Director of Tanzania Circumcision Program for MCHIP outlines keys to success.
Iringa, Tanzania – If a picture tells the story, then this line of young men waiting outside Kibena Hospital in the town of Njombe illustrates why the scale up of voluntary medical male circumcision is not only necessary to stem the tide of HIV in eastern and southern Africa but achievable. Tanzania has shown that expanding access to this effective HIV prevention intervention can be done efficiently, safely and with stunning results.
In a few short years, voluntary medical male circumcision has become an important strategy in the arsenal of HIV prevention tools for men and their partners. The shift occurred when research findings showed that medical male circumcision reduces female to male sexual acquisition of HIV by approximately 60% and WHO recommended that countries with high HIV and low male circumcision prevalence adopt the programming in their countries. Since the government of Tanzania launched male circumcision-for-HIV-prevention services in October 2009, more than 40,000 men and adolescents have chosen to be circumcised in Iringa region, the area with the highest prevalence of HIV (15.7%) in the country. Those procedures occurred in less than two years – and modeling suggests that they will avert nearly 9,000 future HIV infections.
The work in Iringa, a largely rural region with limited infrastructure, has gone from pilot to scale in less than one year – with all services implemented through public sector health facilities. The government — with help from a team of health experts, community organizations, international NGOs and funding from the President’s Emergency Plan for AIDS Relief through the U.S. Agency for International Development — is poised to perform another 40,000 procedures in the next year, bringing to 80,000 the number of men who have undergone voluntary medical circumcision and making significant progress toward the estimated 205,000 adolescents and men required to reach 80% saturation. Couple these plans with the program’s current success and future aspirations and there’s every reason to push ahead.
As part of the team that has helped implement the MC campaign in Iringa, I attribute the success of the program to several factors:
Extraordinary Leadership from the Government of Tanzania: The Government of Tanzania’s decision to make voluntary medical male circumcision a public health priority to be addressed within the health system gave the program a high community profile. The Ministry of Health in Iringa region contributed health care providers and locales for services. District and facility officials are taking a leadership role, managing MC services at all sites, and regional authorities are conducting quality assurance and supervision exercises.
Nurses are in the Lead: Trained nurses are 90% of the providers performing MC services in Iringa. With an adverse event rate of less than 1% (among the lowest in the region), the Iringa program proves that nurses trained in MC skills are more than capable of providing high quality minor surgical services like male circumcision.
Surgical Efficiencies Embraced: When the World Health Organization published Models for Optimizing Volume and Efficiency (MOVE), the Tanzania team reviewed and embraced suggestions such as the use of task sharing, time-saving surgical techniques like the forceps-guided method, and the use of multiple surgical bays to serve clients more efficiently. These innovative approaches more than quadrupled the number of clients who can be served daily.
Demand Creation – A Job for Everyone: All HIV prevention partners in the region should be responsible for driving demand for MC services. Iringa regional and district health authorities also contributed by forming committees during each campaign season to help generate community engagement and voluntary participants.
Public Willing to Address the Problem of HIV: Although male circumcision is not a traditional practice for the ethnic groups in Iringa region, the community has embraced the voluntary medical MC program. The people of Iringa are the first to acknowledge that HIV is a problem there, and as a result they have brought their sons, spouses and selves for services.
No Fees Increase Access: In the past, the high cost of circumcision, which was usually done by private providers or for a fee in public health facilities, kept people away. With free services available now in Iringa, many of those who wanted to be circumcised but couldn’t afford it are coming in large numbers.
Women Play Key Roles: Access to male circumcision services has the potential to reduce HIV and HPV within a community, benefiting women as much as their partners. In Iringa, women line up at MC sites with their adolescent sons – wanting to shield them from the regional epidemic in the future. Women are encouraging their partners to access the services and seeking more information on post-operative challenges such as making return visits to the clinic and abstaining from sex for six weeks. Women also serve in the role of service provider.
Public support, visionary leadership, accessible and high quality health services and enthusiastic supporters are the main ingredients that have facilitated scale up of voluntary medical male circumcision in Iringa region. But the full impact of this biomedical prevention intervention will only be realized when these services are available to the majority of men who remain at risk for contracting the virus. In Iringa, it’s 205,000. In the 14 countries of eastern and southern Africa where the disease is most prevalent, circumcising 80 percent of adult men would require an estimated 28 million procedures, averting up to 4.1 million new infections.
The Iringa program’s success provides a model for the way forward. As Tanzanians say: Tohara wa wannaume, oie yey! (Male Circumcision — Onwards and upwards!)
Hally Mahler works for Jhpiego, a global health non-profit organization and an affiliate of Johns Hopkins University. She directs the Tanzania Male Circumcision program for USAID’s Maternal and Child Health Intergrated Program (MCHIP) and the UHAI-CT program.