Conceived and designed the experiments: HM BK KC MP TA AH EN BF. Analyzed the data: HM BK MP MM MLD BF. Wrote the first draft of the manuscript: HM. Contributed to the writing of the manuscript: HM BK KC MP TA AH SK SN MM MLD DC EN BF.
The authors have declared that no competing interests exist.
Hally Mahler and colleagues evaluate a six-week voluntary medical male circumcision campaign in Iringa province of Tanzania, providing a model for matching supply with demand for services and showing that high-volume circumcisions can be performed without compromising client safety.
The government of Tanzania has adopted voluntary medical male circumcision (VMMC) as an important component of its national HIV prevention strategy and is scaling up VMMC in eight regions nationwide, with the goal of reaching 2.8 million uncircumcised men by 2015. In a 2010 campaign lasting six weeks, five health facilities in Tanzania's Iringa Region performed 10,352 VMMCs, which exceeded the campaign's target by 72%, with an adverse event (AE) rate of 1%. HIV testing was almost universal during the campaign. Through the adoption of approaches designed to improve clinical efficiency—including the use of the forceps-guided surgical method, the use of multiple beds in an assembly line by surgical teams, and task shifting and task sharing—the campaign matched the supply of VMMC services with demand. Community mobilization and bringing client preparation tasks (such as counseling, testing, and client scheduling) out of the facility and into the community helped to generate demand. This case study suggests that a campaign approach can be used to provide high-volume quality VMMC services without compromising client safety, and provides a model for matching supply and demand for VMMC services in other settings.
The government of Tanzania has adopted voluntary medical male circumcision (VMMC) as an important component of its HIV prevention strategy and aims to reach 2.8 million uncircumcised men within the next three years.
In June and July 2010, a six-week VMMC campaign in Tanzania's Iringa Region performed 10,352 circumcisions.
Strategies adopted by the campaign to generate demand included the widespread dissemination of messages focused on the provision of free VMMC by specially trained health care providers and on the HIV prevention benefits of VMMC.
Clinical efficiency was improved through, for example, the use of multiple beds in an assembly line, and the efficient use of staff time through task shifting and task sharing.
The experiences of this campaign suggest that high-volume VMMC can be performed without compromising client safety, and provide a model for matching supply and demand for VMMC services elsewhere.
Several randomized controlled trials have demonstrated the safety and efficacy of voluntary medical male circumcision (VMMC) in HIV transmission prevention among heterosexual men
In 2009, the government of Tanzania adopted WHO's recommendation to scale up VMMC
In 2010, the government of Tanzania set a goal of 80% VMMC coverage in its draft proposal “National Strategy for Scaling Up Male Circumcision for HIV Prevention”
Iringa Region, a largely rural region with a population of 1.9 million, has the highest adult HIV prevalence in Tanzania (15.7%) and relatively low circumcision coverage (29%)
In June 2010, the Iringa Region VMMC program undertook its first VMMC campaign. In this case study, we describe the campaign's approach to service delivery and the factors that influenced its quality, efficiency, and safety, and we discuss how the experiences of this campaign might serve as a model for future VMMC campaigns in the Iringa Region and elsewhere.
The Iringa Region VMMC campaign was conducted in three districts of the region between June 21 and July 31, 2010, to coincide with school leave, the end of the harvest season, and Iringa's cool season (previous formative assessment revealed strong community preference for VMMC during the cool season
At the regional level, a committee of key stakeholders, which was formed three months before the campaign and included regional health and administrative authorities, campaign managers, and monitoring and evaluation experts, provided campaign oversight. The committee supervised VMMC facilities, provided quality assurance of services, and oversaw the dispensing of regular supplies of HIV test kits, condoms, and other consumable commodities such as sutures, gloves, lidocaine, and antibiotics provided by MCHIP. MCHIP also provided additional surgical beds and instruments, and other infrastructure items to the facilities providing VMMC services during the campaign.
At the district level, demand creation subcommittees were composed of district officials, health facility staff, and international and community-based organizations. These subcommittees, which were tasked with recruiting clients and sensitizing community political and administrative leaders, met several times before and during the VMMC campaign.
Finally, each campaign site had a management team composed of the health facility's medical officer in charge, who was responsible for overall service delivery and quality at the site, and a site campaign manager, who was responsible for daily reporting on and oversight of the VMMC service. Every evening during the campaign, site managers participated in a debriefing session with campaign headquarters, during which problems with campaign implementation, shortages of commodities, issues related to client demand, and AEs were addressed.
These three levels of organization worked together to ensure the efficiency, quality, and safety of the campaign. In particular, as described below, they followed the guidance provided by WHO for using human resources efficiently, for maximizing the throughput of clients, for detecting AEs, and for creating a minimum VMMC package
The regional campaign committee developed a human resources plan that considered the WHO guidance for improving efficiencies, the number of surgical bays available, the expected client load, and available counseling and clinical staff. In this assembly-line service model, every four beds at a site required one circumcising surgeon, four bed nurses, one or two equipment and commodities runners, an equipment cleaner, and two HIV counselors. Regardless of the number of beds, each site also required a receptionist, an autoclave operator, a janitor, and a data manager. To reduce burnout, the clinical staff on the VMMC team, who were dedicated fully to VMMC throughout the campaign, rotated between roles (surgeon, bed nurse, and counselor). In addition, the most productive “surgeons” rotated among sites to encourage a spirit of collegiality. Other motivators for providers included T-shirts, daily meals, and overtime pay equivalent to US$7.00 per day. The Ministry of Health and Social Welfare paid staff salaries, with the exception of six counselors working for local non-governmental organizations, who were funded through other PEPFAR-supported programs. Finally, to ensure efficient and high-quality service provision, all the nurses (who constituted 80% of the campaign's VMMC providers, including “surgeons”), clinical officers, and physicians involved in the campaign were trained using the WHO/UNAIDS/Jhpiego male circumcision manual
Several approaches were taken to create demand for VMMC during the campaign. Through the district-based demand creation subcommittees, community-based organizations received a one-day training session designed to enable the promotion of the campaign by peer educators and outreach workers through activities such as traditional theater, small group sessions, one-to-one peer education, and speeches to community groups. These community workers received no additional compensation or incentive for adding the topic of VMMC to their usual activities. Brochures and other print materials were distributed that targeted specific audiences including adolescents and their guardians, female partners of potential VMMC clients, and men aged 18 years and above. In addition, three radio advertisements promoting the campaign ran eight times per day on regional radio stations, and regional officials appeared on local chat and health-related programs in the weeks leading up to the campaign. Finally, during the campaign, the regional health authorities arranged for announcements about the availability of services to be made across facility catchment areas. Based on the national situation assessment, in which cost was identified as a barrier to services
All of the efficiency considerations recommended by WHO were adopted for increasing client volume, with the exception of electrocautery (which was not endorsed for VMMC services in Tanzania) and the use of disposable surgical instruments kits. Specifically, time-saving surgical techniques, such as the forceps-guided method of circumcision, were used, and the number of surgical kits was doubled at sites without an autoclave to minimize the interruption of services caused by transfer of kits to autoclave-equipped sites for processing. To reduce client congestion during initial and follow-up visits and increase efficiency, the campaign provided additional trained counselors to prepare a large number of clients for the surgery; added tents and other temporary structures at VMMC sites (
Before the campaign, this space was empty, having been built but not yet configured to function as a reproductive health facility. The Iringa Region team adapted the space for efficient VMMC service delivery by expanding the number of surgical bays (eight beds to accommodate two surgical teams), providing a large space for decontamination, increasing the number of individual counseling areas (including a tent to accommodate additional counselors), and including a separate postoperative area.
As stipulated in WHO guidance, HIV testing was offered to all clients on an opt-out basis during individual counseling. Consent for HIV testing was verbal (the standard of care in Tanzania); a guardian's consent was required for clients under the age of 18. VMMC clients who tested HIV-positive received circumcision if they were eligible for surgery (eligibility was based upon their overall health and the absence of physiological abnormalities of the penis or STIs that would otherwise preclude them) and gave consent (during the campaign, all clients provided written consent for surgery), but were counseled about the lack of HIV prevention benefits for HIV-infected men and the increased risk of transmitting HIV to sexual partners during postoperative healing. All HIV-positive clients were referred to HIV care and treatment services, which were available at each circumcising site; clients with STIs were referred to STI treatment services at the same health facility and counseled to return for circumcision after their treatment was complete; and clients with physiological abnormalities were referred to the district or regional urologist.
Infection prevention quality standards were applied at each of the campaign facilities, and the definitions for AEs in the WHO/UNAIDS/Jhpiego “Manual for Male Circumcision under Local Anaesthesia” were used to monitor AEs during the campaign
Throughout the campaign, client-level data on service delivery and AEs were entered daily by data clerks within each health facility team into an electronic web-based data system designed for intensive monitoring and feedback. This system allowed each site management team to receive nightly reports of clients prepared, clients circumcised, AEs, and other key client data. The Johns Hopkins University Institutional Review Board and the Tanzanian Ministry of Health and Social Welfare approved the use of these data for this case study.
During the six weeks of the VMMC campaign, six circumcising teams of 16 individuals, plus site managers, drivers, and data clerks (140 participants in total) circumcised 10,352 adolescent and adult males, 1.72 times the campaign's target of 6,000 men. The average number of clients served per week increased as the campaign progressed (
The substantial increase in VMMC delivery at Ngome Health Centre (uppermost line) was due to the addition of more surgical bays mid-campaign. IRH, Iringa Regional Hospital.
Site | District | Characteristics of Site | Number of Beds | Number of Surgical Teams | Total VMMCs | VMMC Clients from Outside the Catchment Area |
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Percent | ||||||
Iringa Regional Hospital | Iringa Municipal | Urban; regional referral hospital | 4 | 1 | 1,784 | 1,114 | 62% |
Ngome Health Centre | Iringa Municipal | Urban; collaboration with Iringa Regional Hospital to serve overflow of clients | 8 | 2 | 2,781 | 843 | 46% |
Lugoda Hospital | Mufindi | Rural; services aimed primarily at tea plantation workers | 4 | 1 | 1,847 | 6 | 0.3% |
Mafinga District Hospital | Mufindi | Peri-urban; district referral hospital | 5 | 1 |
1,896 | 1,874 | 33% |
Tosamaganga Hospital | Iringa Rural | Rural; large, well-established, and well-utilized facility | 4 | 1 | 2,044 | 1,394 | 68% |
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Catchment area defined as within 15 km of the facility.
With extra nurse.
The overall AE rate during the campaign was less than 1% (
AE | Occurrence | Severity | Total AEs | ||
Intra-operative | Postoperative | Mild/Moderate | Severe | ||
Damage to penis | 1 | 1 | 1 | ||
Excess skin removal | 3 | 3 | 3 | ||
Excessive bleeding | 4 | 4 | 4 | ||
Swelling of the penis or scrotum | 28 | 15 | 13 | 28 | |
Infection | 64 | 64 | 64 | ||
Total | 8 | 92 | 79 | 21 | 100 |
HIV testing uptake was virtually universal (99%), and the overall HIV prevalence was less than 1% for the campaign clients, although it increased with age (
Result | Age | ||||
10–14 y | 15–19 y | 20–24 y | 25–34 y | ≥35 y | |
Negative | 2,199 | 5,616 | 1,754 | 565 | 134 |
Positive | 10 | 10 | 9 | 31 | 14 |
Not tested | 0 | 5 | 5 | 0 | 0 |
Total | 2,209 | 5,631 | 1,768 | 596 | 148 |
The data collected during the Iringa Region campaign indicate that, using the efficiency model adopted by the campaign, a four-bed/one surgeon facility can circumcise up to 60 clients and an eight-bed/two surgeon facility can achieve 120 circumcisions per day over a six-week period, and that the efficiency of VMMC service provision can increase over time. Importantly, the experiences gained during this campaign indicate that, by transferring some VMMC providers from larger sites to smaller sites, it is possible to provide a high-volume service at small sites without greatly impacting on the provision of normal health services provided at these sites. The data presented in this case study also suggest that supply and demand for VMMC can be matched by focusing on community-driven demand, and by ensuring efficient site-level client flow by adding counselors as needed and by expanding the space available for VMMC with tents, careful scheduling, detailed logistics, and the adoption of surgical efficiencies.
The long distances traveled by many clients to receive services during the campaign (some clients stated that they traveled as far as 100 km) was unanticipated and suggests that a well-motivated population will travel long distances to VMMC sites during campaigns. However, the willingness to travel long distances may also reflect a need for anonymity or client perceptions of service quality. For example, Iringa Regional Hospital's high “long-distance” caseload may have been related to client perceptions that a referral facility would provide higher quality services, a possibility that warrants further investigation. The high uptake of HIV testing seen during the campaign is not unusual—HIV testing acceptability is generally very high in Tanzania—but may have been magnified by a low perception of HIV risk among young (pre-sexual) clients, by the decreasing stigma associated with an HIV-positive status in the region, or by the knowledge that HIV care and treatment services were available at the circumcising sites.
AE rates fell below those of normal service delivery (from just under 2% to 1%) during the campaign period
This case study highlights several major challenges for future high-volume VMMC campaigns. For example, it suggests that ways will need to be found to improve the participation of older male clients. Only 24% of clients served during the Iringa Region campaign were older than 20 years, and previous modeling has shown that for the greatest immediate public health impact, VMMC should cover the sexually active population
The Iringa Region experience shows that VMMC service delivery can be provided to large numbers of men efficiently without compromising quality of service and client safety through a campaign mode of service delivery implemented almost exclusively in the public sector. Although there are considerable challenges associated with implementing such campaigns, they are not insurmountable, as this case study illustrates. Moreover, with contextualization, we suggest that similar campaigns could be replicated in other settings in east and southern Africa where VMMC for HIV prevention has been prioritized.
Notably, since the completion of the Iringa Region campaign, expansion of VMMC services to the remaining five districts of the Iringa Region has become a priority. In December 2010, a three-week campaign that coincided with the school holidays resulted in nearly 3,000 clients being circumcised. By April 2011, all districts in the Iringa Region were offering VMMC and, between June 20 and August 13, 2011, another eight-week campaign served 31,046 VMMC clients across the Iringa Region.
The authors would like to acknowledge the following people who played important roles in the implementation of the campaign and synthesis of campaign lessons learned: Ezekial Mpuya, Paul Luvanda, Menrad Dimoso, Caroline Kiame, Leonard Ndeki, Sekasua Mndeme, Rajabu Muhombolage, Benny Lugoe, Flora Hezwa, and the health providers of Iringa Region. We also wish to thank the Tanzania National AIDS Control Programme and USAID/Tanzania.
The campaign data were presented as a poster at the 18th Conference on Retroviruses and Opportunistic Infections in February 2011 and in an oral poster presentation at the 6th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention in July 2011.
adverse event
Maternal and Child Health Integrated Program
United States President's Emergency Plan for AIDS Relief
sexually transmitted infection
Joint United Nations Programme on HIV/AIDS
United States Agency for International Development
voluntary medical male circumcision
World Health Organization