What was the problem?
Since its inception in Tanzania in 2009, voluntary medical male circumcision (VMMC) services for HIV prevention supported by Jhpiego have reached more than 870,000 clients. Subnational units reaching 80 percent male circumcision coverage shift from a scale up phase (where services are focused on achieving high targets) to a sustainability phase (where the focus is on maintenance of the 80 percent circumcision coverage over time). During the scale-up phase, more than 90 percent of the clients are served through periodic outreach activities supported by aggressive demand creation. Typically lasting two to four weeks at a time, the outreach activities are implemented by mobile teams of health care providers and community health promoters distributed over multiple sites close to population hubs in places far from health facilities. The remaining 10 percent of clients are served in facilities providing routine health services. In the sustainability phase, the service model shifts to focus the bulk of service provision in health facilities instead of at outreach sites. It was expected that during the sustainability phase uptake at routine health facilities would increase. This, however, did not happen: uptake of VMMC at health facilities remained low. There was an urgent need to devise a new strategy to increase uptake at health facilities.
What is the solution?
Through the AIDSFree program, Jhpiego has supported VMMC services in three regions since fiscal year (FY) 2015 and in two additional regions since FY 2017. Between April 2015 and March 2016, the AIDSFree project engaged Community Health Promoters (CHPs) to lead VMMC demand creation efforts. Previously, CHPs were typically not from the area where they were working and they typically focused on supporting outreach sites.
A study to explore how to motivate older men to access VMMC services (conducted by the Tanzania National Institute for Medical Research and Jhpiego) revealed that older men are more receptive to health promoters from their own communities as they are more likely to trust them and engage in conversations with them.
Following the study’s findings, and to address the need to increase uptake in health facilities, AIDSFree replaced CHPs with Volunteer Community Advocates (VCAs) in April 2016. This solution focuses on the impact of introducing VCAs on VMMC service uptake. Unlike CHPs, VCAs are required to originate from and be residents of the communities where they are assigned to work. VCAs are embedded within existing community networks to drive community-led, sustainable demand at health facilities offering integrated VMMC services in three regions in Tanzania (Njombe, Iringa, and Tabora). VCAs are assigned to a health facility in their community and only support that facility. They attend a two-day training after which they prepared a plan to volunteer the equivalent of 24 hours a week distributed in a flexible arrangement to accommodate their personal activities. VCAs are encouraged to incorporate VMMC promotion in their day-to-day activities, local routines, and schedules. VCAs receive a small stipend to cover their transport, meals, and airtime on the days they volunteered. They are mentored by Community Cluster Leaders (CCLs) who are employed by Jhpiego and oversee the activities of 5-10 VCAs in “a cluster”. A cluster is usually equivalent to a district with 2-6 health facilities providing VMMC services. CCLs hold biweekly scheduled meetings with their VCAs and provide supportive supervisions in the community sometimes incorporating accompanied activities on a monthly basis.
What is the impact?
VCAs increased VMMC uptake at health facilities by 484 percent in Iringa, Njombe, and Tabora regions between April and September 2016, six months after VCA introduction. Figure 2 shows uptake in Iringa, Njombe and Tabora regions six months before and six months after the roll out of VCAs. As demonstrated in Figure 2, there were significant increases in VMMC uptake in all regions. This increase in adolescent boys and men receiving VMMC services in health facilities also continued after 12 months of implementation. Increases in VMMC uptake continued 12 and 18 months after VCA roll out, with uptake increasing from 2,333 VMMCs 6 months before VCA implementation to an additional 11,296 VMMCs in the 6 months after VCA introduction, an additional 14,880 VMMCs at 12 months, and an additional 19,006 VMMCs at 18 months of VCA implementation. This represents a cumulative total of 45,182 male circumcisions performed in the 18 months after VCA introduction.
According to the Voluntary Medical Male Circumcision Decision-Maker’s Program Planning Toolkit 2 (DMPPT2), cumulative VMMC services uptake has reached 80 percent coverage among adolescent boys and men ages 15-29 in Iringa and Njombe regions. Figure 4 shows progress in coverage of VMMC in Iringa, Njombe, and Tabora regions since 2009 when VMMC services started, with projected full coverage by the end of 2018. This success has been reached through closely monitoring coverage data to determine when new demand creation strategies were needed.
During the first year that AIDSFree deployed VCAs exclusively (October 2016 to September 2017), the project served 144,989 clients at a unit cost of US$74 per VMMC performed, as compared to the previous year where 78,826 clients were served at a unit cost of US$85 per VMMC performed. Therefore, between FY 2017 and FY 2018, the VCA strategy helped to double the number of clients served and drive them to a more sustainable service delivery model with a unit cost reduction of US$11 per VMMC performed.
The project also noted that utilizing VCAs supported sustainable demand creation where they continued promoting VMMC services through their other personal activities and social networks even in their “off days”. VCAs remained resident in these communities for the long term while paid CHPs who did not usually reside in these communities also left the regions when their employment ended.
How does it work?
Male and female VCAs target HIV-negative adolescent boys and men ages 10-29, who reside in the same neighbourhood located on the outskirts of catchment areas served by health facilities that offer VMMC. VCAs employ a settings-based approach utilizing person-to-person communication. Working in settings in which adolescents, older youth, and young men spend most of their time (e.g., schools, work places, places of worship, community hubs, and households) has enabled VCAs to integrate demand creation into their local routines and schedules. Personalized interaction between the VCA and a potential VMMC client, client’s peers, partner, and parent occurs multiple times. VCAs leverage the power of opinion leadership and social networks to help individuals make a decision about VMMC.
VCAs receive an initial two-day training where they learn about HIV prevention and VMMC and gain skills in active listening and “walking in the shoes of clients” to provide person-to-person support. The person-centred approach aims to optimize client interaction and empathize with a client’s position in order to be able to help them to address individual and service barriers to accessing VMMC.
SYSTEMS AND SERVICES LEVEL
AIDSFree assigned 91 VCAs to 29 health facilities in the area where they reside ranging from 2-4 VCAs per health facility, depending on size of catchment area. VCAs were introduced to VMMC health care providers at their assigned facility establishing two-way communication to facilitate direct referrals. VCAs work with health facilities to achieve their set targets contributing to PEPFAR’s subnational unit targets. Volunteering 24 hours per week in a flexible format, VCAs recruit clients, register them, issue referrals, arrange appointments, escort clients on request and follow up with referrals before and after VMMC. As part of follow up, VCAs check in to find out if their referrals have accessed VMMC services and communicate with missing referrals to explore barriers.
Being a resident of the same communities where they serve provides VCAs with intimate local knowledge about how services are perceived, who has not used them, and what deterrents exist for individuals, groups, or within certain localities. VCAs channel their community insights back to facilities, which helps to address VMMC service barriers within the health care providers’ control. These include long waiting times, lack of privacy, harsh language and handling, and turning away of clients. VCAs close the feedback loop informing their communities that outstanding issues have been addressed, which further improves VMMC uptake.
MANAGEMENT & OVERSIGHT
AIDSFree Tanzania developed a flexible structure to manage VCAs. Volunteering up to 24 hours per week, VCAs were allowed to distribute their time to fit in with their personal activities using a biweekly planning and assessment form on which they would plan. VCAs were supported by CCLs with oversight of 5-10 VCAs within their cluster. CCLs meet with VCAs biweekly for about 30 minutes supplemented by monthly community-based supportive supervision. AIDSFree developed and uses four key tools to support the VCA program, namely: (a) Daily Referral Register maintained by VCAs; (b) Biweekly Planning and Assessment Form filled by VCAs during planning and by CCLs during assessment; (c) Biweekly Time Log maintained by VCAs; and, (d) Local Leaders’ Community Activity Certification Form filled by VCAs and countersigned by a local leaders in localities or settings where an activity takes place. Tools are reviewed by CCLs during supportive supervision and the scheduled meeting.
Cost of Solution
VCAs are paid an allowance (US$105 per month) to cover transport, meals, and airtime. They are supported by CCLs through two scheduled meetings and one supportive supervision every month, which includes VCA transport and transport, accommodation, and per diems for CCLs.