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Safety of task-shifting for male medical circumcision: a systematic review and meta-analysis

Ford, Nathana,b; Chu, Kathrynb,c; Mills, Edward J.d

doi: 10.1097/QAD.0b013e32834f3264
Clinical Science

Introduction: Task-shifting for male medical circumcision is proposed as a strategy to overcome the lack of surgeons and doctors in high HIV prevalence settings. We undertook a systematic review and meta-analysis to review the safety of task-shifting for circumcision in Africa.

Methods: We searched online databases and conference websites up to July 2011 without language restriction for studies reporting outcomes of task-shifting for circumcision in Africa. Information was extracted independently and in duplicate on study characteristics, quality, and outcome data. Case reports and case series were excluded.

Results: Ten studies met our inclusion criteria, providing outcome data on 25 119 circumcisions. The proportion of adverse events ranged from 0.70 [95% confidence interval (CI) 0.44–1.02%] to 37.36% (95% CI 27.54–47.72%), with an overall pooled proportion of 2.31% (95% CI 1.46–3.16%; τ2 = 1.21; P < 0.001). Two studies reported outcomes separately for both doctors and non-physicians; there was no difference in the risk of adverse events by provider (pooled relative risk 1.18; 95% CI 0.78–1.78). The frequency of excessive bleeding ranged from 0.30 (0.09–0.65%) to 24.71% (16.27–34.26%) with an overall pooled prevalence of 0.55% (95% CI 0.13–0.97%). Infection occurred in 0.30 (0.14–1.47%) to 1.85% (0.07–5.96%) of cases, with an overall pooled proportion of 0.88% (95% CI 0.29–1.47%). All adverse events were reported to be non-severe.

Conclusion: Task-shifting of male medical circumcision to non-physician clinicians can be done safely, with reported rates of adverse events similar to doctors and specialists.

aCentre for Infectious Disease Epidemiology and Research, University of Cape Town

bMédecins Sans Frontières, Cape Town, South Africa

cDepartment of Surgery, Johns Hopkins University, Baltimore, Maryland, USA

dFaculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada.

Correspondence to Dr Nathan Ford, Centre for Infectious Diseases Epidemiology and Research, University of Cape Town, Cape Town, Private Bag X3, Rondebosch 7701, South Africa. E-mail:

Received 23 August, 2011

Revised 16 October, 2011

Accepted 14 November, 2011

© 2012 Lippincott Williams & Wilkins, Inc.