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Reducing provider workload while preserving patient safety

a randomized control trial using 2-way texting for post-operative follow-up in Zimbabwe’s voluntary medical male circumcision program

Feldacker, Caryl1,2; Murenje, Vernon3; Holeman, Isaac1,4; Xaba, Sinokuthemba5; Makunike-Chikwinya, Batsirai3; Korir, Michael4; Gundidza, Patricia Tapiwa6; Holec, Marrianne2; Barnhart, Scott1,2,7; Tshimanga, Mufuta6

JAIDS Journal of Acquired Immune Deficiency Syndromes: October 16, 2019 - Volume Publish Ahead of Print - Issue - p
doi: 10.1097/QAI.0000000000002198
Original article: PDF Only

Background: Voluntary medical male circumcisions (MC) is safe: the vast majority of men heal without complication. However, guidelines require multiple follow-up visits. In Zimbabwe, where high mobile phone ownership, severe healthcare worker shortages, and rapid MC scale up intersect, we tested a two-way texting (2wT) intervention to reduce provider workload while safeguarding patient safety.

Setting: Two high-volume facilities providing MC near Harare, Zimbabwe.

Methods: A prospective, un-blinded, non-inferiority, randomized control trial of 722 adult MC clients with cell phones randomized 1:1. 2wT clients (n=362) responded to a daily text with in-person follow-up only if desired or an AE suspected. The control group (n=359) received routine in-person visits. All men were asked to return on post-operative day 14 for review. Adverse events ≤ day 14 visit and number of in-person visits were compared between groups.

Results: Cumulative AEs were identified in 0.84% (%% CI: 0.28,2.43) among routine care men as compared to 1.88% (95% CI: 0.86, 4.03) of 2wT participants. Non-inferiority cannot be ruled out (95% CI: -∞, +2.72); however, AE rates did not differ between groups (p=0.32). 2wT men attended an average of 0.30 visits as compared to 1.69 visits among routine care men, a significant reduction (p<0.001).

Conclusion: Although non-inferiority cannot be demonstrated, increased AEs in the 2wT arm likely reflect improved AE ascertainment. 2wT serves as a proxy for active surveillance, improving the quality of MC patient care. 2wT also reduced provider workload. 2wT provides an option for men to heal safely at home, returning to care when desired or if complications arise. 2wT should be further tested to enable widespread scale-up.

1Department of Global Health, University of Washington, Seattle, WA, USA.

2International Training and Education Center for Health (I-TECH), Seattle, WA USA;

3International Training and Education Center for Health (I-TECH), Harare, Zimbabwe;

4Medic Mobile, Nairobi Kenya

5Ministry of Health and Child Care, Harare Zimbabwe;

6Zimbabwe Community Health Intervention Project (ZiCHIRE), Harare, Zimbabwe;

7Department of Medicine, University of Washington, Seattle, WA, USA.

Corresponding author: Caryl Feldacker, Box 359932, University of Washington, Seattle, WA 98104-3508 USA,

Competing interests: The authors declare no competing interests

Email addresses of all authors: Caryl Feldacker: Vernon Murenje: Isaac Holeman: Sinokuthemba Xaba: Batsirai Makunike: Michael Korir: Patricia Tapiwa Gundidza: Marrianne M Holec: Scott Barnhart: Mufuta Tshimanga:

Funding: Research reported in this publication was supported by the Fogarty International Center of the National Institutes of Health under Award Number R21TW010583. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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