{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,5]],"date-time":"2026-07-05T18:13:23Z","timestamp":1783275203971,"version":"3.54.6"},"reference-count":44,"publisher":"Public Library of Science (PLoS)","issue":"10","license":[{"start":{"date-parts":[[2021,10,20]],"date-time":"2021-10-20T00:00:00Z","timestamp":1634688000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/publicdomain\/zero\/1.0\/"}],"funder":[{"DOI":"10.13039\/100009054","name":"U.S. President\u2019s Emergency Plan for AIDS Relief","doi-asserted-by":"publisher","award":["NU2GGH001430-05"],"award-info":[{"award-number":["NU2GGH001430-05"]}],"id":[{"id":"10.13039\/100009054","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Introduction<\/jats:title>\n<jats:p>Monitoring clinical safety of voluntary medical male circumcision (VMMC) is critical to minimize risk as VMMC programs for HIV prevention are scaled. This cross-sectional analysis describes the adverse event (AE) profile of a large-scale, routine VMMC program and identifies factors associated with the development, severity, and timing of AEs to provide recommendations for program quality improvement.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Materials and methods<\/jats:title>\n<jats:p>From 2015\u20132018 there were 28,990 circumcisions performed in International Training and Education Center for Health (I-TECH) supported regions of Namibia in collaboration with the Ministry of Health and Social Services. Two routine follow-up visits after VMMC were scheduled to identify clients with AEs. Summary statistics were used to describe characteristics of all VMMC clients and the subset who experienced an AE. We used chi-square tests to evaluate associations between AE timing, patient age, and other patient and AE characteristics. We used a logistic regression model to explore associations between patient characteristics and AE severity.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Results<\/jats:title>\n<jats:p>Of the 498 clients with AEs (AE rate of 1.7%), 40 (8%) occurred \u22642 days, 262 (53%) occurred 3\u20137 days, 161 (32%) between day 8 and 14, and 35 (7%) were \u226515 days post-VMMC. Early AEs (on or before day 2) tended to be severe and categorized as bleeding, while infections were the most common AEs occurring later (p&lt;0.001). Younger clients (aged 10\u201314 years) experienced more infections, whereas older clients experienced more bleeding (p&lt;0.001).<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Conclusions<\/jats:title>\n<jats:p>Almost 40% of AEs occurred after the second follow-up visit, of which 179 (91%) were infections. Improvements in pre-surgical and post-surgical counselling and post-operative educational materials encouraging clients to seek care at any time, adoption of alternative follow-up methods, and the addition of a third follow-up visit may improve outcomes for patients. Enhancing post-surgical counselling and emphasizing wound care for younger VMMC clients and their caregivers could help mitigate elevated risk of infection.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0258611","type":"journal-article","created":{"date-parts":[[2021,10,21]],"date-time":"2021-10-21T03:46:31Z","timestamp":1634787991000},"page":"e0258611","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":13,"title":["Adverse event profile and associated factors following surgical voluntary medical male circumcision in two regions of Namibia, 2015\u20132018"],"prefix":"10.1371","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4235-9869","authenticated-orcid":true,"given":"Gillian","family":"O\u2019Bryan","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Caryl","family":"Feldacker","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2627-6764","authenticated-orcid":true,"given":"Alison","family":"Ensminger","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Magdaleena","family":"Nghatanga","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laura","family":"Brandt","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mark","family":"Shepard","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Idel","family":"Billah","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mekondjo","family":"Aupokolo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Assegid Tassew","family":"Mengistu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Norbert","family":"Forster","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brigitte","family":"Zemburuka","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Edwin","family":"Sithole","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gram","family":"Mutandi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Scott","family":"Barnhart","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gabrielle","family":"O\u2019Malley","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2021,10,20]]},"reference":[{"issue":"11","key":"pone.0258611.ref001","doi-asserted-by":"crossref","first-page":"e298","DOI":"10.1371\/journal.pmed.0020298","article-title":"Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trial.","volume":"2","author":"B Auvert","year":"2005","journal-title":"PLoS Med"},{"issue":"9562","key":"pone.0258611.ref002","doi-asserted-by":"crossref","first-page":"643","DOI":"10.1016\/S0140-6736(07)60312-2","article-title":"Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial","volume":"369","author":"RC Bailey","year":"2007","journal-title":"Lancet"},{"issue":"9562","key":"pone.0258611.ref003","doi-asserted-by":"crossref","first-page":"657","DOI":"10.1016\/S0140-6736(07)60313-4","article-title":"Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial","volume":"369","author":"RH Gray","year":"2007","journal-title":"Lancet"},{"key":"pone.0258611.ref004","unstructured":"WHO\/UNAIDS. A framework for voluntary medical male circumcision: effective HIV prevention and a gateway to improved adolescent boys\u2019 & men\u2019s health in Eastern and Southern Africa by 2021 [cited 2020 Jan 02]. Available from: https:\/\/apps.who.int\/iris\/bitstream\/handle\/10665\/246234\/WHO-HIV-2016.17-eng.pdf?sequence=1&isAllowed=y"},{"key":"pone.0258611.ref005","unstructured":"Namibian Ministry of Health and Social Services Directorate of Special Programmes. Policy on male circumcision for HIV prevention [cited 2020 Jan 02]. Available from: http:\/\/www.mhss.gov.na\/documents\/119527\/433663\/Circumcision%2Bpolicy%2B.pdf\/5f5851fc-983e-45a0-b4d5-50609ff0dd2a"},{"key":"pone.0258611.ref006","unstructured":"Namibian Ministry of Health and Social Services Directorate of Special Programmes. National strategic framework for HIV and AIDS response in Namibia 2017\/18 to 2021\/22 [cited 2020 Jan 02]. Available from: https:\/\/hivpreventioncoalition.unaids.org\/wp-content\/uploads\/2018\/05\/NSF-Final-1.pdf"},{"key":"pone.0258611.ref007","unstructured":"Population Services International, College of Surgeons of East, Central and Southern Africa. Adverse event action guide for voluntary medical male circumcision by surgery or device, 2nd Edition, 2016 [cited 2019 Dec 20]. Available from: https:\/\/www.malecircumcision.org\/resource-bundle\/adverse-event-guide"},{"issue":"1","key":"pone.0258611.ref008","doi-asserted-by":"crossref","first-page":"e13","DOI":"10.1097\/QAI.0000000000000535","article-title":"Evaluation of loss-to-follow-up and post-operative adverse events in a voluntary medical male circumcision program in Nyanza Province, Kenya","volume":"69","author":"J Reed","year":"2015","journal-title":"J Acquir Immune Defic Syndr"},{"issue":"9","key":"pone.0258611.ref009","doi-asserted-by":"crossref","first-page":"e0137376","DOI":"10.1371\/journal.pone.0137376","article-title":"A clinical trial to introduce voluntary medical male circumcision for HIV prevention in areas of high prevalence in the Dominican Republic","volume":"10","author":"MO Brito","year":"2015","journal-title":"PLoS One"},{"key":"pone.0258611.ref010","doi-asserted-by":"crossref","first-page":"19275","DOI":"10.7448\/IAS.17.1.19275","article-title":"Low adverse event rates following voluntary medical male circumcision in a high HIV disease burden public sector prevention programme","volume":"17","author":"R Phili","year":"2014","journal-title":"South Africa. J Int AIDS Soc"},{"issue":"1","key":"pone.0258611.ref011","doi-asserted-by":"crossref","first-page":"93","DOI":"10.9745\/GHSP-D-13-00120","article-title":"Safety of adult medical male circumcision performed by non-physician clinicians in Kenya: a prospective cohort study","volume":"2","author":"V Frajzyngier","year":"2014","journal-title":"Global Health Sci Practice"},{"issue":"8","key":"pone.0258611.ref012","doi-asserted-by":"crossref","first-page":"e100008","DOI":"10.1371\/journal.pone.0100008","article-title":"The safety and acceptance of the PrePex device for non-surgical adult male circumcision in Rakai, Uganda. A non-randomized observational study","volume":"9","author":"G Kigozi","year":"2014","journal-title":"PLoS One"},{"issue":"5","key":"pone.0258611.ref013","doi-asserted-by":"crossref","first-page":"e95357","DOI":"10.1371\/journal.pone.0095357","article-title":"Safety, effectiveness and acceptability of the PrePex device for adult male circumcision in Kenya","volume":"9","author":"PJ Feldblum","year":"2014","journal-title":"PLoS One"},{"issue":"5","key":"pone.0258611.ref014","doi-asserted-by":"crossref","first-page":"e63134","DOI":"10.1371\/journal.pone.0063134","article-title":"Reach and cost effectiveness of the PrePex device for safe male circumcision in Uganda","volume":"8","author":"K Duffy","year":"2013","journal-title":"PLoS One"},{"issue":"9","key":"pone.0258611.ref015","doi-asserted-by":"crossref","first-page":"e0138755","DOI":"10.1371\/journal.pone.0138755","article-title":"Piloting PrePex for adult and adolescent male circumcision in South Africa\u2014pain is an issue","volume":"10","author":"L Lebina","year":"2015","journal-title":"PLoS One"},{"issue":"Suppl 1","key":"pone.0258611.ref016","doi-asserted-by":"crossref","first-page":"S49","DOI":"10.1097\/QAI.0000000000000774","article-title":"Safety, feasibility, and acceptability of the PrePex device for adult male circumcision in Malawi","volume":"72","author":"PK Kohler","year":"2016","journal-title":"J Acquir Immune Defic Syndr"},{"issue":"Suppl 1","key":"pone.0258611.ref017","doi-asserted-by":"crossref","first-page":"S43","DOI":"10.1097\/QAI.0000000000000742","article-title":"Safety and efficacy of the PrePex male circumcision device: results from pilot implementation studies in Mozambique, South Africa, and Zambia","volume":"72","author":"P Feldblum","year":"2016","journal-title":"J Acquir Immune Defic Syndr"},{"issue":"1","key":"pone.0258611.ref018","doi-asserted-by":"crossref","first-page":"e86631","DOI":"10.1371\/journal.pone.0086631","article-title":"Adverse events profile of PrePex a non-surgical device for adult male circumcision in a Ugandan urban setting","volume":"9","author":"M Galukande","year":"2014","journal-title":"PLoS One"},{"issue":"10","key":"pone.0258611.ref019","doi-asserted-by":"crossref","first-page":"773","DOI":"10.2471\/BLT.12.106112","article-title":"Factors associated with the safety of voluntary medical male circumcision in Nyanza province, Kenya","volume":"90","author":"A Herman-Roloff","year":"2012","journal-title":"Bull World Health Organ"},{"issue":"1","key":"pone.0258611.ref020","doi-asserted-by":"crossref","first-page":"61","DOI":"10.1186\/s12913-016-1305-x","article-title":"Classification and rates of adverse events in a Malawi male circumcision program: impact of quality improvement training","volume":"16","author":"PK Kohler","year":"2016","journal-title":"BMC Health Serv Res"},{"issue":"11","key":"pone.0258611.ref021","doi-asserted-by":"crossref","first-page":"e0185904","DOI":"10.1371\/journal.pone.0185904","article-title":"A prospective cohort study of safety and patient satisfaction of voluntary medical male circumcision in Botswana","volume":"12","author":"KE Wirth","year":"2017","journal-title":"PloS One"},{"key":"pone.0258611.ref022","unstructured":"WHO\/UNAIDS\/JHPIEGO. Manual for male circumcision under local anesthesia, version 3.1, December 2009 [cited 2020 Jan 23]. Available from: https:\/\/www.who.int\/hiv\/pub\/malecircumcision\/who_mc_local_anaesthesia.pdf"},{"key":"pone.0258611.ref023","unstructured":"WHO\/JHIPEGO. Manual for male circmcision under local anesthesia and HIV prevention services for adolescent boys and young men, April 2018 [cited 2020 Jan 23]. Available from: https:\/\/apps.who.int\/iris\/bitstream\/handle\/10665\/272387\/9789241513593-eng.pdf?ua=1"},{"issue":"47","key":"pone.0258611.ref024","article-title":"Voluntary medical male circumcision-southern and eastern Africa, 2010\u20132012","volume":"62","author":"Centers for Disease Control and Prevention","year":"2016","journal-title":"MMWR Morbidity and mortality weekly report"},{"issue":"6","key":"pone.0258611.ref025","doi-asserted-by":"crossref","first-page":"e0218137","DOI":"10.1371\/journal.pone.0218137","article-title":"Trust but verify: is there a role for active surveillance in monitoring adverse events in large-scale voluntary medical male circumcision programs?","volume":"14","author":"P Marongwe","year":"2019","journal-title":"PloS One"},{"key":"pone.0258611.ref026","unstructured":"President\u2019s Emergency Plan for AIDS Relief. PEPFAR\u2019s Best Practices for Voluntary Medical Male Circumcision Site Operations: A service guide for site operations [cited 2020 Jan 02]. Available from: https:\/\/www.malecircumcision.org\/sites\/default\/files\/document_library\/2017.9.26_ch7_vmmc-site-ops.pdf"},{"key":"pone.0258611.ref027","unstructured":"President\u2019s Emergency Plan for AIDS Relief. Monitoring, evaluation, and reporting indicator reference guide [cited 2020 May 13]. Available from: https:\/\/datim.zendesk.com\/hc\/en-us\/articles\/360000084446-MER-Indicator-Reference-Guides"},{"issue":"9","key":"pone.0258611.ref028","doi-asserted-by":"crossref","first-page":"e0205113","DOI":"10.1371\/journal.pone.0205113","article-title":"Correction: Timing of adverse events among voluntary medical male circumcision clients: implications from routine service delivery in Zimbabwe","volume":"13","author":"C Feldacker","year":"2018","journal-title":"PloS One"},{"key":"pone.0258611.ref029","unstructured":"Namibian Ministry of Health and Social Services and ICF International. The Namibian Demographic and Health Survey 2013 [cited 2020 Mar 23]. Available from: https:\/\/dhsprogram.com\/publications\/publication-fr298-dhs-final-reports.cfm"},{"issue":"7","key":"pone.0258611.ref030","doi-asserted-by":"crossref","first-page":"e25369","DOI":"10.1002\/jia2.25369","article-title":"Adverse events in a large-scale VMMC programme in Tanzania: findings from a case series analysis","volume":"22","author":"A Hellar","year":"2019","journal-title":"J Int AIDS Soc"},{"issue":"11","key":"pone.0258611.ref031","doi-asserted-by":"crossref","first-page":"e0186831","DOI":"10.1371\/journal.pone.0186831","article-title":"Early resumption of sexual activity following voluntary medical male circumcision in Botswana: a qualitative study","volume":"12","author":"JH Ledikwe","year":"2017","journal-title":"PLoS One"},{"key":"pone.0258611.ref032","unstructured":"WHO. Preventing HIV through safe voluntary medical male circumcision for adolescent boys and men in generalized HIV epidemics: recommendations and key considerations [cited 2021 Jul 29]. Available from: https:\/\/www.who.int\/publications\/i\/item\/978-92-4-000854-0"},{"key":"pone.0258611.ref033","unstructured":"PEPFAR. PEPFAR technical guidance in context of COVID-19 pandemic, 01 July 2020. [cited 2020 Jul 09]. Available from: https:\/\/www.state.gov\/wp-content\/uploads\/2020\/07\/07.01.2020-PEPFAR-Technical-Guidance-During-COVID.pdf"},{"issue":"suppl_3","key":"pone.0258611.ref034","doi-asserted-by":"crossref","first-page":"S229","DOI":"10.1093\/cid\/cix953","article-title":"Adolescent wound-care self-efficacy and practices after voluntary medical male circumcision\u2014a multicountry assessment","volume":"66","author":"W Mavhu","year":"2018","journal-title":"Clinical Infectious Diseases"},{"issue":"suppl_3","key":"pone.0258611.ref035","doi-asserted-by":"crossref","first-page":"S198","DOI":"10.1093\/cid\/cix1036","article-title":"Providers\u2019 perceptions and training needs for counseling adolescents undergoing voluntary medical male circumcision","volume":"66","author":"AA Tobian","year":"2018","journal-title":"Clinical Infectious Diseases"},{"key":"pone.0258611.ref036","doi-asserted-by":"crossref","first-page":"S233","DOI":"10.1097\/QAD.0000000000001484","article-title":"Voluntary medical male circumcision among adolescents: a missed opportunity for HIV behavioral interventions","volume":"31","author":"MR Kaufman","year":"2017","journal-title":"AIDS"},{"issue":"suppl_3","key":"pone.0258611.ref037","doi-asserted-by":"crossref","first-page":"S173","DOI":"10.1093\/cid\/cix951","article-title":"Age differences in perceptions of and motivations for voluntary medical male circumcision among adolescents in South Africa, Tanzania, and Zimbabwe","volume":"66","author":"EU Patel","year":"2018","journal-title":"Clinical Infectious Diseases"},{"issue":"suppl_3","key":"pone.0258611.ref038","doi-asserted-by":"crossref","first-page":"S161","DOI":"10.1093\/cid\/cix950","article-title":"Adolescent Male Circumcision for HIV Prevention in High Priority Countries: Opportunities for Improvement","volume":"66","author":"C Lane","year":"2018","journal-title":"Clinical Infectious Diseases"},{"issue":"suppl_3","key":"pone.0258611.ref039","doi-asserted-by":"crossref","first-page":"S189","DOI":"10.1093\/cid\/cix970","article-title":"Parental Communication, Engagement, and Support During the Adolescent Voluntary Medical Male Circumcision Experience","volume":"66","author":"KH Dam","year":"2018","journal-title":"Clinical Infectious Diseases"},{"key":"pone.0258611.ref040","volume-title":"Report of the WHO Technical Advisory Group on Innovations in Male Circumcision\u2013consultative review of additional information, 12 August 2016.","author":"World Health Organization","year":"2016"},{"issue":"1","key":"pone.0258611.ref041","doi-asserted-by":"crossref","first-page":"855","DOI":"10.1186\/s12913-019-4604-1","article-title":"Need for improved detection of voluntary medical male circumcision adverse events in Mozambique: a mixed-methods assessment","volume":"19","author":"A Brito","year":"2019","journal-title":"BMC Health Serv Res"},{"issue":"1","key":"pone.0258611.ref042","first-page":"16","article-title":"Reducing Provider Workload While Preserving Patient Safety: A Randomized Control Trial Using 2-Way Texting for Postoperative Follow-up in Zimbabwe\u2019s Voluntary Medical Male Circumcision Program","volume":"83","author":"C Feldacker","year":"2020","journal-title":"JAIDS"},{"key":"pone.0258611.ref043","article-title":"RE: Switching from the Forceps-Guided to the Dorsal Slit Technique in a Voluntary Medical Male Circumcision Program, 13 March 2019","author":"AM Nitschke","year":"2019","journal-title":"Namibian Ministry of Health and Social Services Directorate of Special Programmes"},{"key":"pone.0258611.ref044","unstructured":"PEPFAR. Namibia Country Operational Plan (COP) 2020 Strategic Direction Summary, 10 March 2020 [cited 2021 September 14]. Available from: https:\/\/na.usembassy.gov\/wp-content\/uploads\/sites\/132\/COP20-Namibia-SDS-V11-FINAL.pdf"}],"container-title":["PLOS ONE"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0258611","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,10,21]],"date-time":"2021-10-21T03:47:08Z","timestamp":1634788028000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0258611"}},"subtitle":[],"editor":[{"given":"Webster","family":"Mavhu","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2021,10,20]]},"references-count":44,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2021,10,20]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0258611","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,10,20]]}}}