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Category: Quality Improvement

I-TECH Attends 25th IAS International AIDS Conference

Post categories: Cote d'Ivoire DIGI Gender/Women & Girls HIV Care and Treatment India Lydia Chwastiak Nancy Puttkammer Quality Improvement Stefan Wiktor Ukraine Zimbabwe
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Representatives from I-TECH, I-TECH Ukraine, I-TECH India, and Zim-TTECH attend the 25th IAS AIDS Conference in Munich, Germany.
Representatives from I-TECH HQ, I-TECH Ukraine, I-TECH India, and Zim-TTECH attend the 25th IAS AIDS Conference in Munich, Germany. Photo Credit: I-TECH

The International AIDS Society (IAS) hosted the 25th International AIDS Conference on 22–26 July 2024 in Munich, Germany, and virtually. The theme this year was “put people first” to emphasize the importance of “thinking of solutions from the point of view of those most affected.” The conference brings together HIV researchers and experts for presentations and discussions on a wide range of HIV- and AIDS-related topics.

This year, representatives from the International Training and Education Center for Health (I-TECH) presented findings from I-TECH-supported programs in Côte d’Ivoire and Ukraine:

Côte d’Ivoire

Ukraine

Additionally, representatives from I-TECH India, PLC, and the Zimbabwe Technical Assistance, Training, and Education Center for Health (Zim-TTECH)—two of I-TECH’s partner network organizations—as well as their program partners presented findings from I-TECH-supported programs being implemented in India and Zimbabwe:

India

Zimbabwe

Note: Bolded names represent I-TECH authors and an asterisk (*) indicates the presenting author

CSiM, a Center for Rural Health Stewardship, Joins I-TECH as Key Network Partner

Post categories: Best Practices CSiM Health Systems Strengthening Human Resources for Health John Lynch Quality Improvement United States
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The Center for Stewardship in Medicine (CSiM) has joined the International Training and Education Center for Health (I-TECH) Network as a partner, operating within the University of Washington’s Department of Global Health. CSiM is a collaborative of over 80 rural hospitals across nine states in the U.S. working together on stewardship challenges through education, quality and process improvement, and mentoring.

I-TECH and CSiM will mutually benefit from collective decades of experience tackling rural health challenges – including workforce shortages, staff who wear “many hats,” and disparities in services – in the U.S. and around the world.

“CSiM is a collaborative of physicians, nurses, laboratory professionals, and pharmacists working to bridge bi-directional knowledge gaps between academic medical centers and rural health care facilities,” said John Lynch, MD, MPH, co-director of CSiM. “Like I-TECH, we value collaborative, anti-hierarchical work that honors expertise and experience at all levels of the health care system, and from all sectors.” Dr. Lynch leads the center with Chloe Bryson-Cahn, MD, and Zahra Kassamali-Escobar, PharmD.

The CSiM team with guest speakers at the center’s conference in Spokane, WA, May 2023. Photo courtesy of CSiM.

CSiM works in antimicrobial stewardship and infection prevention, building sustainable quality improvement programs, and providing customized, long-term technical assistance to rural health facilities. The center’s main activities include leading the UW Tele-Antimicrobial Stewardship (TASP ECHO®) project, a telementoring program; coordinating Intensive Quality Improvement Cohorts; and providing resources and tools to support facilities in reaching their goals and improving the quality of healthcare.

“I-TECH and CSiM share a dedication to finding innovative and local solutions to provide ongoing education and mentoring to health care workers in resource-limited settings,” said Pamela Kohler, BSN, PhD, I-TECH co-director. “We are incredibly excited about the opportunity to learn from each other.”

Currently, CSiM has projects in Arizona, Idaho, Illinois, Louisiana, Maine, Montana, Oregon, Utah, and Washington and is exploring opportunities to extend its model globally.

“CSiM’s inclusive, team-based approach results in work that really matters to communities in need – particularly those in underserved, hard-to-reach, rural areas,” said Ivonne Ximena “Chichi” Butler, MPH, I-TECH co-director. “This approach makes it a perfect fit within the I-TECH Network.”

Lydia Chwastiak

Lydia Chwastiak, MD, MPH

Lydia Chwastiak MD, MPH is a psychiatrist and internal medicine physician and Professor in the Department of Psychiatry and Behavioral Sciences and Adjunct Professor in Global Health in the University of Washington. Her research for the past 21 years has focused on improving the care and outcomes of people with chronic medical conditions and serious mental disorders. She has been a principal investigator (PI) or co-investigator on eight NIH-funded clinical trials of integrated care in both medical and community mental health settings, including MPI on the multi-center INDEPENDENT Study (R01 MH100390) which demonstrated the effectiveness of collaborative care for the treatment of depression among patients with poorly controlled type 2 diabetes in 4 diabetes centers in India.

At I-TECH, Dr. Chwastiak is also the PI on a large global HRSA-funded grant to support capacity building for sustainable HIV services in Jamaica, Trinidad and Tobago, India, Mozambique, and Ukraine (U91HA06801). The goal of Capacity Building Program is to improve health outcomes for people living with HIV (PLHIV) along the HIV care continuum by building sustainable health systems. The program seeks to improve the efficiency and client-centeredness of HIV care systems by strengthening the operational and adaptive capacities of health institutions and the health workforce; expand the use of evidence-based methodologies and best practice approaches to improve health outcomes for PLHIV; increase the functionality and coverage of innovative technology platforms to improve HIV service delivery, public health communication, and data use for decision making; and strengthen equitable collaborations between country governments, implementing partners and communities to achieve and sustain epidemic control.

In addition to her work with I-TECH, Dr. Chwastiak is Associate Director of the UW Behavioral Research Center in HIV (BIRCH), an NIMH-funded developmental AIDS Research Center and directs the Center’s Integrated Care Research Core. She also is the PI and co-director of the SAMHSA-funded Northwest Mental Health Technology Transfer Center (Northwest-MHTTC), which provides training and technical assistance to support the behavioral health workforce of HHS Region 10 (AK, ID, OR and WA) to disseminate and implement evidence-based practices for mental disorders.

I-TECH Presents at 2023 IAS Conference on HIV Science

Post categories: Gabrielle O'Malley HIV Care and Treatment India Key Populations Malawi PrEP Quality Improvement Stefan Wiktor Surveillance Tuberculosis Zimbabwe
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The 2023 IAS Conference on HIV Science logo. Read the full background and inspiration behind the 2023 IAS Logo. Image credit: IAS

The International AIDS Society (IAS) hosted the 12th IAS Conference on HIV Science on 23 – 26 July 2023 in Brisbane, Australia, and virtually. This biennial conference brings together top HIV researchers, experts, and scientists for presentations and discussions on the latest advances in HIV research and practice.

This year, representatives from the International Training and Education Center for Health (I-TECH), I-TECH’s partner network organizations, and the Centers for Disease Control and Prevention (CDC) shared findings from I-TECH-supported programs in India, Malawi, and Zimbabwe. Read the ePoster abstracts below.

India:

Malawi:

Zimbabwe:

I-TECH and Partners Fête Quality Improvement Teams in Côte d’Ivoire

Post categories: Cote d'Ivoire HIV Care and Treatment PrEP Quality Improvement
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Honorees from well-performing sites in the QISSEC project

In late February, the International Training and Education Center for Health (I-TECH) hosted an awards ceremony for the 10 best-performing health facility-based quality improvement teams focused on improving HIV prevention, care, and treatment services in Côte d’Ivoire. I-TECH currently operates in 80 HIV care and treatment (C&T) health facilities throughout Côte d’Ivoire.

Out of a total of 20 points, and using strict criteria, 10 sites received scores greater than or equal to 18 and were honored at the ceremony. Awards included computer equipment, printers, video projectors, blood pressure monitors, and other vital office equipment.

The ceremony was part of the U.S. Health Resources and Services Administration (HRSA)-funded Quality Improvement Solutions for Sustained Epidemic Control (QISSEC) project, which seeks to improve interventions such as the  provision of pre-exposure prophylaxis (PrEP), decreasing treatment interruption, and improving viral load testing coverage and suppression.

“This ceremony was a way to applaud the enthusiasm from the teams, demonstrate an understanding of the methodology, and share the projects that have so far been implemented,” said Dr. Nathalie Krou Danho, QISSEC Project Director.

PEPFAR Coordinator Bibola Ngalamulume

In addition to Dr. Danho, ceremony attendees included the National AIDS Control Program (PNLS) Director, PEPFAR Coordinator Bibola Ngalamulume, HRSA representatives, QISSEC Principal Investigator Ellen MacLachlan, CDC and USAID Country Directors, and representatives from the regions, districts, and sites.

“It is important that we put an accent on service quality,” said Ms. Ngalamulume. “The CQI project that is being implemented by I-TECH is an initiative that is extremely important because not only does it ensure that we improve access to care for all the HIV population–those who are infected and affected–but also it gives us the opportunity to create some kind of a mentorship network between health facilities that are performing well and facilities that need support. [This ceremony] is going to drive even more innovation moving forward.”

Within the QISSEC project, I-TECH has been working closely with the Ministry of Health and Public Hygiene (MSHP) and implementing partners to strengthen provider and community counselor capacity in quality improvement to ensure HIV epidemic control.

I-TECH’s methodology is to build a culture of quality improvement from central, to regional, to site levels. Importantly, I-TECH supports sites to work with the community to center their needs, and patient needs, in providing quality care.

One of the sites honored, an urban health center in Libreville, had set a goal to increase individuals on PrEP from 23 in December 2021 to 78 in June 2022. Their root cause analysis revealed that training in PrEP was insufficient. After orienting prescribers and clinical advisors to PrEP, and organizing community awareness sessions where eligible individuals were identified, the site surpassed their goal by 200%, initiating 230 individuals on PrEP by June 2022. The site continued to increase that pace, reaching 353 by August of that year.

“It’s been a lot for the teams to do this work on top of their day-to-day jobs: to form a quality improvement team, brainstorm, and think of ideas on how to implement the changes,” said Dr. MacLachlan, “but they have taken great care in this work. The quality of HIV care in Côte d’Ivoire will be better for it.”

THIS PROJECT IS SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION (HRSA) OF THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS) UNDER U91HA06801, THE INTERNATIONAL AIDS EDUCATION AND TRAINING CENTER (IAETC). THE CONTENT OF THIS POST IS THE AUTHOR’S AND SHOULD NOT BE CONSTRUED AS THE OFFICIAL POSITION OR POLICY OF, NOR SHOULD ANY ENDORSEMENTS BE INFERRED BY HRSA, HHS OR THE U.S. GOVERNMENT.

I-TECH in Côte d’Ivoire Hosts National HIV QI Conference

Post categories: Caryl Feldacker Cote d'Ivoire Quality Improvement
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On 18-19 May 2022, the International Training and Education Center for Health (I-TECH), in collaboration with the Programme National de Lutte Contre le Sida (PNLS; National AIDS Control Program) under the coordination of the General Directorate of Health, hosted its first national HIV prevention, care, and treatment quality improvement (QI) conference in Abidjan, Côte d’Ivoire. The conference brought together over 100 representatives from the Centers for Disease Control and Prevention, United States Agency for International Development, the Human Resources and Services Administration (HRSA), US President’s Emergency Plan for AIDS Relief (PEPFAR), and PEPFAR implementing partners from around the country to agree on a national approach to QI; update the national strategic plan for improving Quality, Health, and Safety; and learn about the unique QI approach being implemented by I-TECH through the Quality Improvement Solutions for Sustained Epidemic Control (QISSEC) program.

Dr. Nathalie Krou Danho
I-TECH QISSEC Project Director, Dr. Nathalie Krou Danho, describes the QISSEC approach at the National HIV QI Conference. Photo Credit: I-TECH

“This is an historic workshop. [There have been] many conversations and meetings with the PNLS/Ministry of Health and USG agencies [over the years] to gather all the stakeholders to harmonize QI interventions,” says Dr. Jean T. N’Guessan, QISSEC QI Consultant. “This national QI workshop was a success because the leadership was carried by the PNLS, the national Program to fight AIDS, and supported by I-TECH.”

The goal of the conference was to elevate QI practices on a national level and work with stakeholders to adopt and integrate the QISSEC QI approach into their own HIV prevention, care, and treatment programs to improve HIV services while identifying and addressing gaps in care (e.g., viral load monitoring, antiretroviral therapy uptake).

“In Côte d’Ivoire, all hospitals—both public and private—are required to implement continuous quality improvement for all care and services, which can lead to a one-size-fits-all approach to QI,” explains Dr. Nathalie Krou Danho, I-TECH QISSEC Project Director. “This workshop made it possible for us to identify gaps in national standards for the prevention, care, support, and treatment of HIV infection, while also providing an effective QI framework that helps clarify the roles and responsibilities of the stakeholders implementing QI initiatives across the country.”

QI interventions are often applied unilaterally across all sites regardless of analysis of the sites’ specific needs, but I-TECH’s approach tailors each QI intervention and related activities to the needs of the site according to self-identified gaps by the sites. This approach allows sites to be involved in each step of the process, reinforces skills and knowledge, and ultimately creates a sustainable approach to QI. By using the QISSEC approach, HIV programs around Côte d’Ivoire will be able to align their QI work and substantially improve HIV services, while also fulfilling PEPFAR priorities and targets.

“Since I-TECH’s approach works in collaboration with all levels (national, district, and site) of the health system pyramid, we are able to coach sites to develop a QI plan based on the identified gaps, implement it, as well as monitor and evaluate it,” says Dr. Nathalie Krou Danho. “Through data analysis of MER indicators and SIMS data, the approach takes into account the organizational improvement of the quality and the services offered to the patients.”

The QISSEC project, a five-year cooperative agreement with HRSA under PEPFAR, works with local partners to implement customized site-level QI interventions using patient-centered approaches in clinics to ensure a facility-owned and locally led response to the persistent challenges seen in HIV prevention, care, and treatment programs (e.g., HIV testing, retention, suppression, PrEP, TB prevention) and support Côte d’Ivoire in reaching the UNAIDS 95-95-95 targets. The project has initially been focused on 60 priority sites throughout the country but plans to expand to Abidjan’s 75 high-impact sites next year, bringing the total number of sites to 101.

“The QISSEC project aims to strengthen ownership of continuous QI at all levels of the health system pyramid,” says Dr. Nathalie Krou Danho. “To do this, I-TECH collaborates with all national stakeholders, including PEPFAR implementing partners and civil society organizations who can help motivate beneficiaries to take part in QI efforts and extend its QI approach to the community.”

I-TECH’S WORK IN CÔTE D’IVOIRE IS SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION (HRSA) OF THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS) UNDER 1 U1NOA45176-01-00 THE CONTENT OF THIS POST IS THE AUTHOR’S AND SHOULD NOT BE CONSTRUED AS THE OFFICIAL POSITION OR POLICY OF, NOR SHOULD ANY ENDORSEMENTS BE INFERRED BY HRSA, HHS, OR THE U.S. GOVERNMENT.

Improving Data Quality and Strengthening Capacity in Côte d’Ivoire

Post categories: Cote d'Ivoire Quality Improvement
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Through a five-year cooperative agreement with the United States (US) Health Resources and Services Administration (HRSA) under the US President’s Emergency Plan for AIDS Relief (PEPFAR), I-TECH implements the Quality Improvement (QI) Solutions for Sustained Epidemic Control (QISSEC) project in Côte d’Ivoire. This project aims to support Côte d’Ivoire in reaching the UNAIDS 95-95-95 Fast-Track Targets, which to date have not been consistently achieved with specific populations faring worse than others.

The QISSEC approach supports Côte d’Ivoire’s National AIDS Program, Côte d’Ivoire’s International Training and Education for Health (I-TECH CIV), and other implementing partners to help close HIV-related service delivery gaps across clinics and communities, aiming to reach the UNAIDS 95-95-95 targets. Focused on 80 priority sites throughout the country, QISSEC works closely with local clinic- and community-based partners to implement customized site-level QI interventions; integrate community or civil society groups into QI approaches; establish national QI learning networks; and disseminate QI successes and lessons learned across the learning networks. Using this patient-centered approach, QISSEC aims to ensure a facility-owned and locally-led response to persistent challenges in patient testing, retention, and suppression.

I-TECH Remembers Transgender Activist and Leader Brandy Rodriguez

Post categories: Key Populations Quality Improvement Trinidad and Tobago
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Brandy Rodriguez gives feedback to a clinician during the pilot training of I-TECH’s Key Population Preceptorship program in Trinidad & Tobago. Photo credit: Lauren Dunnington/I-TECH.

In honor of Transgender Awareness Week (November 13-19), the International Training and Education Center for Health (I-TECH) pays tribute to Trinidad & Tobago transgender activist and esteemed community leader Brandy Rodriguez, who passed away in late October.

Ms. Rodriguez leaves a legacy of leadership as president of the Trinidad and Tobago Transgender Coalition and a member of the Pan Caribbean Partnership against HIV and AIDS. She improved countless lives among those she supported in her many years as a peer navigator at the Family Planning Association of Trinidad and Tobago. Countless more lives were touched – and perspectives broadened – through her tenacity and compassion.

Staff at I-TECH are honored to have worked with Ms. Rodriguez, who served as a patient-trainer for I-TECH Caribbean’s Key Populations Preceptorship program in Trinidad & Tobago.

“A tireless champion for the trans community, Brandy held an open door and a willing ear to any lost children of our LGBTQ tribe,” says Conrad Mitchell, I-TECH’s Program Coordinator in Trinidad & Tobago. “Her fiery tongue and sharp wit kept us all in check, whilst her warm heart overflowed with a love that was unsurpassed. Her fearlessness was legendary both within the community and across local, regional, and international platforms. We are shaken to the core by this loss. The world is forever a little less ‘fierce’ with Brandy gone.”

The Key Populations Preceptorship program’s intensive trainings use targeted role-play scenarios to build clinicians’ capacity to provide nonjudgmental, high-quality comprehensive HIV care to communities most at risk: men who have sex with men, transgender people, and sex workers. Through this work with I-TECH, Ms. Rodriguez contributed to critical efforts to break down stigma and barriers to care experienced by marginalized communities. The first physician trained as part of the program in Trinidad & Tobago, Dr. Vedavid Manick, shared his experience with Ms. Rodriguez beautifully in a Trinidad and Tobago Newsday letter to the editor.

To learn more about the impact Ms. Rodriguez’s work, see these tributes at Trinidad and Tobago Newsday and UNAIDS.org.

Kayla Cody-Lushozi Reflects on I-TECH’S Global Health Leadership Development Program

Post categories: Cambodia Caribbean Health Systems Strengthening HIV Care and Treatment Jeff Lane Quality Improvement Uncategorized Zimbabwe
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Kayla Cody-Lushozi

By Chelsea Elkins

For the past 10 months, Kayla Cody-Lushozi has served as the inaugural Global Health Program Officer for I-TECH’S Global Health Leadership Development Program. The aim of this program is to support the development of skills in global health program implementation, management, and leadership for recent master’s degree graduates with diverse backgrounds who are transitioning into the public health field.

This program is structured to directly support the programmatic needs of multiple I-TECH projects while providing the Program Officer with mentorship across the I-TECH network and supporting the transition into a non-temporary global health position. In 2019, Cody-Lushozi received her Master’s in Social Work (MSW) from the University of Washington (UW) and has used this background, along with her unique experiences and expertise, to inform her work at I-TECH.

During her time as a Program Officer, Cody-Lushozi has worked with three teams across the I-TECH network, plunging into a few of the many areas of work I-TECH implements and supports. In collaboration with partners from FHI 360 and leaders from the Cambodian Ministry of Health, Cody-Lushozi supported a health informatics program, working to streamline databases and strengthen health systems in Cambodia. Additionally, she explored how to revive Community Advisory Boards for people living with HIV (PLHIV) in Jamaica in a sustainable and community-centered way with I-TECH network partner the Caribbean Training and Education Center for Health (C-TECH). She worked with community partners in Zimbabwe, as well, exploring the support systems in place for case managers supporting young PLHIV. This work was done with I-TECH partner the Zimbabwe Technical Assistance, Training and Education Center for Health (Zim-TTECH).

September marks the end of Cody-Lushozi’s time with I-TECH. Below, she shares some reflections on her time in the Leadership Development Program, as well as what might come next.

What has the experience of being a Program Officer at I-TECH meant to you?

This has been an incredible experience, and it came at a perfect time. Right before I-TECH, I was working at the Washington State Department of Social and Health Services doing direct service social work with economically marginalized clients with mental and physical health needs. While I enjoyed this role and understood its importance, this was not the type of social work practice that I wanted to pursue in the long run.

My passion and interests lie in research, especially community-centered research that allows me to work directly with Black communities in improving access to health justice. I-TECH came along at the right time and allowed me to dive deeper into the world of global health implementation.

The projects I’ve done at I-TECH have been really varied, and I’ve gotten an inside look and experience across different areas. I am constantly learning at I-TECH. I-TECH does a million things, which might have been overwhelming to a new person entering the organization, but I always felt very supported by my teams. They made it clear that I didn’t need to have all the answers.

I also appreciate that this program aims to attract a diversity of experience, background, and perspective. It encourages more than just a singular lens. I’ve been able to share my unique background and experiences as a Black woman social worker in global health. I’m excited to see where this program goes and how it continues to support I-TECH’s evolution.

This has been a beautiful experience for me. Working at I-TECH served as a great affirmation that this is the area of work that I want to continue to grow in.

How has your background in social work shaped how you’ve entered the global health field?

Before getting my MSW I already had an interest in public health, even before I was calling what I was doing public health. I wanted to use the framework and the lens that social work provides within a public health setting. I always gravitate toward work that is community-centered and centers the voices and expertise of those in the margins. These are some of the values that I bring with me into the global health space and that I hold very close to my professional and personal practice.

These values have helped me in this field because public and global health work is not always operating from the pillars of anti-oppressive practice. There’s so much historical and contemporary discourse that needs to be addressed and often isn’t in this field. You can’t be ahistorical if you’re truly trying to get to the root causes of global health inequity and injustice. Many of the issues that we see in global health are connected to issues of global white supremacy, imperialism, and resource extraction. It’s a tension that I hold in this field but something I try to do my part to shed light on.

You have done a lot of meaningful work during your time with I-TECH. What does your life look like when you’re not working?

I’ve gone through a lot of life changes these past 10 months. I’m a newlywed; I got married in June to my now husband Mawande. Being a new wife is really exciting.

A big chunk of my husband’s and my time outside of work is dedicated to our small homemade skincare business, K+M Homemade Skincare, that we officially launched during COVID. We do a lot of farmer’s markets and pop-ups on the weekends. Ask anyone and they can tell you that we love making and talking about our skincare.

In what direction do you see yourself moving after I-TECH?

After I-TECH, I see myself continuing to engage in global and public health spaces that are truly committed to community work and radical racial and social justice transformation. I am not comfortable doing this work in the absence of working directly with community members and local stakeholders. Top-down approaches have colonial and imperialist roots. I believe in doing “with” and not doing “to” and actively partnering with communities for long-term sustainability and quality health care reform.

I will be packing up and moving to South Africa in 2022 and am currently open to a position that will allow me to continue to practice in this exciting field. My interests lie in research, project management, and implementation work related to HIV care and treatment, maternal and child health, and mental health. I am also contemplating pursuing an MPH or a PhD in global health and implementation science sometime in the future. It’s been an incredible past 10 months with I-TECH and I am excited to stay in contact with this global network. I thank everyone who has been part of this journey with me!

The I-TECH network thanks Kayla Cody-Lushozi for her work and wishes her well as she continues to forge her path in global health!

If you are interested in participating in the Global Health Leadership Development Program, more information is available here.

Reducing HIV through Voluntary Medical Male Circumcision in Zimbabwe

Post categories: Caryl Feldacker HIV and STI Prevention Male Circumcision Quality Improvement Scott Barnhart Zimbabwe
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Since 2013, the ZAZIC Consortium has been implementing Voluntary Medical Male Circumcision (VMMC) as part of a combination HIV prevention package approved by the Ministry of Health and Child Care (MoHCC) in Zimbabwe. Unlike other VMMC programs in the region, the ZAZIC model uses an integrated approach, blending local clinic staff supported by MOHCC with partner staff. The ZAZIC consortium supports:

  • Training using MoHCC approved curricula, health workers in the supported districts are trained on the surgical technique as well as on demand creation
  • Development and implementation of age appropriate demand creation strategies
  • Support service delivery in 13 districts from consent procedures to post-surgical care and linkage to other services
  • Comprehensive monitoring and evaluation including continuous quality improvement and operations research

From 2013-2018, ZAZIC performed over 300,000 VMMCs with a reported moderate and severe adverse event rate of 0.3%. The safety, flexibility, and pace of scale-up associated with the integrated VMMC model appears similar to vertical delivery with potential benefits of capacity building, sustainability and health system strengthening. Although more complicated than traditional approaches to program implementation, attention should be given to this country-led approach for its potential to spur positive health system changes, including building local ownership, capacity, and infrastructure for future public health programming. Over 80% of the circumcisions occur in outreach settings, an approach that ensures wide coverage and expanded services in hard-to-reach locations.