South Africa - Implementation of Male Circumcision for HIV Prevention
The Medical Male Circumcision (MMC) clinic in Soweto is one of the busiest MMC clinics in the country; however, the volume of patients at the clinic is highly variable, with some months being very busy and other months resulting in wasted staff time due to a lack of patients. Given the seasonality in demand for MMC, we are interested to evaluate the "true" cost-effectiveness of the MMC intervention, and to evaluate the potential role for demand generating activities during the off-peak months. This investigation will take the form of a combined costing and survey study, including the ascertainment of patient volume and seasonality from records, empirical costing of the MMC intervention through direct observation, and formal analysis of these data collected.
Global Health Mentor: David W. Dowdy, MD
I arrived at the Johannesburg Tambo International Airport, not knowing how this summer would impact my view about research in an international setting. My first impression was that the city was much more developed and modern than I had expected. There were huge malls and nice cars seemingly everywhere, and the downtown had definite bustling atmosphere. However, it didn’t take me long to see the remnants of apartheid and variability in socioeconomic status just outside of the city. The area near Chris Hani-Baragwanath Hospital in Soweto is one of the poorest regions in South Africa, and many people live in shacks and suffer from high unemployment rate over 50%. In the hospital, there were always long queues of patients, who otherwise would not have the access to healthcare service, even prior to opening of the hospital in the morning.
For the first month, I was involved in the project to evaluate the cost-effectiveness of introducing the PrePex device which includes a plastic ring to conduct male circumcision without anesthesia or surgery. The device has been rapidly implemented in many clinics in high HIV-burden settings. Without much prior background in economic evaluation, I started by developing data collection tools, collecting necessary cost information from team members and clinicians, and visiting the clinic site. I watched about 15 forceps-guided male circumcision procedures to record the time of each procedure to correctly calculate labor cost, observed overall patient flow and collected information on usage of capitals, non-consumables and consumables. It was challenging but exciting to apply my skills learned in classrooms and to contribute to answer a research question relevant to clinical practice.
After finishing the data collection, I moved to Klerksdorp, two hours from Johannesburg to work on a different project for another month. This project focused on understanding patients’ perspectives on preventive therapies among HIV-infected patients and was still in the process of developing questionnaires and getting IRB approved. Before this summer, I had worked as a research assistant for three years, mainly analyzing the data already collected. However, I found that starting a project on the ground was massively different experience. Every little detail had to be sorted out to properly function on the ground. Revising and pilot-testing questionnaires seemed never-ending and were constant process with lots of back and forth feedbacks. As much as I was excited about working on the study I helped to design, I learned the responsibility and professionalism associated with that and fully appreciated study staffs who put tremendous efforts to set up the project and to collect the data.
At the site, my routine schedule started around 7am and finished at 4pm. I often drove the team around to different local clinics to talk to nurses in charge and physicians to understand the dynamics of launching the project. Sometimes when I think about epidemiologic studies, I forget about the individual stories of patients and providers and the challenges they face in their daily lives. Meeting people on the ground definitely helped me to understand cultural difference, logistical challenges, and various perspectives in the local context. I learned how privileged I am to have the access to abundant educational and environmental resources at Hopkins and that it comes with responsibility to conduct good research and to use these resources to improve the health at the population level. I firmly believe that students who consider a career in international health or working abroad will gain valuable field experience through this amazing opportunity.
2. MC clinic
3. Klerksdorp clinic substudy
4. My research team