Background: Voluntary medical male circumcision (VMMC) provides males with lifelong, partial protection against HIV and other sexually transmitted infections (STIs). The WHO minimum package of VMMC services stresses screening men for VMMC eligibility and recommends referral to a higher level of care for clients with contraindications or management of conditions that pose increased risk. Men who initially screen ineligible frequently undergo treatment and are later circumcised when they meet eligibility criteria. Jhpiego, with funding from the US Centers for Disease Control and Prevention, has been implementing VMMC in Lilongwe District, Malawi since April 2016, and routinely reviews reasons for VMMC ineligibility among men seeking services in Lilongwe to better anticipate and address clients'' health needs while ensuring the safety of the procedure.
Methods: Project data from April 2016 to October 2018 were retrospectively analyzed for reasons for VMMC ineligibility. Information on the types of contraindications identified was captured from the clinical record.
Results: Out of 90,012 clients seeking VMMC services between April 2016 and September 2018. 89,356 (99%) were eligible and received VMMC services. A total of 656 males (1%) were ineligible for VMMC at the time of initial screening. Of all the ineligible clients, 486 (74.1%) were syndromically diagnosed with STIs, 35 (5.3%) had phimosis that required referral to specialist, 22 (3.4%) had high blood pressure, 18 (2.7%) had epispadias/hypospadias, 18 (2.7%) reported allergic reactions, not specified, 8 (1.2%), had diabetes, 8 (1.2) had high fever and were referred for a malaria test, and 60 (9.1%) had other contraindications (Paraphimosis , painful urination, bleeding disorders, psychiatry, Bacterial skin infection, HIV with immunosuppression (Low CD4 count and a WHO stage 2 or 3 condition observed), hydrocele).
Conclusions: Comprehensive screening procedures are essential to ensuring the safety of VMMC for HIV prevention. We found that less than 1% of clients presenting for VMMC screened ineligible, which is lower than expected and suggests there may be room to improve screening. Additionally, the majority of clients presented with conditions that are easily managed, highlighting the need for proper management with follow up mechanisms for all ineligible clients to ensure they receive VMMC services after treatment.