Male circumcision (MC) is a critical HIV prevention intervention with global support for expansion across sub- Saharan Africa (SSA). MC is safe: routine programs in SSA report adverse event (AE) rates well under 2%. Nevertheless, global MC guidelines require one or more follow-up visits within 14 days for AE detection. With low AE rates, overstretched clinic staff waste invaluable resources conducting unnecessary routine reviews for MC clients without complications. Men healing well needlessly pay for transport, miss work, and wait for reviews, discouraging MC uptake. In weak healthcare systems in SSA, MC quality is buckling under pressure to provide quality MC services and meet ambitious global targets of 5 million annual MCs. Our prior research in Zimbabwe employed two-way texting (2wT) between patients and providers to focus follow-up on men with potential AEs, allowing men healing without complication to opt-out of routine post-operative visits. 2wT safely reduced client visits by 85%, suggesting that 2wT can make MC services dramatically more efficient while maintaining safety. Whether 2wT can be replicated and scaled in other routine program settings is now a critical implementation research question. The Republic of South Africa’s (RSA) MC context of high-volume urban clinics, remote service delivery, and low AE identification threaten quality at scale. Across more than 500,000 annual MCs performed, up to 1 million multi-stage, unnecessary MC reviews are likely conducted. In urban sites, this causes service delivery bottlenecks; in rural areas, follow-up requires multiple, multi-hour trips, curtailing productivity. RSA pressure for MC expansion and severe health system constraints, combined with good cell coverage, suggest 2wT’s impact would be significant for MC care quality and efficiency, especially in rural areas. Therefore, we seek to develop an adaptable 2wT dissemination and implementation model at scale (2wT-2-SCALE) delivered by routine MC teams, not research teams. First, a randomized control trial (RCT) (phase 1: test) will rigorously evaluate how 2wT improves AE ascertainment and follow-up efficiency in urban and rural clinics. Then (phase 2: intensive), we scale (2wT-2-SCALE) via a one-year, quasi-experimental, step-wedge design with insights gained from one additional year of 2wT with routine MC teams (phase 3: maintain). Guided by implementation science, we employ mixed-methods to evaluate 2wT-2-SCALE’s impact on VMMC service quality. Our specific aims are to 1) conduct an RCT to determine how 2wT increases AE ascertainment while reducing workload in the RSA implementation context; 2) develop an effective dissemination and implementation strategy at scale (2WT-2-SCALE) using RE-AIM to evaluate program reach, effectiveness, adoption, implementation, and maintenance; and 3) use activity based micro-costing to estimate the payer-perspective budget and program impact from 2wT scale-up compared to routine care. This implementation research is feasible, highly innovative and systems-focused, establishing local evidence and timely, real-world data to support further adaptation, adoption, and spread of 2wT to improve efficient, safe, high-quality MC services at scale in RSA and beyond.

Project narrative Through a randomized control trial and subsequent stepped-wedge designed study in high- volume facilities providing male circumcision (MC) in South Africa, we will demonstrate that two- way texting (2wT) between providers and patients increases adverse event (AE) ascertainment while reducing provider workload as compared to routine, in-person follow-up. Implementation science methods and costing analysis will rigorously evaluate 2wT, determining how to optimize 2wT-2-SCALE within routine MC program settings. It is expected that 2wT-2-SCALE will be a cost-effective method to improve MC efficiency and AE ascertainment at scale, enabling rapid, sustainable improvement in the quality of MC services at the population level.