Photo by Trevor Snapp for IntraHealth International

In Tanzania, 225,093 men and boys have lowered their risk of contracting HIV after seeking out voluntary medical male circumcision (VMMC) services, provided by IntraHealth International’s Tohara Plus project in its first year.

About 1.4 million Tanzanians live with HIV today. And officials estimate that each year, 55,000 more become infected and 33,000 die of AIDS-related causes. The HIV prevalence among 15-49 year olds is 4.7%, and even higher among pregnant women (5.6%) and key populations (25-36%). Urban (7.2%) and rural (4.3%) prevalence rates also vary.

Expanding access to VMMC services—which can reduce a man’s risk of acquiring HIV through heterosexual intercourse by 60% or more—is one of Tanzania’s key HIV-prevention strategies. The 2015-2016 male circumcision rate nationally was 80%, and regional estimates ranged from 34%-99%.

“VMMC services not only help prevent the spread of HIV, but also provide an opportunity to reach boys and men with critical health information and additional sexual health services,” says Lucy Mphuru, IntraHealth’s country director in Tanzania. “Since IntraHealth began expanding access to these services in 2011, we’ve helped the ministry reach more than 800,000 boys and men, including those we reached in the first year of Tohara Plus.”

Through the project, IntraHealth and our partner, the Tanzania Youth Alliance, are working with the Ministry of Health, Community Development, Gender, Elderly, and Children/National AIDS Control Program, the President’s office regional administration, and local government officials to strengthen and scale-up a comprehensive package of high-quality, safe VMMC services for adolescents and men 10‐29 years old. The goal is to reach 80% of men in targeted districts where coverage is currently lowest by 2020, and to sustain high coverage where VMMC rates already exceed 80%. The project is funded through PEPFAR by the US Centers for Disease Control and Prevention (CDC).

Additional results from the project’s first year include:

• More than 92% of VMMC clients were within the PEPFAR/CDC priority age group of 10-29.
• Eighty-nine percent of clients returned for post-circumcision, follow-up care.  
• Less than 0.2% of VMMC clients reported adverse results post-procedure, an indication of high-quality care. All reported complications were successfully treated and managed.
• All VMMC clients were offered HIV testing, and 70% opted to get tested. Of those who received testing and counseling, 0.2% tested HIV-positive.
• Eighty-five percent of the HIV-positive clients were successfully linked and enrolled into care and treatment services.

The project achieved all of these results with a $7.1 million budget by scaling up VMMC services in 16 districts in four Lake Zone regions. This included providing services at 32 static and 56 lower-level health facility outreach sites.

The outreach campaigns use what’s called a parent-child model, where services are initially offered at a larger parent site, and as soon as the client load falls below 40 per day, the outreach team splits off to serve at another nearby smaller facility (or child site).

Some of the project’s successful approaches include:

• Optimizing a stakeholder-involvement model that promotes local ownership and continued commitment by engaging stakeholders at all levels in planning, implementing, monitoring, and evaluating the program.
• Institutionalizing VMMC services within the national health care delivery system for sustainability, i.e., working within the existing national structures and using VMMC service providers from the public sector instead of contracting male circumcision providers or relying on the project’s staff, which would have added salary expenses.
• Building the capacity of regional-, district-, and facility-level health officials in planning and operationalizing VMMC activities to help sustain these services over time. 
• Task-shifting VMMC services to registered nurses instead of the more expensive cadres of medical officers and assistant medical officers.
• Using data and geographical information systems (GIS) to plan effective and efficient VMMC strategies, outreach, and campaigns to reach high numbers of uncircumcised men in underserved rural areas.
• Developing and implementing community informed, tailor-made demand-creation packages that account for specific community needs and overcome sociocultural barriers for increasing the uptake of VMMC services.

Tohara Plus provided about one third of all PEPFAR-funded VMMCs in Tanzania for fiscal year 2017. The project is now working to scale up services to 28 districts in five regions and to reach 334,235 additional clients—or 40% of PEPFAR’s 2017-2018 total target of 866,552—with VMMC and other HIV services in its second year.