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J Acquir Immune Defic Syndr. 2019 Oct 16. doi: 10.1097/QAI.0000000000002198. [Epub ahead of print]

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.

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Department of Global Health, University of Washington, Seattle, WA, USA.
International Training and Education Center for Health (I-TECH), Seattle, WA USA.
International Training and Education Center for Health (I-TECH), Harare, Zimbabwe.
Medic Mobile, Nairobi Kenya.
Ministry of Health and Child Care, Harare Zimbabwe.
Zimbabwe Community Health Intervention Project (ZiCHIRE), Harare, Zimbabwe.
Department of Medicine, University of Washington, Seattle, WA, USA.



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.


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


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.


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).


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.

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