Uptake of Voluntary Medical Male Circumcision Among Men Attending a Sexually Transmitted Infections Clinic in Lilongwe, Malawi
Phase: NA
Conditions: HIV Infections, Sexually Transmitted Infections
Sponsor: University of North Carolina, Chapel Hill

STUDY PROTOCOL 
 
Uptake of Voluntary Medical Male Circumcision among Men 
Attending a Sexually Transmitted Infections Clinic in Lilongwe Malawi 
 
 
 
NCT number NCT04677374 
Document Date 03/05/2020 
 

 
i 
 
 
 
 
 
 
 
 
 
 
 
Uptake of Voluntary Medical Male Circumcision among Men attending a 
Sexually Transmitted Infections Clinic in Lilongwe Malawi 
 
 
 
 
 
PhD Protocol 
Epidemiology – Implementation Science 
Wits School of Public Health 
UNIVERSITY OF WITWATERSRAND 
 
 
 
 
 
Mitch Matoga 
Student number: 1314741 
 
 
 
 
 
Supervisors: 
Dr Sara Nieuwoudt 
Associate Professor Charles Chasela 
Professor Mina Hosseinipour 
 
 

 
 
 
vi
1 
TABLE OF CONTENTS 
 
Main Aim .............................................................................................. Error! Bookmark not defined. 
Specific objectives ................................................................................ Error! Bookmark not defined. 
2 
LIST OF TABLES AND FIGURES .............................................................................................................. 1 
3 
LIST OF ACRONYMS AND ABBREVIATIONS.......................................................................................... 2 
4 
DEFINITIONS ......................................................................................................................................... 3 
5 
INTRODUCTION .................................................................................................................................... 1 
5.1 
Background Information ............................................................................................................ 1 
5.2 
Problem statement ...................................................................................................................... 4 
5.3 
The conceptual framework ........................................................................................................ 6 
5.4 
Study Objectives .......................................................................................................................... 9 
5.4.1 
Main Aim ............................................................................................................................. 9 
5.4.2 
Specific objectives ............................................................................................................... 9 
6 
METHODOLOGY .................................................................................................................................. 10 
6.1 
Study design ............................................................................................................................... 10 
6.2 
Study setting .............................................................................................................................. 11 
6.3 
Study population ....................................................................................................................... 12 
6.4 
Inclusion Criteria ...................................................................................................................... 12 
6.5 
Exclusion criteria ...................................................................................................................... 12 
6.6 
The RITE Intervention ............................................................................................................. 13 
6.6.1 
Composition ....................................................................................................................... 13 
6.6.2 
Implementation ................................................................................................................. 15 
6.1 
Sampling .................................................................................................................................... 17 
6.2 
Data Collection .......................................................................................................................... 17 
6.3 
Sample Size Calculation and Justification .............................................................................. 22 
6.4 
Ethical Considerations .............................................................................................................. 25 
6.5 
Limitations and anticipated challenges ................................................................................... 26 
6.6 
Proposed publications ............................................................................................................... 26 
6.7 
Timeline of proposed scope of work (Work Plan) .................................................................. 27 
6.8 
Study Budget ............................................................................................................................. 27 
6.9 
References .................................................................................................................................. 27 
7 
APPENDIXES ........................................................................................................................................ 32 

 
 
 
vii
7.1 
Appendix 1: Schema of the Implementation Stages ............................................................... 32 
7.2 
Appendix 2: Routine Clinical Data Collection Tool .................. Error! Bookmark not defined. 
7.3 
Appendix 3: The Rite Uptake Data Collection Tool ................. Error! Bookmark not defined. 
7.4 
Appendix 4: Time to Uptake of VMMC .................................... Error! Bookmark not defined. 
7.5 
Appendix 5: SMS Tracing Form and Sample of Text Message Error! Bookmark not defined. 
7.6 
Appendix 6: Survey 1 – Intensified Health Education (I) ........ Error! Bookmark not defined. 
7.7 
Appendix 7: Survey 2 – Intensified Health Education and Clinic Escorts (IE) ............ Error! 
Bookmark not defined. 
7.8 
Appendix 8: Survey 3 – Intensified Health Education, Clinic Escort and SMS Tracing 
(ITE) Error! Bookmark not defined. 
7.9 
Appendix 9: Survey 4 – Intensified Health Education, Clinic Escort, SMS Tracing and 
Transport Reimbursement (RITE) ........................................................ Error! Bookmark not defined. 
7.10 
Appendix 10: Acceptability and Feasibility Interview Guide – RITE Intervention ..... Error! 
Bookmark not defined. 
7.11 
Appendix 11: Acceptability and Feasibility Focus Group Discussion Guide – RITE 
Intervention .............................................................................................. Error! Bookmark not defined. 
7.12 
Appendix 12: Summary of Methods ........................................... Error! Bookmark not defined. 
7.13 
Appendix 13: Informed Consent Form – In-depth Interview .. Error! Bookmark not defined. 
7.14 
Appendix 14: Informed Consent Form – Survey ...................... Error! Bookmark not defined. 
7.15 
Appendix 15: Informed Consent Form – Focus Group Discussion ........ Error! Bookmark not 
defined. 
7.16 
Appendix 16: Lilongwe District Health Office Letter of Support .......... Error! Bookmark not 
defined. 
7.17 
National Health Sciences Research Ethics Committee Approval ........... Error! Bookmark not 
defined. 
7.18 
University of North Carolina Chapel Institutional Regulatory Board Approval ......... Error! 
Bookmark not defined. 
7.19 
Timeline of proposed scope of work (Work Plan) ..................... Error! Bookmark not defined. 
7.20 
Appendix 17: Study Budget ........................................................ Error! Bookmark not defined. 
 
 
 
 
 
 
 
 
 
 

 
 
 
viii 
 
 
 
 
 
 
 

 
 
 
1 
2 LIST OF TABLES AND FIGURES 
Figure 3: Stages of Implementation of the RITE intervention .................................................................... 32 
 
Tables 
Table 1: Sample Size Table ......................................................................... Error! Bookmark not defined. 
Table 2: Summary of Objectives and Methods .............................................. Error! Bookmark not defined. 
Table 3: Proposed Study Timeline ................................................................. Error! Bookmark not defined. 
Table 4: Study Budget ................................................................................... Error! Bookmark not defined. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
2 
3 LIST OF ACRONYMS AND ABBREVIATIONS 
AIDS 
Acquired Immunodeficiency Syndrome 
AIM 
Acceptability of Intervention Measure 
ANOVA 
Analysis of Variance 
BSC 
Bwaila STI Clinic 
EMR 
Electronic Medical registry 
FGD 
Focus Group Discussion 
FGHF 
Fogarty Global Health Fellowship 
FIM 
Feasibility of Intervention Measure 
GHE 
Group Health Education 
HCWs 
Healthcare Workers 
HIV 
Human immunodeficiency Virus 
HTS 
HIV testing Services 
IDI 
In-depth Interview 
IHE 
Intensified Health Education 
LDH 
Lilongwe District Hospital 
LMICs 
Low and Middle-Income Countries 
MoH 
Ministry of Health 
NHSRC 
National Health Sciences Research Ethics Committee 
NIRN 
National Implementation Research Network 
ODK 
Open Data Kit 
PEPFAR 
President’s Emergency Plan For AIDS Relief 
PrEP 
Pre-Exposure Prophylaxis 
RITE 
Re-imbursement, Intensified health education, cell phone Tracing 
and Escorts 
SE Africa 
Southern and Eastern Africa 
SEM 
Structural Equation Modelling 
SMS 
Short Messaging Service 
SOC 
Standard of Care 
STIs 
Sexually Transmitted Infections 
UNAIDS 
The Joint United Nations Program on HIV and AIDS 
UNC IRB 
University of North Carolina Institutional Review Board 
VMMC 
Voluntary Medical Male Circumcision 
WHO 
World AIDS Organization 
WITS HREC 
University of Witwatersrand Human Research Ethics Committee 
 
 
 
 
 
 

 
 
 
3 
4 DEFINITIONS  
Acceptability: the perception among men and healthcare workers that the adaptable RITE 
intervention is agreeable, palatable and satisfactory. 
Appropriateness: the perceived fit of the adaptable RITE intervention to address the problem of 
low uptake of VMMC among men and healthcare workers. 
Clinic escort: the act of escorting/accompanying a participant interested in VMMC from the STI 
clinic to the VMMC clinic to ensure linkage to care.  
Contamination: a situation where the study population become exposed to more than one 
intervention component 
Feasibility: the extent to which the adaptable RITE intervention will be successfully carried out 
at Bwaila STI clinic. 
Intensified health education: consistent and setting-specific education on VMMC incorporated 
into the routine STI/HIV health education provided at Bwaila STI clinic. 
Interference: a scenario where other stakeholders implement an intervention(s) aimed to scale-
up the uptake of VMMC at the study sites which may affect attribution. 
Seasonality: periodic variation in the uptake of VMMC with calendar time 
SMS reminder tracing: the act of reminding participants with a VMMC appointment about 
their date of procedure through short messaging service. 
Time-to-uptake: the number of days from the day a participant is offered VMMC to the day 
they undergo VMMC  
Transport reimbursement: refunding money used for transportation to Bwaila district hospital 
for participants who undergo VMMC using standard Malawi government rates.  
Uptake: the action of undergoing VMMC. 

 
 
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5 INTRODUCTION 
5.1 
Background Information  
Human Immunodeficiency Virus (HIV) infection remains a huge public health burden globally. 
In 2018, approximately 36.9 million people were living with HIV infection and there were about 
940,000 AIDS-related deaths worldwide [1]. In the past decade, the decline in new HIV 
infections among adults slowed down and has remained static at about 1.9 million people per 
year world-wide in recent years [2]. Southern and Eastern (SE) Africa is the world’s most 
affected region, accounting for 44% of new infections and with about 52% of the people living 
with HIV residing in this region [3]. While some countries in the region, such as Uganda and 
Mozambique, have made great progress in reducing new HIV infections in adults, some, such as 
Lesotho have been less successful [4]. In Malawi, the HIV prevalence among adults was 9.2% in 
2018 [5] 
In 2014, the Joint United Nations Program on HIV and AIDS (UNAIDS) developed the fast-
track target to reduce the number of global new annual HIV infections among adults to fewer 
than 200,000 and, in 2016, revised the target to end AIDS as a public health threat by 2030 [2]. 
As part of achieving this ambitious global plan, UNAIDS called for scale-up of combination 
prevention strategies [2]. Combination prevention approaches promote simultaneous use of 
complementary biomedical, behavioral and structural strategies and can be implemented at 
individual, community and population levels as they are amenable to setting-specific factors such 
as culture, infrastructure and populations most affected by HIV  [2].  One of the immediate goals 
for UNAIDS is to ensure access to combination prevention options which include pre-exposure 
prophylaxis, voluntary medical male circumcision (VMMC), harm reduction and condom use to 

 
 
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at least 90% of people by 2020 [6]. However, as the number of new HIV infections remains 
static at 1.9 million people per year [1], progress in HIV prevention is off-track, highlighting the 
need for innovative ways to scale-up combination prevention strategies.  
One of the existing biomedical prevention methods that is under-utilized in SE Africa is 
voluntary medical male circumcision [3]. The coverage of VMMC in the region remained below 
30% in 2016  compared to other HIV prevention methods such as condom use (83%), HIV 
testing (76%) and prevention of mother-to-child transmission (89%) [2].  
In the mid-2000s, VMMC was confirmed to reduce the risk of HIV transmission by 60% during 
unprotected heterosexual sex [7]. Three randomized controlled trials in South Africa, Kenya and 
Uganda contributed overwhelming evidence that VMMC significantly lowers the rate of HIV 
transmission [8–10]. Consequently, in 2007 the World Health Organization (WHO) and 
UNAIDS recommended VMMC as a part of the comprehensive HIV prevention strategy for high 
HIV prevalence and low male circumcision areas – where the greatest public health impact 
would be realized [11]. As a result, 15 countries in SE Africa, including Malawi, were identified 
by UNAIDS and WHO as priority countries for expansion of VMMC activities for HIV 
prevention [2].  
Since 2008, VMMC activities for HIV prevention increased in SE Africa [3]. This resulted in an 
increase in cumulative VMMCs performed between 2008 and 2015. However, by 2016, the 
coverage of VMMC remained below 30% across the region [3]. In 2016,  UNAIDS and WHO 
set a target to reach 90% of males of 10-29 years in the priority countries with VMMC by 2021 - 
a target not easy to reach [2].  
In Malawi, after several years of debate, VMMC was adopted as a HIV prevention strategy in 

 
 
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2012. The prevalence of male circumcision among men aged 15-49 years was 28% in 2016 with 
only 9% being medical circumcision and 18% traditional circumcision [12]. This coverage is far 
below the 80% regional target and 60% national target [2,12]. In fact, Malawi has one of the 
lowest VMMC coverage rates among the priority countries [13]. Since 2008, there has been an 
increase in the number of VMMCs performed through the Ministry of Health (MoH) VMMC 
program with support from the President’s Emergency Plan for AIDS Relief (PEPFAR), 
however coverage and uptake have remained low. About 157,504 circumcisions were performed 
between 2008 and 2014 representing 8% of the target population [14].  Lilongwe, the capital city 
of Malawi also a PEPFAR supported district, has one of the highest HIV prevalence rates and 
lowest national circumcision coverage rates (14% in 2015) [2].  
Despite the low coverage and uptake of VMMC, early acceptability studies in Malawi showed 
that VMMC was acceptable among certain communities [15] and recent data show favorable 
results across different settings in Malawi [16,17]. Some of the most common factors reported to 
deter men from undergoing VMMC in Malawi include low HIV risk perceptions, especially 
among older men; fear of pain; lack of support from partner or parent or peers; a preference for 
traditional circumcision as part of culture in some communities; fear of complications including 
bleeding, impotence and infections; religious influence; costs associated with accessing VMMC; 
lack of knowledge on medical benefits of VMMC including myths and misconceptions and 
unwillingness to be attended to by female healthcare providers [16,18–23].   
Carrasco and colleagues conducted a study in three high HIV prevalence districts in southern 
Malawi and found that only 8% of high-risk group of men accessed VMMC services [13]. Men 
attending STI clinics are a high-risk population because sexually transmitted infections (STIs) 
increase the risk of HIV acquisition and transmission by three-fold or more [24]. STI clinics in 

 
 
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Malawi have high HIV prevalence estimated at around 19% in 2018 [25] and low VMMC rates 
28% [26]. In the STI setting, VMMC is not only protective against HIV but also against curable 
STIs [24]. In view of this background, increasing the coverage and uptake of VMMC in men 
attending STI clinics could potentially result in a greater impact, making STI clinics an ideal 
setting for scale-up of VMMC services.  
Therefore, in an attempt to address the factors outlined above in order to increase the demand 
and uptake of VMMC, this study proposes to use an adaptable intervention comprising four 
intervention components that include transport reimbursements (R), intensified health education 
(I), SMS reminder tracing (T) and clinic escorts (E) – coined as the RITE intervention. This 
intervention was developed based on literature. Details of the intervention have been outlined in 
the methods section below. 
5.2 
Problem statement 
Since the inception of VMMC, many countries have fallen below targets resulting in the new 
fast-track target - to have 90% of males of 10-29 years in priority countries circumcised by 2021 
[2]. To achieve this goal, there is need to intensify current efforts and to develop novel strategies 
in the implementation of VMMC programs [4]. In Malawi, despite efforts to increase the supply 
of VMMC services in order to improve national coverage, the demand/uptake has remained low 
[2]. The low demand/uptake poses a great risk of continued HIV and STI transmission. 
UNAIDS recommends prioritizing VMMC to sub-populations (for example by age or risk level) 
to maximize its impact and efficiency [2]. One such sub-population is men attending STI clinics 
who may have symptomatic or asymptomatic STIs. The Malawi STI guidelines stipulate that 
VMMC should be offered to all male uncircumcised STI clients, however, this population has 

 
 
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not been prioritized [27]. Recently, the Malawi VMMC program introduced a mobilizer to STI 
clinics who conduct health education talks on VMMC every morning, however MC rates have 
continued to remain low – estimated at 28% [26]. Finally,  the lack of knowledge on medical 
benefits of VMMC among the general population  may translate to a lack of knowledge on the 
same among men at STI clinics,  which may pose as a major barrier for the demand for VMMC 
in this population [16,18–23]. In addition, time from when men are offered VMMC to when they 
undergo the procedure is not well studied and documented. We hypothesize that uptake of 
VMMC will be higher within the first seven days of exposure to intervention. Obtaining insight 
on this would help with the design of interventions and programs and the period needed to 
sustain intervention or program exposure. 
Justification 
Despite VMMC being a primary focus of the HIV prevention in Malawi, uptake has been far 
below expected levels due to varied reasons since its inception in 2012. Some of the common 
reasons include perception of low HIV risk especially among older men, lack of knowledge on 
medical benefits of VMMC, lack of support from partners or parents or peers and fear of pain 
and complications of VMMC. Further, the uptake of VMMC has been much lower in men 
presenting to health facilities with STIs – a high-risk group for HIV acquisition and transmission. 
Currently, published data on coverage and uptake of VMMC among STI clients in Malawi is 
unavailable. Further, there are no registered trials of novel strategies for improving the 
implementation of the VMMC program among men attending STI clinics in Malawi. This study 
aims to evaluate the RITE implementation intervention implemented systematically to increase 
the demand and uptake of VMMC among men attending a STI clinic in Lilongwe Malawi.   

 
 
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5.3 The conceptual framework  
Creating demand for VMMC is a key strategy for improving uptake in the priority countries [2]. 
This study is anchored on the theory that knowledge is an integral component of perceptions and 
that perceptions are a major determinant of behavioral change [28].  
Overall, our framework aims to increase the demand of VMMC by first developing insight on 
the factors that influence decision making whether or not to undergo VMMC among men 
attending STI clinics then develop health education content and to inform possible modification 
of the linkage-to-VMMC approaches based on these factors.  
Sgaier et al’s (2015) framework for demand generation [29], Maibvise and Mavundla (2019) 
model to promote the uptake of male circumcision [28] and the National Implementation 
Research Network (NIRN) stages of implementation (2010) by Fixsen et al [30] form the 
conceptual framework for this study (Figure 1). Sgaier et al’s framework focuses on developing 
insight into reasons for low demand for VMMC in subpopulations and developing innovative 
solutions to the identified reasons and Maibvise et al’s model conceptualizes the processes 
through which health care workers can promote the uptake of VMMC as an HIV-preventive 
method in high HIV prevalence and low circumcision settings. NIRN provides a set of 
systematic stages through which the implementation of an intervention should follow. 
The main features of the framework are related and are in two iterative steps. The two steps 
illustrate the transition from improved demand towards improved uptake of VMMC.  
Steps of the conceptual framework: The overall approach for this study will be in two steps 
detailed below: 

 
 
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Step A: Insight Development, Exploration and Installation–  
The aim of this step is to develop insight on the factors that influence decision making for 
circumcision among men in STI clinics. This step was guided by Sgaier et al’s, and Maibvise and 
Mavundla’s frameworks; and have been combined with the exploration and installation stages of 
the NIRN framework.  
To develop insight, we will conduct key stakeholder consultations. Key stakeholders will include 
the ministry of health VMMC program, the Centers for Disease Control (CDC) VMMC 
program, Population Services International (PSI) VMMC program, Johns Hopkins Program for 
International Education in Gynecology and Obstetrics (Jhpiego) and healthcare workers at 
Bwaila VMMC clinic and STI clinic. The aim of the meeting will be understand the views of 
men of VMMC from the experts and identify the best way to conduct health education and the 
appropriate content to include in health education material in a STI clinic setting. This is the 
NIRN ‘exploration’ stage. 
The identified factors will inform the development of health education material for demand 
creation and the best way to deliver the material. Education sessions will be interactive to allow a 
continuum of insight development and improvement processes. Sustained education is aimed to 
create a sustained social support system for the men, from peers and sexual partners. Healthcare 
workers and Bwaila STI clinic and VMMC clinic will be trained on the final intervention. This is 
the NIRN ‘installation’ stage.  
 
 

 
 
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Figure 1: Conceptual Framework for Scale-up of VMMC - Adapted from Maibvise, 2019, Sgaier 2015 and Fixsen 2010 
 
Step B: Linkage to care, Initial Implementation and Full Implementation 
The aim of this step is to improve uptake of VMMC by improving linkage and access to VMMC.  
Healthcare workers (HCW) at the STI clinic will facilitate access and utilization of safe VMMC 
services using different intervention components. However, before fully implementing the 
intervention, we will pilot the intensified health education among men and healthcare workers 

 
 
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delivering the education. This is the ‘initial implementation’ stage of the NIRN framework. Once 
our intervention is piloted, we will proceed with full implementation, the final NIRN stage. 
 
5.4 
Study Objectives 
5.4.1 Main Aim 
The aim of this study is to evaluate the RITE intervention for improved uptake of VMMC among 
men attending Bwaila STI clinic in Lilongwe, Malawi between May 2020 and October 2020.  
5.4.2 Specific objectives 
1. To compare uptake of voluntary medical male circumcision between the RITE 
intervention and the standard of care among men attending Bwaila STI clinic in Lilongwe 
Malawi 
a. To compare time-to-uptake of voluntary medical male circumcision between the 
RITE intervention and the standard of care among men attending Bwaila STI 
clinic in Lilongwe Malawi 
b. To assess factors affecting uptake of voluntary medical male circumcision among 
men attending Bwaila STI clinic in Lilongwe Malawi  
2. To develop STI clinic setting-specific voluntary medical male circumcision educational 
material at Bwaila STI clinic in Lilongwe Malawi 
3. To assess the acceptability, appropriateness and feasibility of the RITE intervention 
among men and healthcare workers at Bwaila STI clinic in Lilongwe, Malawi.  

 
 
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a. To assess the acceptability and appropriateness of the RITE intervention among 
men at Bwaila STI clinic in Lilongwe, Malawi 
 
6 METHODOLOGY 
6.1 
Study design 
This is a pragmatic, pre- and post-interventional quasi-experimental study combined with a 
prospective observational study design. The primary aim is to determine the effectiveness of the 
RITE intervention in increasing the uptake of VMMC at Bwaila STI clinic. The implementation 
science aim is to determine the potential utility (feasibility, acceptability and appropriateness) of 
RITE intervention in an STI clinic setting [31]. We will use a sequential mixed methods 
approach, starting with formative qualitative study to refine the proposed intervention (RITE), 
followed by a pragmatic, mixed-methods quasi-experimental study with one pre-exposure and 
four distinct exposure groups [7]. This stand-alone intervention will be implemented at a 
practical STI clinic setting without random allocation to the intervention. We will observe for the 
standard of care (SOC) in the pre-intervention phase and introduce our intervention in a step 
fashion of different intervention combinations with four different intervention groups. This 
approach will allow us to assess the effect of the intervention while assessing the effect of 
different combinations of the intervention components, building up to the full intervention.  
Since the STI clinic is an outpatient clinic and STIs are generally acute infections that resolve 
quickly with treatment, it is not possible to randomize intervention components and follow the 
same participants over time as a cohort hence the different exposure groups. The key outcome of 
interest, VMMC uptake, will be measured at the VMMC facility. 

 
 
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6.2 
Study setting 
The study setting is the Bwaila STI Clinic (BSC) and Bwaila VMMC clinic at Bwaila District 
Hospital (BDH). BDH is a public secondary level facility in Lilongwe and the only facility 
offering specialized STI care situate in a busy central town area of the Lilongwe district. 
Approximately 80 patients visit BSC per day. The VMMC clinic and BSC are about 300 meters 
apart within the BDH campus. Twenty (20) people comprising nurses, clinicians, HIV testing 
services (HTS) counsellors, receptionists and support staff run BSC. As standard of care, all STI 
patients at BSC receive group health education (GHE) and are offered opt-out provider initiated 
HIV testing as standard of care, before receiving care for their STIs. We propose to integrate 
intensified health education to the GHE. About two to three GHE sessions are conducted per day 
with different cohorts of patients based on their time of arrival at the clinic however only one 
GHE includes education on VMMC. The clinic receptionist assisted by a nurse or counsellor 
conducts GHE. The first GHE session includes a mobilizer from the VMMC clinic who conducts 
an educational talk on VMMC every morning at the STI clinic and refers men to the VMMC 
clinic using referral slips. The additional GHE sessions do not have educational talks by the 
mobilizer. We will train the clinic receptionist, counselors, nurses and the mobilizer to conduct 
intensified health education. As standard of care, uncircumcised men with STIs are supposed to 
be offered VMMC at the STI clinic by clinicians however this is not reinforced. Data on 
demographics, HIV testing and treatment, sexual history and STIs are collected routinely through 
an electronic medical registry.  
The VMMC clinic has a director, administrator, program officers, clinicians (male and female), 
nurses (both male and female), data clerks, mobilizers and support staff. A team consisting of 
one clinician, an assisting nurse and other support staff conduct circumcisions. Circumcisions are 

 
 
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done at the VMMC clinic and in the community through outreach clinics and mobile vans. Data 
such as demographics, referral source, date and outcome of VMMC are recorded in registers. We 
will use these registers to track men referred from the STI clinic who will undergo circumcision. 
Men attending the STI clinic may either be index cases (symptomatic) or sexual partners 
(symptomatic or asymptomatic). Men with symptomatic STIs will not undergo VMMC on the 
same day of their STI clinic visit until they complete treatment for their current STI.  
 
6.3 
Study population 
 
The study population is uncircumcised men ≥ 18 years accessing STI care regardless of their 
HIV status, at Bwaila STI clinic between April and September 2020 in Lilongwe Malawi. The 
population will also include healthcare workers at Bwaila STI and VMMC clinics and other key 
stakeholders. The other key stakeholders will MoH VMMC program officials, and the private 
sector such as the CDC, PSI and Jhpeigo. 
6.4 
Inclusion Criteria 
The inclusion criteria will be as follows: 
 Uncircumcised men ≥ 18 years accessing STI care regardless of their HIV status 
 Willingness to participate in the study 
 Willingness to provide informed consent 
6.5 
Exclusion criteria 
Men with prior exposure to research activities who come for repeat STI visits 

 
 
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6.6 
The RITE Intervention  
The RITE intervention was developed solely based on literature. As such, based on results from 
the formative research, the content of the intensified health education will be designed to make it 
more setting specific. 
6.6.1 Composition  
The  RITE intervention has been guided by the conceptual framework (figure 1) and Powell et 
al’s refined compilation of implementation strategies [32].  
Intensified Health Education (I) 
Intensified health education will be more consistent and setting-specific education on VMMC 
incorporated into the routine STI/HIV health education provided at Bwaila STI clinic. 
Currently, health education on VMMC at Bwaila STI clinic is offered once in the morning 
session – leaving out patients who come later to the clinic. The health education session 
combines education on HIV and STIs, usually offered by HIV testing counselor or clinic 
receptionists, and education on medical circumcision, offered by a VMMC mobilizer from the 
Bwaila VMMC clinic.  
In this PhD study, we intend to make health education more setting specific and delivered better 
by conducting formative research to understand the views of men on VMMC with emphasis on 
men accessing STI care. In addition, we intend to intensify the education by conducting 
additional (more than one educational talk as per current standard) educational talks. The health 
talks will be delivered at Bwaila STI clinic – the recruitment point. The current format of the 
educational talks will be maintained but in addition, educational material on medical 
circumcision will be developed based on results from the formative research. The VMMC 

 
 
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mobilizer including the clinic receptionist and counselors will be trained on the educational 
material. We anticipate that the content of the health talk may involve the following fundamental 
information: description of VMMC, medical benefits of VMMC and addressing myths and 
misconceptions around VMMC among other topics. After the group education, men will be 
asked of their interest in circumcision individually by counsellors (during standard HIV testing) 
and clinicians as they receive care at the STI clinic. 
Clinic Escorts (E) 
Clinic escorts will be the act of escorting/accompanying a participant interested in VMMC from 
the STI clinic to the VMMC clinic to ensure linkage to care. We propose to use clinic escorts 
who will accompany men interested in VMMC from the STI clinic to the VMMC clinic to 
ensure that men are not lost in transit. Men may either undergo same day VMMC (if 
asymptomatic) or have an appointment for VMMC on a later date if symptomatic or if they have 
other viable reasons. Escorting patients is beneficial in linkage and retention in care and is policy 
in varied clinical settings [32]. Clinic escorts will be data clerks and clinic aides. 
SMS Tracing (T) 
SMS reminder tracing will be the act of reminding participants with a VMMC appointment about 
their date of procedure through short messaging service. This PhD study proposes to use SMS 
tracing to remind men who could not have same day VMMC of their appointment for VMMC. 
The content and frequency of the SMS messages will be guided by the findings from formative 
research however we have included a modifiable guide of the messages. Cell phone tracing is 
also a proven strategy for minimizing loss to follow-up and improving retention [33–35] 
Transport Reimbursement (R) 

 
 
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Transport reimbursement will be refunding money used for transportation to the Bwaila district 
hospital for participants who undergo VMMC using standard Malawi government rates. 
Transport reimbursement equivalent to US$10 as stipulated by the National Health Sciences 
Research Ethics Committee (NHSRC) in Malawi, will be offered to all men who will undergo 
VMMC on the day of the procedure to minimize the opportunity cost. Incentives also have been 
shown to improve many medical outcomes [40, 41]. Eligible men will receive transport 
reimbursement when they undergo VMMC. Men who cannot have same day circumcision will 
receive a coupon to present on the day of the procedure for reimbursement. Documentation of 
the VMMC procedure will be confirmed in the VMMC clinic’s procedures register before 
payment. 
6.6.2 Implementation 
The implementation will be guided by the NIRN stages of implementation framework.  
Exploration 
As detailed under the conceptual framework, we will conduct expert consultation meetings with 
key stakeholders including MoH, CDC, PSI, Jhpeigo and healthcare workers from Bwaila STI 
and VMMC clinics. The aim of the meeting will be understand the views of men of VMMC from 
the experts and identify the best way to conduct health education and the appropriate content to 
include in health education material in a STI clinic setting. This stage may last for one week.  
Installation 
This stage will be used for developing and endorsing educational material and the delivery 
methods. Necessary resources for the study will be mobilized. All staff (STI clinic and VMMC 

 
 
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clinic) will be trained by the investigator on the intervention. The clinic receptionist, VMMC 
mobilizer, counsellors and nurses will be specifically trained on the intensified health education 
material. This stage will be one week. 
Initial Implementation (Pre-test) 
This stage will be used to pre-test the intensified health education. We will use the lessons learnt 
from the pre-test to refine the educational material. This stage will also allow HCWs at the two 
clinics to internalize the intervention. Support to healthcare workers will be provided through 
supervision, retraining and constructive feedback. This stage may last about two weeks – one 
week for pre-testing and another week for making necessary modifications if necessary. 
Full implementation 
This will be full roll-out of our intervention. The intervention will have four implementation 
blocks (Appendix 1) that will be different combinations of the intervention components in an 
incremental manner. There will be one week of no intervention between interventions as a wash-
out period. The implementation will be as follows: First we will observe the SOC VMMC 
referral process. In block one, we will introduce IHE which will then be maintained throughout 
the implementation period. Clinic escorts combined with IHE in block two. Block three, IHE, 
clinic escorts and SMS tracing will be combined. In block four, all intervention components will 
be combined including transport reimbursement to form the full intervention. Supportive 
supervision and constructive feedback will be maintained throughout the implementation period. 
Based on the sample sizes detailed below, we anticipate that each intervention block will last 
about 3-4 weeks.  

 
 
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6.1 
Sampling 
We will use purposive sampling to select experts or stakeholders involved in VMMC programs 
(MoH officials, HCWs and private sector officials) to attend the consultative meeting. Men who 
will participate in the surveys and focus group discussions will be purposively recruited and 
segmented by meaningful characteristics, such as age, marital status, religion or other factors that 
the experts think are vital. We will also use purposive sampling to select healthcare workers 
(HCWs) to participate in the in-depth interviews (IDIs) and surveys. No sampling techniques 
will be required for measurement of uptake of VMMC. The sample sizes and time points of 
measurements have been outlined in the sections below. 
6.2 
Data Collection 
Overall, we will collect demographic characteristics for our study population. Among men 
accessing STI care, we will collect demographic data such as age, marital status, educational 
status and socioeconomic status. Additional data collected may include sexual history, HIV and 
ART status. Data will be collected using the routine electronic medical registry at Bwaila STI 
clinic and exported into a Microsoft Excel spreadsheet. 
 
Objective 1: To compare uptake of voluntary medical male circumcision between the standard 
of care and the different combinations of the RITE intervention among men attending Bwaila 
STI clinic in Lilongwe Malawi 
Uptake in this study will be the action of undergoing VMMC. Uptake of the intervention will be 
measured for each implementation block. Data on demographic characteristics including contact 
information, HIV history, sexual history and STI data will be collected for all participants from 

 
 
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the STI clinic using a routine clinical form through the electronic medical registry (EMR) 
(Appendix 2). We will collect data on the number of uncircumcised men offered VMMC and the 
number of men referred to the VMMC clinic from the STI clinic using study specific data 
collection form (Appendix 3). In addition the number of men who underwent VMMC will be 
collected from routine VMMC clinic registers using a study specific data collection form 
(Appendix 4). Data clerks and the VMMC mobilizer will collect these data on a daily basis from 
both clinics. SMS tracing attempts will be collected separately on a study-specific SMS tracing 
form (Appendix 5). The content of the SMS will be designed during the pre-test but we have 
included a draft of what the content may include (Appendix 5). The data will be collected and 
collated daily by a data clerk. Data will be entered into a Microsoft Excel spreadsheet by a data 
assistant. 
Objective 1a: To compare time-to-uptake of voluntary medical male circumcision between the 
pre- and post-intervention periods among men attending Bwaila STI clinic in Lilongwe Malawi 
Time-to-uptake will be the number of days from the day a participant is offered VMMC to the 
day they undergo VMMC. Data clerks will collect data on the date the participant is offered 
VMMC from the STI clinic using a study-specific data collection form (Appendix 3) while the 
date the participant undergoes VMMC will be collected from routine VMMC clinic registers on 
a daily basis and entered into Microsoft Excel. 
Objective 1b: To assess factors affecting uptake of voluntary medical male circumcision among 
men attending Bwaila STI clinic in Lilongwe Malawi  
We will collect data on demographic, sexual and HIV/ART will be collected from the Bwaila 
STI clinic electronic medical registry and exported to Microsoft excel spreadsheet. Data will be 

 
 
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exported on a weekly basis by a data assistant. We will use these covariates to assess factors 
affecting uptake of VMMC among men who will undergo VMMC. 
Objective 2: To develop STI clinic setting-specific voluntary medical male circumcision 
educational material at Bwaila STI clinic in Lilongwe Malawi 
 
To achieve this objective, firstly, we will collect data from the consultative meeting with key 
stakeholders outlined in the above sections as notes. The notes will be collected by the 
investigator and another note-taker. Data will be analyzed in real-time. The suggested content 
and delivery methods will be identified. Secondly, we will conduct a pilot of the intensified 
health education material and methods on men accessing care at Bwaila STI and collect more 
notes on possible ways to refine intensified health education. Any necessary refinements will be 
done and the intensified health education material and methods will be endorsed. 
Objective 3: To assess the acceptability, appropriateness and feasibility of the RITE intervention 
among men and healthcare workers at Bwaila STI clinic in Lilongwe, Malawi.  
Acceptability will be defined as the perception among men and HCWs that the RITE 
intervention is agreeable, palatable and satisfactory [36]. Appropriateness will be the perceived 
fit of the RITE intervention to address the problem of low uptake of VMMC among men and 
HCWs [36]. Feasibility will be the extent to which the RITE intervention will be successfully 
carried out at Bwaila STI clinic [36]. Acceptability, appropriateness and feasibility will be 
measured quantitatively using surveys and qualitatively using in-depth interviews (IDIs) and 
focus group discussions (FGDs). Acceptability and appropriateness will be measured before (at 

 
 
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baseline) and during implementation of our intervention for each implementation block. 
Feasibility will be measured during implementation for each implementation block because it 
cannot be measured before exposure to the intervention [36].  A vignette (embedded in the data 
tools) on the RITE intervention will be read out to respondents to describe the intervention. Data 
on acceptability, appropriateness and feasibility will be collected using the following methods: 
Surveys: For acceptability, we will use the acceptability of intervention measure (AIM), a tool 
designed by Weiner et al  [37], to collect quantitative data for acceptability. The AIM uses Likert 
scales of four constructs which assess if an intervention is appealing, likeable, welcome and 
approved. For appropriateness, we will use the intervention appropriateness measure (IAM) to 
collect quantitative data for appropriateness [37]. The IAM uses a Likert scales of constructs 
which assess if an intervention is fitting, suitable, applicable, and a good match. For feasibility, 
we will used the feasibility of intervention measure (FIM) for feasibility Surveys [37].  The FIM 
uses a Likert scales of constructs which assess if an intervention is implementable, possible, 
doable, and easy to use. These tools have been slightly modified to suit the study setting.  
Acceptability and appropriateness will be conducted at baseline and for each implementation 
block except for feasibility which cannot be assessed before exposure to the intervention 
(Appendix 6 - 9). Surveys data will be collected on electronic tablets through open data kit 
(ODK). Data clerks will administer surveys on an electronic tablet for the men while HCWs will 
self-administer the surveys. Each survey will to last approximately 10 - 20 minutes. Survey data 
will be downloaded from the tablets to a Microsoft Access password-locked database. IDIs and 
FGDs will complement the surveys. 
In-depth interviews: IDIs will be conducted with HCWs from Bwaila STI clinic only. IDIs will 

 
 
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be ideal for HCWs because they are fewer in number, easier to reach and will provide a platform 
to explore in more detail if our intervention is practical for the clinic. IDIs will be conducted in 
the local language (Chichewa) by the investigator with the help of a qualitative researcher. We 
will conduct interviews with HCWs before implementation (baseline) and during implementation 
(during the last implementation block with the full RITE intervention) to explore implementation 
issues until saturation is reached. Each interview will last approximately 45 – 60 minutes. IDIs 
will be administered using an interview guide developed by the investigator in consultation with 
qualitative researchers are the University of North Carolina Project (UNC Project) in Malawi 
(Appendix 10).   
Focus Group Discussions: FGDs will be conducted with the men only. FGDs will be ideal for 
the men because they will allow us to collect opinions from more men at one time compared to 
IDIs. Men will be purposively recruited and segmented by meaningful characteristics, such as 
age, marital status, religion or other factors that the experts think would influence what and how 
men may share information. FGDs will be conducted in Chichewa by the investigator with help 
from qualitative researchers. The FGDs will be administered using a guide developed by the 
investigator and qualitative researchers from UNC project (Appendix 11). Each FGD will have 
between 8 to 12 men. We will conduct two FGDs before implementation at baseline (appendix 
11) and another two FGDs during implementation of the full RITE intervention only (appendix 
11). Each FGD will be approximately 60 – 90 minutes. The IDIs and FGDs will complement the 
quantitative methods by exploring factors identified in surveys. 
We will take notes and record the IDIs and FGDs.  IDIs and FGDs will be translated to English 
during transcription. The investigator and one qualitative researcher will conduct the 
transcription and coding using Nvivo 14 S.E. in preparation for thematic analysis. We will 

 
 
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ensure intra-coder and inter-coder consistency by comparing codes. In case of inter-coder 
inconsistencies, a third person (socio-behavioural scientist) will conduct the coding (tiebreaker). 
We will collect demographic data from all respondents. A summary of methods is available in 
Table 1, Appendix 12. 
6.3 
Sample Size Calculation and Justification 
Data on the incidence of VMMC among men with STIs is unavailable. Based on routine data, the 
Bwaila STI clinic sees about 60 patients per day. Of these, 27 patients are men. Using the 
prevalence of circumcision from the MoH integrated HIV Program third quarter report of 28% 
among men with STI, we estimate that at least 19 uncircumcised men will visit the STI clinic per 
day and at least 380 uncircumcised men per month. Since the project implementation period is 
expected to be about 6 months, we expect that a minimum of 2280 uncircumcised men will be 
exposed to our intervention and observed for VMMC uptake. 
We will offer all men who express interest in VMMC to participate in a survey. We anticipate 
between 5-15% of the men will decline participation in the survey. All (approximately 12) 
healthcare workers will be offered to take the surveys. All available experts (approximately 10) 
will be offered to take a survey. 
Sample size for surveys 
Based on the total sample size of 80 men indicated below, we calculated that 67 surveys are 
required for each intervention component to achieve 95% confidence level with 5% margin of 
error [38]. We will offer all men who express interest in VMMC to participate in a survey. We 
anticipate between 5-15% of the men will decline participation in the survey. All (approximately 

 
 
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12) healthcare workers will be offered to take the surveys. All available experts (approximately 
10) will be offered to take a survey. 
Data Analysis 
Overall, we will use descriptive statistics such as mean, median and proportion to describe the 
demographic characteristics of the study population by implementation block. Demographic 
characteristics will include but not limited to age, marital status, educational status and socio-
economic status. These characteristics will be compared with the SOC group using Student’s T-
test or Chi-squared test at α=0.05 and 95% confidence interval, assuming normal distribution.  
 
Objective 1: To compare uptake of voluntary medical male circumcision between the standard 
of care and the different combinations of the RITE intervention among men attending Bwaila 
STI clinic in Lilongwe Malawi 
Uptake will be calculated as a proportion - the number of men who will undergo VMMC divided 
by the number of uncircumcised men offered VMMC at the STI clinic. Uptake will be calculated 
for each implementation block. Uptake for each block will be compared against SOC using 
Student’s T-test at α=0.05 significance level and 95% confidence interval, assuming normal 
distribution.  
Objective 1a: To compare time-to-uptake of voluntary medical male circumcision between the 
standard of care and intervention period among men attending Bwaila STI clinic in Lilongwe 
Malawi 

 
 
Page 24 of 39 
 
Time-to-uptake of VMMC will be calculated as the number of days taken for an individual to 
undergo circumcision at the VMMC clinic from the day they were offered circumcision at the 
STI clinic. To compare time-to-uptake between SOC and the intervention blocks, we will 
conduct time-to-event analysis to estimate duration to circumcision and Kaplan Meier curves 
will be plotted and compared between SOC and implementation blocks. We will also study 
factors affecting time-to-uptake using cox regression. 
Objective 1b: To assess factors affecting uptake of voluntary medical male circumcision among 
men attending Bwaila STI clinic in Lilongwe Malawi  
We will assess factors affecting uptake of VMMC using logistic regression modeling. We will 
use univariate models to assess association. Covariates with P<0.05 and those based on expert 
knowledge of this topic will be fit into multivariate logistic regression models to control for 
confounders.  
Objective 2: To develop STI clinic setting-specific voluntary medical male circumcision 
educational material at Bwaila STI clinic in Lilongwe Malawi 
 We will use thematic analysis approach for qualitative analysis of the consultative meeting 
notes. The notes will be coded and salient themes will be identified. The content and delivery 
methods will be deduced from the salient themes.  
Objective 3: To assess the acceptability, appropriateness and feasibility of the adaptable RITE 
intervention among men and healthcare workers at Bwaila STI clinic in Lilongwe, Malawi.  
We will use mixed methods to assess acceptability, appropriateness and feasibility. For 
acceptability, appropriateness and feasibility quantitative surveys, these outcomes will be 

 
 
Page 25 of 39 
 
calculated as a median score and percentages for each of the survey questions. The results will be 
compared between SOC and each implementation block using Wilcoxon sign-ranked test, 
analysis of variance (ANOVA) and test of proportions as required. We propose to use structural 
equation modelling to assess predictors of acceptability, appropriateness and feasibility.  The 
latent variables will be acceptability, appropriateness and feasibility. We assume that the 
constructs measuring each of these latent variables are correlated, we will conduct principal 
component analysis and calculate factor loadings and error variance to estimate the true effect of 
the constructs. We also assume that the latent variables will be correlated. Therefore, we will 
conduct confirmatory factor analysis to assess how the latent variables will affect the impact of 
our intervention on uptake of VMMC. 
Qualitative data will be analyzed using a thematic approach (thematic framing and coding, 
indexing, and charting). We will conduct data analysis concurrent with interviews to identify 
salient themes and areas that may require further exploration in the subsequent interviews. 
Salient themes will be deduced from codes identified from the IDIs and FGDs.  
6.4 
Ethical Considerations 
Using the informed consent forms, the study will be explained to all participants and written 
informed consent (Appendixes 13 - 15) will be obtained from respondents for participating in the 
study. Informed consent for audio recordings will be obtained as part of the main informed 
consent form based on the Malawi ethics board requirements. Permission was obtained from the 
Lilongwe District Health Officer (appendix 16) to conduct the study at the STI and VMMC 
clinics. All data forms, informed consent forms, interview notes and voice recorders will be 
stored under a double-lock system at the UNC Project during the study period. Electronic data 

 
 
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will be stored in a password-protected database. Both paper and electronic data will not contain 
identifiable information. Ethics approvals have been obtained from the National Health Sciences 
Research Ethics committee of Malawi (NHRSC) (appendix 17) and the University of North 
Carolina at Chapel Hill Internal Review Board (appendix 18). Final ethics approval will be 
obtained from the University of the Witwatersrand Human Research Ethics Committee (HREC) 
6.5 
Limitations and anticipated challenges 
Contamination may be challenge in this implementation study however, we believe we have 
partly addressed this by using wash-out periods of one week between interventions. Selection 
bias may be a potential limitation if men with certain common characteristics enroll to a specific 
intervention block and affect the uptake of VMMC. Seasonality (circular trends) is a well-known 
confounding factor in VMMC research. Men in LMICs prefer to undergo circumcision in the 
cold season [39]. Our study will recruit participants during a period that will transition through 
the cold season however, we will monitor circular trends by measuring the prevalence of 
circumcision among men at Bwaila STI clinic. Interference in this study will be defined as a 
stakeholder implementing any intervention aimed to scale-up the uptake of VMMC at the study 
sites. 
6.6 
Proposed publications 
1. Study designs paper with a description of how the intensified health education and RITE 
were developed and the implementation science research methodology 
2. The impact of the RITE intervention on uptake of VMMC among men at Bwaila STI 
clinic in Lilongwe Malawi. This will include results on time-to-uptake of VMMC and 
factors affecting uptake of VMMC 

 
 
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3. The acceptability, appropriateness and feasibility of the RITE intervention for improve 
uptake of VMMC among men attending a STI clinic in Lilongwe Malawi 
6.7 
Timeline of proposed scope of work (Work Plan) 
The timeline and scope of work have been detailed in Appendix 19. 
6.8 
Study Budget 
This PhD will be funded by National Institute of Health; Fogarty Global Health Fellowship 
(FGHF) grant and the D43 training grant number; D43 TW01 0060-01 under the Malawi HIV 
Implementation Research Scientist Training Program (M-HIRST). Details are in Appendix 20. 
 
 
 
 
 
 
6.9 
References 
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HIV prevention programmes overview AVERT. Available from: 
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April 2019 
3.  
UNAIDS. Scale-Up of Voluntary Medical Male Circumcision Services for HIV 
Prevention -12 Countries in Southern and Eastern Africa between 2013 – 2016. Vol. 66. 
2017.  
4.  
Sandøy IF, Blystad A, Shayo EH, Makundi E, Michelo C, Zulu J, et al. Condom 

 
 
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availability in high risk places and condom use: A study at district level in Kenya, 
Tanzania and Zambia. BMC Public Health. 2012;12(1).  
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UNAIDS. Malawi AIDS Statistics. 
https://www.unaids.org/en/regionscountries/countries/malawi. Accessed 16 April 2019 
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UNAIDS. Fast-Track Commitments to end AIDS by 2030. 2016;8.  
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Siegfried N, Muller M, Deeks JJ, Volmink J. Male circumcision for prevention of 
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8.  
Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, 
Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: 
The ANRS 1265 Trial. Deeks S, editor. PLoS Med. 2005 Oct 25;2(11):e298.  
9.  
Gray RH, Kigozi G, Serwadda D, Makumbi F, Watya S, Nalugoda F, et al. Male 
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Bailey RC, Plummer FA, Moses S. Male circumcision and HIV prevention: current 
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WHO, UNAIDS. New Data on Male Circumcision and HIV Prevention : Policy and 
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National Statistical Office (NSO) [Malawi] and ICF. Malawi 2015-16 Demographic and 
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Male Circumcision Among High Risk Men in Malawi. AIDS Behav. 2016;  
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Carrasco MA, Nguyen TQ, Kaufman MR. Low Uptake of Voluntary Medical Male 

 
 
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Circumcision Among High Risk Men in Malawi. AIDS and Behavior. 2016 Dec 9;1–7.  
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Ngalande RC, Levy J, Kapondo CPN, Bailey RC. Acceptability of Male Circumcision for 
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Shacham E, Godlonton S, Thornton RL. Perceptions of male circumcision among married 
couples in Rural Malawi. J Int Assoc Provid AIDS Care. 2014;13(5):443–9.  
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Medical Male Circumcision in a Traditionally Circumcising Community in Machinga 
District, Malawi. Malawi World J AIDS. 2017;7:40–58.  
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Motivators to Voluntary Medical Male Circumcision Uptake among Different Age Groups 
of Men in Zimbabwe: Results from a Mixed Methods Study. PLoS One. 2014 May 
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Program Report April - June 2016. 2016. 1–37 p.  
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Malawi; 2018.  
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Malawi Guidelines for Syndromic Management of Sexually Transmitted Infections 2017. 
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32.  
Powell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, et al. A 
refined compilation of implementation strategies: Results from the Expert 
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Keane J, Pharr JR, Buttner MP, Ezeanolue EE. Interventions to Reduce Loss to Follow-up 
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7 APPENDIXES 
 
 
7.1 
Appendix 1: Schema of the Implementation Stages 
 
Figure 1: Stages of Implementation of the RITE intervention