1. Voluntary Medical Male Circumcision Our Experience in Iringa, Njombe and Tabora. Pre WAD- 29 November 2014 NJOMBE.

2. BACKGROUND

3. USAID-Supported VMMC Regions in Tanzania Source: Tanzania HIV and Malaria Indicator Survey (THMIS) 2011/12  Jhpiego has received VMMC funding in Tanzania through MCHIP since FY 2009  In late 2009, MCHIP began working with the MOHSW to adapt WHO/UNAIDS/Jhpiego training, counseling and M&E materials for Tanzania with partners  Program interventions launched in September 2009 with a pilot site in Iringa region and has scaled up in three regions – Iringa, Njombe and Tabora

4. Objectives of the VMMC Program 1. Scale up high quality VMMC services in Iringa, Njombe and Tabora regions 2. Pilot early infant male circumcision (EIMC) services in Iringa region, work with national authorities to plot way forward 3. Contribute to the knowledge base on VMMC 4. Provide technical and other support to the NACP in VMMC 5. Provide support to other VMMC partners, as requested

5. OVERVIEW OF VMMC DATA

7. Total Number of VMMCs Life of Project

8. Total Number of VMMCs by Region, to September 2014

9. Target vs. Progress (per 2010 National VMMC Strategy) 100.7% of Target 41% of Target

10. Meeting the Catch Up Goals Will Have Big Pay Offs Courtesy Futures Institute Iringa Data: Futures Institute

11. And Has Big Benefits to Both Men and Women 15,000 Infections Averted in Iringa – 40% of Total Infections Expected Courtesy Futures Institute

12. Target vs. Progress by Age in Iringa/Njombe

13. Additional Targets for Country Operational Plan 2014-2017  Iringa: 87,076  Njombe: 74,333  Tabora: 212,752

14. Age Disaggregation of Clients, Life of Project 397,675 VMMCs 22% of clients are aged 20+

15. Percentage VMMCs by Service Delivery Type – Iringa Tabora Njombe Overall Campaign75% Outreach13% Routine11% Mobile1%

16. # of Health Facilities Providing VMMC REGION # of Sites Ever Providing VMMC TOTAL Hospitals Health CentersDispensaries IRINGA619116141 NJOMBE916172197 TABORA716127150 TOTAL2251415488 385 in FY 14, 339 of which were dispensaries 27 fixed sites

17. Overall 1% of Clients Tested HIV+

18. HIV Rates Among Adolescents Source: Jhpiego VMMC Database

19. Providers Trained in VMMC Under Local Anesthesia, by Cadre

20. MAINTAINING SCALE AT THE END OF THE CATCH UP PHASE AND BEYOND

21. VMMC Progress (Tanzania Country Operational Plan – Draft) Pilot Phase Establish Center of Excellence and Training One fixed site per district Consistent outreach and campaigns Scale-up Phase Maintain and expand number of fixed sites Continuous demand creation Regular outreach and campaign services Initiation of EIMC services Sustainability Phase Continued services at hospitals and health centers Expanding services to dispensaries Focus on remaining older clients and boy turning 10 Scale up EIMC services

22. How Is the Program Staying at Scale? 1.VMMC goes to the people (we don’t wait for them to come to us)  Circumcise at every health facility and where there aren’t any via mobile services Use GIS to assist with planning Mobile VMMC teams for small communities 2.Overcoming barriers (seasonality, rumors about the use of foreskins and Freemasons) 3.Increased engagement of women 4.Expansion of peer promoter program

23. TAKING VMMC TO THE PEOPLE

24. There are 600+ Health Facilities in the 3 Regions

26. OVERCOMING BARRIERS ESPECIALLY SEASONALITY

27. Early in the Program People Have Told Us They Only Want to be Circumcised in the Winter  Local belief that healing is better in the cold  School is out of session – it is when people in circumcising regions do it  For three years our service delivery data supported this – even though we addressed healing myth through BCC  Most years we were only at 25% of target at SAPR, so 75% of target achieved in winter – but increasing targets made this impossible to maintain

28. Percent of VMMCs Performed in Winter

29. 3 Tactics Used to Overcome Seasonality 1. People with a choice will still go to fixed services in winter. So in the off season go to far flung places, where if you aren’t there, they won’t be able to get circumcised at another time 2. Make a deal with the secondary schools in these far flung places. Agree that students (with parental consent) can go for VMMC even when school is in session 3. Expose the uncircumcised to the guys who were circumcised off season, especially via radio and nterpersonal communication. At this point EVERYONE in Iringa and Njombe knows someone who was circumcised off season who can tell his story

30. Overcoming Rumors RumorProgram Addressing Rumor Foreskins are being exported to the US OR Shipping containers of foreskins have been discovered at the Port of Dar es Salaam for overseas destinations OR Foreskins are being used for witchcraft Using radio shows – communicating with providers - to make it clear that anyone who is concerned about his foreskin can leave the clinic with it. (Not a single person has taken us up on this year-old offer.) Being circumcised will turn you into a Freemason (sexually loose, non-religious person) Rumor likely started from certain factions within the Catholic Church. Have worked with Catholics to achieve VMMC détente. Using various BCC, including radio shows to address issue, invite anyone who has been changed into a Freemason to come on the air and talk about their experience. (Not a single person has taken us up on this year-old offer.)

31. INCREASED ENGAGEMENT OF WOMEN

32. Qualitative Research – Leading the Way on the Role of Women in VMMC  Research conducted in Iringa/Njombe in 2011 by Erica Layer (JHU) showed that women were still largely confused about partial protection and their roles in the VMMC program  We set out to better communicate with women – all layers of communication channels  BCC materials (brochures, posters)  Radio ads and radio shows  Big investment in peer-to-peer communication  Research conducted in Njombe and Tabora via CDC/NIMR study in early 2014 tells very different story - that women now largely understand and are playing a much greater role in VMMC decision- making and exerting their womanly influence  AND men are now saying they want women to play greater roles but OUTSIDE the facility setting only

33. EXPANSION OF THE PEER PROMOTER PROGRAM

34. Peer Promoter Program  Initially the idea was to add to promoters working through CSOs to increase uptake at fixed sites  We needed to be able to reach women and older men in a way that was more comfortable to them  As we went more and more rural opportunities to use mass and large group media decreased

35. Tracking of Peer Promoter Referrals

36. TECHNICAL SUPPORT FOR THE NACP

37. Monitoring and Evaluation  Since the initiation of the program MCHIP has provided the NACP with technical support to develop and roll out M&E systems  M&E reporting tools  Site summary reporting  Finalization of M&E tools  Development of national database  Transfer of database to DMIS  Training and technical support for partners, regional and district authorities in use of database  Developed pilot EIMC tools, database 37 VMMC Database

38. Training Curricula  Adapted the WHO/UNAIDS/Jhpiego Manual for Male Circumcision for Tanzania  Developed (under review):  VMMC Counseling Manual  Peer Promotion Training Manual  VMMC Surgeon Refresher Manual  Adapted WHO/Jhpiego EIMC Training Manual 38 Emergency Resuscitation Training

39. Supported Development of the Tanzania Country Operational Plan (2014-2017)

40. EIMC PILOT

41. Background  MCHIP worked with the Reproductive and Child Health Unit, the NACP and other stakeholders to design a pilot for EIMC  EIMC pilot began in late April 2013 in 4 sites in Iringa – 3 of which also have adult VMMC services  An EIMC study was designed to be implemented with the pilot To August 2014 Source: Jhpiego EIMC database

42. RESEARCH

43. Research Studies Under MCHIP  The Unpeeled Mango: Formative Assessment of VMMC Views  Systematic Monitoring of the VMMC Scale Up (SYMMACS)  HIV Counseling and Testing Integration into VMMC  Tanzania PrePex Safety and Acceptability Study (T-PASS)  Early Infant Male Circumcision Views on Acceptability and Service Delivery Integration  Also many journal article and conference abstracts related to these studies and service delivery statistics. See research compendium.

45. VMMC Done from 2009 to 2014 by Region(from DHIS)

46. ASANTENI KWA KUNISIKILIZA  ASANTENI KWA KUNISIKILIZA!