TITLE: Male Circumcision Situational Analysis, Results Dissemination and Advocacy Efforts

NEED and COMPARATIVE ADVANTAGE: Evidence of the effectiveness of male circumcision as an HIV

prevention intervention has been met with great excitement, and this intervention is being considered for

implementation and scale-up in communities with high rates of HIV infection and low rates of circumcision of

male circumcision. However, it is also widely acknowledged that scaling up of this intervention is

complicated by various factors that require careful evaluation. These include the following: religious, cultural

and societal beliefs and norms; the fact that male circumcision is not 100% effective and thus it must be

combined with other known effective HIV prevention methodologies (e.g. consistent use of male or female

condoms and treatment of sexually transmitted infections); and the procedure that may be associated with

potential adverse events.

ACCOMPLISHMENTS: A potential partner has been identified for this activity and pending official

reprogramming approval from OGAC and CDC, the situational analysis can begin using WHO draft

assessment tools.

ACTIVITIES: In order to appropriately plan for possible implementation and scale-up of male circumcision in

Tanzania, careful assessments are needed. FY 2008 funds are requested to finalize assessments to guide

male circumcision policy development and planning for future service delivery in Tanzania. Assessments

will be conducted to determine: the prevalence and acceptability of male circumcision; the feasibility and

current capacity of the Tanzanian medical infrastructure to delivery male circumcision services; the current

policy environment; and the associated costs with male circumcision. The assessments will be designed

and carried out by a TBD partner with assistance from the PEPFAR male circumcision task force.

WHO/UNAIDS tools will be adapted and used for assessment activities.

In order to determine acceptability of male circumcision, focus group discussions and surveys were initiated

with FY 2007 funds in Kagera and Kigoma, regions where there is high prevalence of HIV infection and low

rates of male circumcision. In FY 2008, focus will be on completing the assessments focusing on:

demographic characteristics, health status, social characteristics, sexual behaviors, knowledge of male

circumcision and its effect on HIV acquisition, perceived benefits and risks, other attitudes regarding this

procedure, and anticipated effects on sexual behavior.

Prior to initiation of specific activities, appropriate human subjects review will be obtained at the TBD partner

organization, in Tanzania and at CDC.

To determine feasibility of scale-up of male circumcision, the TBD partner will conduct facility surveys. The

survey instrument will be developed to determine facility readiness to provide adult male circumcision as

well as the necessary post-operative care. Cost of the procedure including post-operative care will be

determined based on information collected through survey instruments. This will be developed through

collaboration with a health economist. Cost per case averted will be calculated.

A meeting of key stakeholders including the Ministry of Health and Social Welfare (MHSW) staff will be

organized upon completion of the project. Data from every aspect of the effort will be shared including

feasibility, acceptability, and costs. In addition, materials and tools developed for the purpose of scale-up of

this intervention will be also shared with meeting attendees. All information will be collated in a compendium

for use by stakeholders and other interested parties.

At the request of the MHSW, educational material may be developed with key messages appropriate for

potential candidates for male circumcision and their sexual partners. The key messages will be carefully

developed and will need to highlight accurate information regarding the protective effect of male

circumcision, need for continued use of other preventive behaviors (e.g. condom use), risks and benefits of

the procedure, appropriate post-operative wound management and the need to abstain from sex until

certified complete incision healing.

LINKAGES: The situational analysis and assessments will be conducted in facilities and regions supported

by USG care and treatment partners. Data from every aspect of the effort will be shared with these partners

including feasibility, acceptability and costs. In addition, materials and tools developed for purpose of scale-

up of this intervention will be also shared.

CHECK BOXES: Gender: addressing male norms and behaviors

Male circumcision

Adults (men and women 25 and over)

Discordant couples

M&E:

As progress towards actual implementation begins, the TBD partner will advocate for the development of a

single sentinel surveillance and reporting system.

SUSTAINABILITY: The focus of this activity is to collect data that will be used to shape national policy on

male circumcision, which will ultimately shape a sustainable male circumcision program in Tanzania.