Voluntary Medical Male Circumcision (VMMC) in Tanzania and Zimbabwe: Service Delivery Intensity and Modality and Their Influence on the Age of Clients

Abstract

BackgroundScaling up voluntary medical male circumcision (VMMC) to 80% of men aged 15–49 within five years could avert 3.4 million new HIV infections in Eastern and Southern Africa by 2025. Since 2009, Tanzania and Zimbabwe have rapidly expanded VMMC services through different delivery (fixed, outreach or mobile) and intensity (routine services, campaign) models. This review describes the modality and intensity of VMMC services and its influence on the number and age of clients.Methods and FindingsProgram reviews were conducted using data from implementing partners in Tanzania (MCHIP) and Zimbabwe (PSI). Key informant interviews (N = 13 Tanzania; N = 8 Zimbabwe) were conducted; transcripts were analyzed using Nvivo. Routine VMMC service data for May 2009–December 2012 were analyzed and presented in frequency tables. A descriptive analysis and association was performed using the z-ratio for the significance of the difference. Key informants in both Tanzania and Zimbabwe believe VMMC scale-up can be achieved by using a mix of service delivery modality and intensity approaches. In Tanzania, the majority of clients served during campaigns (59%) were aged 10–14 years while the majority during routine service delivery (64%) were above 15 (p<0.0001). In Zimbabwe, significantly more VMMCs were done during campaigns (64%) than during routine service delivery (36%) (p<0.00001); the difference in the age of clients accessing services in campaign versus non-campaign settings was significant for age groups 10–24 (p<0.05), but not for older groups.ConclusionsIn Tanzania and Zimbabwe, service delivery modalities and intensities affect client profiles in conjunction with other contextual factors such as implementing campaigns during school holidays in Zimbabwe and cultural preference for circumcision at a young age in Tanzania. Formative research needs to be an integral part of VMMC programs to guide the design of service delivery modalities in the face of, or lack of, strong social norms.

Increasing voluntary medical male circumcision uptake among adult men in Tanzania

“…To achieve the maximum number of HIV infections averted (3% of new infections) between 2011 and 2015, VMMC should reach sexually active men [5,14]. However, in Tanzania, the majority of clients are younger men; for example, 76% of VMMC clients in 2014 were under 20 years of age [15,16]. Studies in Kenya, Zambia, and Tanzania have described strategies to increase VMMC demand among men aged 20 years or above [17–19] but these strategies did not explicitly explore the relationship between a comprehensive demand-creation approach and uptake of services by older men.…”

“…In addition, these studies did not explicitly focus on outreach delivery strategy. Outreach delivery strategy is used when targeting a large volume of VMMC clients [15]. Thus, strategies are needed to increase the number and proportion of male clients aged 20–34 years [15].…”

A Comparative Evaluation of the Voluntary Medical Male Circumcision Program for Seke and Goromonzi Districts, Mashonaland East Province, Zimbabwe, 2017

“…Both districts had two teams each for VMMC implementation. Goromonzi had two more nurses Median years in service 5 Q1 = 4; Q3 = 10 9 Q1 = 6; Q3 = 11 (14) as compared to Seke which had 12. Both Seke and Goromonzi had one vehicle each for service delivery and none for demand creation.…”

“…This seemed to work against the program in both districts since workers would need relief from routine duties to attend to VMMC clients. In a study by Ashengo et al in Tan-zania, integration of VMMC into key health facility activities through the designation of the facility as a department yielded positive results in regard to resource supply, both human and material [14].…”

Implementing voluntary medical male circumcision using an innovative, integrated, health systems approach: experiences from 21 districts in Zimbabwe

“…Initially, vertical VMMC services were largely implemented in urban areas by one non-government organization employing a predominantly outreach model with independent, VMMC-focused teams, campaigns, and stand-alone VMMC clinics [29,30]. Early VMMC progress using the vertical model was slow [29]: by the end of 2012, Zimbabwe completed only 91,335 (4.8%) of its intended 1.9 million VMMCs [31]. …”