Dr. Bennet Fimbo is the head of the Tanzania MC Technical Working Group and MC Program lead at the Tanzania Ministry of Health and Social Welfare. His interview is the fourth in a week-long series on the potential impact of medical male circumcision (MC) in the fight against AIDS on Science Speaks. Meredith Mazzotta spoke with him regarding the current campaign in Tanzania to circumcise 2.8 million males by 2015. The procedure is proven to reduce HIV transmission through vaginal sex by up to 60 percent.
Explain the accelerated medical MC initiative going on in Tanzania right now and who is being targeted.
Tanzania is implementing a National Strategy for scaling up male circumcision over five years (2010-2015) for HIV prevention, targeting sexually active men. The first priority is the 10 to 24 year olds followed by the 25 to 34 year olds; however, any adult man seeking the service – even if he is above this age category – will be given the service. The strategy is to be implemented in phases, the first phase will focus on eight regions only and the second phase will expand to include other regions of low MC prevalence rates and/or high HIV prevalence, before stabilizing to neonatal circumcision.
How are you promoting this service to men? Is the service free? How are you finding men that are willing? How are you reaching remote populations?
This service is just beginning and there are very minimal promotion activities at the moment. However, in the pilot sites (Iringa, Mbeya and Kagera Regional Hospitals) men are being reached through local promotion activities conducted at the hospital premises and through the recipients of the services. In some sites local radio has been used as well as mobilization from institutions – especially schools to arrange for MC services during their holidays. Other sites have conducted some street/open air campaign activities to target audiences.
Was the government of Tanzania resistant at all to the MC scale up?
How long did it take for the program to launch?
The process took about five years. We needed to conduct a situational analysis regarding many things: MC acceptance issues; preference for MC; on-going male circumcision service availability within the health facilities to identify who (by cadre) was doing MC services at the time at the hospital/dispensary levels; whether there is any client documentation at each facility, etc.
This information was required for the development of the National MC Strategy. We also conducted a study on the traditional male circumcision services being conducted in some parts of the country. Traditional male circumcision is practiced in about 11 of the 21 regions of Tanzania for various reasons, but mainly as an early initiation to manhood. The processes were being done while waiting for the randomized controlled trial studies looking at the efficacy of MC on HIV transmission that were being conducted in South Africa, Uganda and Kenya. The strategy also took two years to be finalized.
A combination of all those were among the issues to be sorted out before we could initiate a large-scale male circumcision program in the country.
What are the goals of the program, and what is the projected impact over time?
The goal is to circumcise at least 2.8 million men by 2015 from eight priority regions: Mbeya, Iringa, Shinyanga, Rukwa, Tabora, Mwanza, Kagera and Mara.
The male circumcision prevalence rate in these eight regions is below the national average – ranging from 26 percent in Kagera to 52 percent in Mwanza. The Mara region however has a higher MC prevalence rate (89 percent), but is lowest in the largest district in this region, the Rorya District (about 30 percent).
Through this program, we expect to raise the MC prevalence rates in the eight regions by at least 30 to 40 percent, and later raise the national average from 70 to 80 percent. This is expected to subsequently reduce the country HIV prevalence rate from the current level of 5.7 percent by about 2 percent. Almost all (except Kagera) of the eight selected regions have higher HIV prevalence rates than the national average. This effort is also expected to significantly reduce the incidence rate in the specific areas/regions where this service will be implemented.
Male circumcision is being offered as a package for HIV prevention, which includes HIV testing and counseling, reproductive health education stressing the medical benefits of MC for men and women, condom use, as well as STI management. Additional benefits include the increased engagement of men into sexual and reproductive health issues, both, as beneficiaries and as advocates for the services.
Are there adequate numbers of health professionals to get this done?
Like many African states, Tanzania faces a serious shortage of human resources for health in all service delivery areas. We are operating with about 43 percent of the required workforce. This has been attributed to low outputs from our training institutions and some of the health professionals not opting for public (government) service – instead many are looking for other, better paying opportunities in and out of the country. In recent years however, the government has tried to provide better incentives for health professionals and some are being attracted back with improved retention. There is also an expansion program in all health training institutions in trying to increase outputs. It is expected that all the different strategies will eventually reduce the existing human resources gap. The current MC strategy is also using task-shifting and task-sharing mechanisms to address the human resources shortage, with nurses being trained as circumcisers in addition to clinical officers and doctors.
Are women in the community actively involved in the initiative? Are they bringing their sons, husbands, boyfriends in for the service?
The strategy provides for active involvement of women in the process to ensure MC clients – who may also be married or having stable sexual relationships – comply with the MC “do’s and don’ts.” These include sexual abstinence during the healing period and condom use thereafter. The other medical benefits of MC that are indirect benefits to women, which include improved personal hygiene and a reduced cervical cancer risk, need to be relayed to women, as women will be expected to encourage their male partners to seek MC services. All these issues are part of the promotion packages to engage women in the program.
Are there community mobilization strategies being implemented to help reach the target?
First, we must ensure there is adequate funding. So we are in the process here.
The situational analysis report informed us that more than 70 percent of uncircumcised men in the country want to be circumcised, but those services are inadequate. Provision of adequate services includes having the required number trained staff, ensuring there is a sustainable supply of all the required equipment, MC supplies and commodities. For that matter, the most important step is to ensure all our health facilities where we want to conduct MC services are fully-equipped with all the materials and human resources before we mobilize communities for this service.
Where is the funding coming from to do this? How much financial support is coming from the Tanzanian government?
We are currently receiving funding from the U.S. government through the President’s Emergency Plan for AIDS Relief and the United Nations Joint Team on AIDS. In-country, the Tanzanian government is in the process of allocating a substantial amount of money during the coming financial year (July 2011/ June 2012). In October 2010, we conducted planning and budget sessions with the eight regions to identify the minimum resource requirement, having identified the number of MC clients we would have from each of these regions. It was agreed then that, while the Ministry of Health and Social Welfare will allocate financial resources during its coming budget session, each local government authority will do the same. The overall budget for the eight regions was about USD $40 million spread over a period of two years. Currently all ministries and local government authorities are in their budget preparations and the Ministry of Health has indicated that it will have a budget line for MC services for the coming year (2011/2012).
Talk about the neonatal MC component of the next stage in this innitiative.
Neonatal circumcision is part of the strategy, but it will be implemented in the next phase, after the pending “adult” lot is over, expected to be shortly before the end of the five-year period (2015). The promotion activities, methodologies and approaches will be established by that time as it will be the long-term strategy for sustained MC services in the country.