MOPED561

TANZANIANS AND AMERICANSIN PARTNERSHIP TO FIGHT HIV/AIDS

Female Volunteer Community Advocates Perform at a Comparable Level with Their Male Counterparts Supporting

Voluntary Medical Male Circumcision Services at Routine Facilities in Tanzania

Cestina George,1 Maende Makokha,1 Alice Christensen,1 Eddah Msafiri,1 Heri Mpunza,1 Godlisten Malisa,1 Devotha Kihahi,1 Chrisantus Ngongi,2 Braine Burure,2 Leticia Nchia,2

George Msalale2, Mohamed Mbalazi,2 Gissenge Lija,2 Zebedee Mwandi,3 Kelly Curran,4,5 and Erick Mlanga6

1AIDSFree Project, Jhpiego Tanzania; 2Tanzania Ministry of Health, Community Development, Gender, Elderly and Children; 3AIDSFree Project, Kenya; 4Jhpiego; 5Johns Hopkins Bloomberg School of Public Health; 6U.S. Agency for International Development

Background• Since 2009, Jhpiego has collaborated with

Tanzania’s Ministry of Health, CommunityDevelopment, Gender, Elderly and Childrenthrough the National AIDS Control Program(NACP) to implement voluntary medical malecircumcision (VMMC) services for over 890,000clients to date.

• The Strengthening High Impact Interventionsfor an AIDS-free Generation (AIDSFree) Projectis funded by the U.S. President’s EmergencyPlan for AIDS Relief through the U.S. Agencyfor International Development. It has providedsupport for five regions in Tanzania since 2014(see Figure 1).

Figure 1. AIDSFree Tanzania VMMC regions

Iringa

Mwanza

SimiyuGeita

Tabora

Arusha

Singida

Shinyanga

Mara

Kilimanjaro

Manyara

Dodoma

Morogoro

Tanga

Pwani

Lindi

Ruvuma

MbeyaRukwa

Katavi

Mtwara

Kigoma

Kagera

Njombe

Pemba

Zanzibar

DSM

AIDSFree VMMC regions

Partners’ VMMC regions

Non-VMMC regions

VMMC/EIMC Demand Creation• AIDSFree supports 66 sites that offer VMMC and

early infant male circumcision (EIMC) services.Each site has a dedicated demand creation teamthat works year-round to improve access toservices in hard-to-reach areas through outreachand campaigns.

• In April 2016, the Project phased out nonlocalcommunity health promoters who had been usedfor demand creation in favor of local volunteercommunity advocates (VCAs) with strongerrelationships and influence in Project catchmentareas.

• AIDSFree typically supports over 200 VCAs,providing them training and a stipend.

• This study compared the performance of femaleversus male VCAs in demand creation activitiesfrom October 1, 2017–September 30, 2018.

Role of Women in Demand Creation There were false concerns that women may not be as effective as men in this role because of:• Local sexual taboos that meant women would not

undertake activities talking about VMMC• Male-led decision-making in Tanzania which

could affect women’s ability to lead demandcreation activities with men

• Women’s demanding schedules that would affecttheir ability ability to carryout the tasks related todemand creation

Performance Monitoring and MeasurementThe Project:• Supervised VCAs biweekly using paper-based

forms to track their performance of planneddemand creation activities.

• VCAs were reviewed on completion of activities,including targeted household door-to-door visits;visiting formal institutions, including workplacesand universities; and informal vijiwe (hangouts),such as motorcycle stands, pool tables, and bars.

• Had mentors score VCAs on a scale of 1 (activitynot started) to 6 (activity completed in full) foreach activity.

MethodsThe Project:• 103 VCAs (45%) who served for the full year were

included in the analysis (of 227 total VCAs).• Conducted a retrospective review of the

AIDSFree Project database to extract individualVCA performance data. Reviewed individualVCA performance data on interpersonalcommunication activities to increase VMMCuptake in routine facilities.

• We tallied each VCA’s performance scores (whichwere based on the completion rate of eachactivity) and then calculated the average scorefor each VCA. We then compared the averagepercentage score by sex.

Results• Since switching to VCAs, the project increased the

female-to-male ratio to 2-to-3, compared to 1-to-2when it used community health promoters.

• Selected VCAs completed 2,266 biweeklyperformance assessments with a mentor, with anaverage of 22 assessments per VCA. The aggregateaverage score was 83% (range = 57–100%).

• Female VCAs achieved the same performancescores as their male counterparts.

Results, continued• Some clients reported that female VCAs spent

more time and followed up with them multipletimes when compared to male VCAs. Other clientsalso stated they preferred female VCAs as theytrusted them and felt they could share things withfemale VCAs that they would not share with theirmale peers.

• “I preferred to be sensitised by a female VCAbecause they are so compassionate, they care anddo the follow-up thoroughly. I felt so peaceful” -VMMC Client.

Conclusions• The project achieved 111% of target in FY 2018

using more female VCAs when compared to theprevious year when the Project achieved 117% oftarget. This suggests the use of female VCAs didnot reduce the Project's ability to achieve targets.

• Concerns about female social norms and/ordomestic roles do not appear to hinder femaleVCAs’ performance as local VMMC promoters.

• Engaging local women as VCAs may positivelyinfluence VMMC perceptions and provide a morebalanced perspective and approach to VMMCpromotion.

• The use of both female and male VCAs seems anappropriate demand creation strategy for VMMCprograms.

• Further exploration is needed to review data onVMMC referral rates by sex of VCA to providefurther evidence that support these findings.

VCA Rehema Daudi with clients in Meli Village in Singida RegionPhoto: AIDSFree/Jhpiego.

Demand creation team supporting the VCA programPhoto: AIDSFree/Jhpiego.

This publication is made possible by the generous support of the American people through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) with the United States Agency for International Development (USAID) under the Cooperative Agreement Strengthening High Impact Interventions for an AIDS-free Generation, number AID-OAA-A-14-00046. The information provided does not necessarily reflect the views of

USAID, PEPFAR, or the US Government.