students on Voluntary Medical Male Circumcision (VMMC) on 21 January 2019, at the University of Pretoria HW Snyman Campus.

Methods

The training comprised half-day theory and half-day classroom practice. The theory component covered penile anatomy, the biomedical modality of protection against HIV, understanding the surgical techniques, Counselling, Infection Prevention and Control as well as Adverse Events.

The classroom practice involved students conducting the dorsal slit technique on penile models with foreskins.

This practice session involved the start-to-end simulation of an entire circumcision procedure.

Students were provided with VMMC packs, guided on the contents of VMMC packs, how to prepare the client and sterile field, work out weight-based local anesthetic dosing, administer the aneasthetic, undertake Dorsal Slit, and complete the wound-dressing.

Results

There are 40 students registered for this class, however only 36 students attended and signed the attendance register.

Students were required to take a pre-course and post-course theory test consisting of 28 questions related to VMMC practice.

All of the 36 students in attendance completed the pre-test, with 32 students completing the post-test theory assessment. The pass-mark for the assessment is 85%.

upca tbl1


All 36 students failed the pre-test assessment. Of the 32 students completing the post-test assessment, 21 (66%) failed the post-test with 11 (34%) passing the assessment

upca fig1
It is noted that the majority of students scored between 40% and 60% in their pre-tests, with the post-test scores improving significantly to a range between 70% and 90%. Despite the rate of increase of 53% between pre- and post-assessments, the majority didn’t reach the 85% pass mark, although 21 students scored greater than 75%.

upca fig2
The average pre-test score for 36 CAs were 52%. The post-test score average for 32 CAs significantly increased to 80%. This comprises an increase of 28%, with a rate of increase of 53%.

Recommendations

  1. It was noted that CAs were not comfortable or versed on suturing techniques during the classroom practice on penile models. It was recommended to the CAs that they practice their suturing techniques on similar materials.
  2. The Online Training Hub (OTH) course is a compulsory VMMC theory course all practitioners in SA must undertake. The course is free and comprises a comprehensive curriculum of all VMMC components involved in safe medical male circumcision. A list of 16 CAs has registered for the compulsory. CAs were encouraged to register and complete the course as part of their competency certification, required for VMMC practice in SA.
  3. The CAs who failed their post-course assessments would need to re-complete the test, which can be done online. It is recommended that our Master Trainers debrief the CAs again, to jog their memories and dispel any misconceptions. This debrief can be done in person (through a classroom), which will take approximately 20 minutes, or it can also be done online, should you approve.
  4. CAs were provided with a MMC log-sheet, where they need to annotate the details of at least 10 MMCs conducted under supervision by a Medical Officer, at their allotted clinic. CAs were guided to the completion of these log-sheets. A copy is attached in Appendix 2.
  5. CAs will be assigned a Master Trainer to mentor and support their training in VMMC and practice in the field. Once we are informed of the specific facilities the CAs had been allocated to, Aurum will assign Master Trainers and undertake the mentorship accordingly.

Course Evaluation

The predominant theme was that the course was comprehensive, that the materials and models were suitable, but that the course was too long. We are cognizant of the load of information provided to the CAs, and will be looking at structuring a weekly section approach of information transfer, with the approval from UP, to facilitate ease of learning. To avoid any disruptions, we propose an on-line case scenario model where students are introduced to a topic within VMMC, and work through a mini case study. A formal results log will be shared with the University in Pretoria depicting the course evaluation scores provided by the CAs.

VMMC services will resume at Winnie Mandela Health Clinic every Wednesday.