Evaluation of the safety and efficiency of the dorsal slit and sleeve methods of male circumcision provided by physicians and clinical officers in Rakai, Uganda

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Abstract
Study Type – Therapy (outcomes research) Level of Evidence 2c What’s known on the subject? and What does the study add? MC reduces heterosexual acquisition of HIV in men for safe and efficient rapid scale‐up; task shifting from physicians to clinical officers is safe and the use of bipolar cautery will reduce operative time, but is associated with higher adverse events. OBJECTIVE: • To assess the safety and efficiency of the dorsal slit and sleeve male circumcision (MC) procedures performed by physicians and clinical officers (COs). PATIENTS AND METHODS: • We evaluated the time required for the MC procedure (efficiency) and moderate/severe adverse events (AEs) for MC (safety) by trained physicians and COs using the sleeve and dorsal slit MC methods in a service programme. • Univariate and multiple regressions with robust variance estimation were used to assess factors associated with operative duration (linear) and AEs (logistic). RESULTS: • Six physicians and eight COs conducted 1934 and 3218 MCs, respectively; there were 2471 dorsal slit and 2681 sleeve MC procedures. The overall mean operative duration was 33 min for newly trained providers, whichdecreased to ≈20 min after ≈100 MCs. • The adjusted mean operative duration for dorsal slit MC was significantly shorter than that for the sleeve MC method (Δ− 2.7 min, P < 0.001). • The operative duration was longer for COs than physicians for the sleeve procedure, but not the dorsal slit procedure; however this difference reduced with increasing numbers of MCs completed. • The unadjusted AE rates were 0.6% for dorsal slit MC and 1.4% for the sleeve method ( P = 0.006) and 1.5% for physicians and 0.68% for COs ( P = 0.003); however, there were no significant differences after multivariate adjustment. • Use of bipolar cautery significantly reduced operative duration (Δ− 4.0 min, P = 0.008), but was associated with higher AE rates (adjusted odds ratio 2.13, 95% confidence interval 1.26–3.61, P = 0.005). CONCLUSION: • The dorsal slit MC method is faster than sleeve resection, and can be safely performed by non‐physicians; however, use of bipolar cautery may be inadvisable in this setting.

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