Safety of Adult Medical Male Circumcision Performed by Non-physician Clinicians in Kenya: a Prospective Cohort Study

Background: Male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%. The Government of Kenya is rolling out voluntary medical male circumcision (VMMC) services, but struggles with health worker shortages, particularly with physician shortages.

Objective: To evaluate the safety of male circumcision performed by non-physician clinicians in Kenya.

Methods: Between December 2009 and December 2010, we conducted a prospective study of VMMC procedures performed by 15 nurses and 11 clinical officers, all trained to competence, in 11 public health facilities in Nyanza Province, Kenya. Providers reported surgical complications and adverse events (AEs), based on standardized definitions, immediately after the procedure and at 7 days and 60 days post-circumcision. We also assessed clients' satisfaction with the circumcision at 60 days.

Results: We recruited 2,244 men and boys, ages 13-54. The retention rate was high, with 2,192 participants (98%) returning for the 7-day follow-up visit and 1,845 (82%) for the 60-day visit. There was no difference in rates of moderate and severe AEs between participants whose circumcision was performed by a nurse (2.1%) or a clinical officer (1.9%) at 7 days post-circumcision. The most common AE was excess swelling (1.1%). Risk factors associated with an AE at 7 days post-circumcision included being employed and participant age ≥ 18 years. Participants circumcised by a provider with ≥ 6 years of professional experience were less likely to have an AE. Nearly all participants reported being satisfied with their circumcision at the 60-day follow-up visit.

Conclusions: Trained nurses and clinical officers provided safe VMMC in Nyanza Province, Kenya. AE rates in this study were similar to those reported in typical service-delivery settings. These results add to the current body of evidence suggesting that trained non-physicians can provide safe medical male circumcision, thereby facilitating increased availability and access to circumcision services.