Male Circumcision Against HIV Hukomboa
Condition: HIV
Study type: Interventional

Summary: 
      Tanzania launched a National Strategy for scaling-up voluntary medical male circumcision in
      2010, and aims to circumcise 2.8 million males by 2015. In September 2009, Jhpiego's Maternal
      and Child Health Integrated Program (MCHIP) launched a PEPFAR-funded voluntary medical male
      circumcision (VMMC) program which has circumcised over 110,000 males in Njombe and Iringa
      regions by June 2012. In line with the national strategy, the target age for the program was
      10-34 years, but 80% of clients were aged 10-19 years. There is an urgent need to increase
      the proportion of older men (aged 20 years and above) who become circumcised, to have
      greatest impact on the HIV epidemic.
    

Detailed description: 
      In order to maintain high client flow in sites, the Iringa service delivery model is flexible
      in terms of how, where and when services are delivered. Approaches include:

      i) Static sites: These sites offer regularly scheduled VMMC services several days a week.
      Services are offered year round rather than periodically. Volume tends to be low (20-50
      clients a week).

      ii) Outreach sites: VMMC services are offered periodically at health facilities. A team
      composed of providers 'borrowed' from other regional health facilities visits the sites for a
      2-3 week period and offers VMMC 6 days a week. This is typically a high volume setting, in
      which 40-120 circumcisions are performed a day, depending on the number of beds which can be
      set up.

      iii) Campaign: Campaigns happen 2-3 times a year, and may include both static and outreach
      sites. Campaigns are high volume, concerted approaches to VMMC where multiple facilities are
      running coordinated VMMC service delivery.

      These services are complemented by demand creation activities (mass media, interpersonal
      activities and outreach activities) designed to recruit and motivate new clients, and a text
      messaging information system which is advertised through radio and other means, providing
      potential clients advice on where VMMC is offered, the benefits of VMMC, and post-surgery
      reminders for wound care, follow-up visits and safer sex. The intensity of the demand
      creation depends on the size of campaign. In general, static sites do not have any demand
      creation but outreach and campaigns do.

      The proposed research will take place at outreach sites; however, the study will not stop
      on-going VMMC services provided at static sites to young men but rather encourage older males
      to come as well as young boys. Outreach sites have larger potential client size than static
      sites because the catchment area round the outreach sites have generally not had access to
      VMMC in the past and clients show up in large numbers to be served, whereas in static sites,
      clients trickle through in lower volume. Outreach activities can be scheduled at the
      convenience of the program. By using outreach activities, the proposed research, can be more
      easily scheduled into the study's data collection timeframe (compared to campaign sites which
      are on a highly prescribed schedule).

      QUALITATIVE ASSESSMENT FINDINGS In February 2011, Jhpiego co-investigators on this study
      conducted qualitative research in 3 districtsin Iringa (Iringa Municipality, Njombe and
      Mafinga), with the aim of understanding men's and women's views on appropriate age for
      circumcision, perceptions on circumcision, barriers and facilitators to older men seeking
      circumcision, and seasonality[9]. Identified barriers among older men included shame
      associated with older men getting circumcised, as it was seen to be an age-inappropriate
      activity, concerns of older men about their partners being faithful to them during the
      healing period, concerns about loss of income during the healing period, and concern around
      erections causing damage to the penis or delay wound healing. The facilitating factors
      included that circumcised men were seen as cleaner, safer from diseases, and more sexually
      desirable to women.

      Exploration of preferences for service delivery showed that participants had a strong
      preference for a model in which boys and men were provided separate services. There was also
      support for all-male service providers to alleviate concerns about embarrassment at having
      women view/touch the penis and the possibility that an erection could occur during the
      procedure. There was little support for including female partners accompanying their partners
      to the facilities. There was a marked preference for the cold season (June-August) for three
      reasons: fewer farming responsibilities, school being out, and a cold temperature which is
      perceived to facilitate wound healing.

      Based on this research, we anticipate that the targeted VMMC strategy evaluated in this
      research will include demand-creation strategies using focused informational communication
      messages for men aged over 20 years, and increased information and education for female
      partners. Service delivery strategies may include separate services for men versus boys and
      increasing the role of male service providers. The targeting strategy will be finalised
      during Study 1, and implemented and evaluated during Study 2.
    

Intervention name(s): A targeted demand creation Activities
Intervention type(s): Behavioral
Intervention description(s): Sites randomized to the intervention arm will receive all activities in the control arm, plus additional demand-creation communication messages that focus on the non-HIV benefits of VMMC and the voluntary nature of HIV testing prior to VMMC ii) use of already circumcised men from the community as auxiliary peer promoters, iii) separate waiting and group education areas for men aged 20 years and above during service delivery, iv) engagement of female partners in community-based demand creation and education and counselling about wound healing and post-circumcision abstinence.
Allocation: Randomized
Intervention model: Single Group Assignment
Masking: Single (Care Provider)
Primary purpose: Health Services Research
Keywords: VMMC; Adult males; HIV Prevention; Africa