TANZANIANS AND AMERICANS IN PARTNERSHIP TO FIGHT HIV/AIDS

Augustino Hellar Program Director, Maternal and Child Health Integrated Program (MCHIP) Jhpiego, an affiliate of Johns Hopkins University Plot 72, Block 45B, Victoria Area, New Bagamoyo Road P.O. Box 9170, Dar es Salaam, Tanzania +255 752 242829

Voluntary Medical Male Circumcision (VMMC) Scale-Up Expands Access to STI Screening and Management and HIV Testing in Tanzania
by: Augustino Hellar1, Dorica Boyee1, Kelly Curran2, Hally Mahler1, Marya Plotkin1, Tigistu Adamu Ashengo2, Michael Machaku1, Flora Hezwa1, Sifuni Koshuma3 and Paul Luvanda3 1 MCHIP/Jhpiego, an affiliate of Johns Hopkins University, Tanzania, Dar es Salaam, Tanzania; 2MCHIP/Jhpiego, an affiliate of Johns Hopkins University,Washington, D.C., USA and 3Iringa Regional Hospital, Ministry of Health and Social Welfare

Background
n VMMC reduces female-to-male HIV transmission by approximately 60%. n Tanzania has been scaling up VMMC in non-circumcising regions since
2009.

Tanzania: Male Circumcision Prevalence among Males 1549 Years of Age

Kagera 26.4% Mwanza 54.1% Mara 89.0% Arusha 96.2% Kilimanjaro 97.0% Manyara 97.3% Singida Dodoma 90.9% 96.9% Tanga 95.0% DSM 97.9%

Results
n Data from 94,749 clients circumcised between 2009 and 2012 were
found in the VMMC database.

HIV Prevalence by Age (HIV Only)

Age Group <10 1014 1519 2024 2534 35+ Total Confirmed HIV Cases 7 316 168 142 392 271 1,296 Total Clients of Percentage p-value This Age Group 438 1.60% 44,917 0.70% 33,017 0.51% <0.001 10,025 1.42% 4,548 8.62% 1,792 15.12% 94,737

n Of these, 16,365 were aged 20 and above. n 74% of clients who had STIs were self-referrals to VMMC services. n Clients were treated syndromically, provided with condoms and given an
appointment for circumcision after treatment. who are identified and treated at the hospital.

n VMMC offers a unique opportunity to link men to other HIV and sexual
and reproductive health services.

n STI screening is an integral part of VMMC, and diagnosed STIs are treated
according to the national algorithm for syndromic management of STIs; circumcision is deferred until treatment has been completed.
Kigoma 68.4%

Shinyanga 26.5%

n Clients were asked to provide information about their sexual partners

n Provider-initiated HIV testing is also part of VMMC. n This review documents the prevalence of STIs and HIV in the VMMC
program in Iringa and Tabora regions.
Rukwa 31.4%

Tabora 42.8%

VMMC Service Package

n Group education on VMMC and HIV n Individual VMMC and HIV counseling including risk assessment and
reduction

Mbeya 34.4%

Iringa 37.7%

Morogoro 93.1% Pwani 96.9%

Age of the Clients

Age Group <10 1014 1519 2024 2534 35+ Total Missing Frequency 438 44,917 33,017 10,025 4,548 1,792 94,737 12 Percentage 0.4% 47.8% 34.8% 10.5% 4.8% 1.8%

STI Prevalence by Age (STI Only)

Age Group
Above 20 Years 17% Under 20 Years 83%

Lindi 93.3% Ruvuma 68.9% Mtwara 93.1%

n HIV testing (opt-out) n Pre-operative physical exam including STI screening n Circumcision by trained VMMC surgeons (doctors, clinical officers and
nurses)

<10 1014 1519 2024 2534 35+ Total

Number Present with Any STI Symptom 0 0 147 85 50 18 300

Total Clients of This Age Group 438 44,917 33,017 10,025 4,548 1,792 94,737

Percentage p-value 0.00% 0.00% 0.45% 0.85% 1.10% 1.00%

Physical examination before the VMMC procedure

<0.001

Conclusion
n VMMC services offer an opportunity to diagnose and treat/refer clients with
STIs and HIV.

n In this setting, HIV is much more common than other STI symptoms. n With current efforts to attract older men to VMMC, it is likely that more
clients with HIV and STIs will be identified. acquiring HIV/STIs in future.

n Promotion and provision of condoms n Post-operative review n Two post-operative follow-up visits (48 hours, 7 days)

Potential Linkages to and from VMMC Services

HIV and STI Prevalence among VMMC Clients

Description HIV Confirmed Cases Cases of Other STIs Either HIV or STI Co-infection of HIV and Other STI Total Number of Clients Analyzed Number 1,296 300 1,561 35 94,749 Percentage 1.37% 0.32% 1.65% 0.04%

STI Prevalence by Marital Status (STI Only)

Marital Status Not Applicable Not Married Married Cohabiting Total Missing
Dysuria 8% Genital warts 4%

n If they are HIV-negative, VMMC will lead to reduced chances of these clients n It is important to find mechanisms to identify, treat and follow up the sexual
partners of these men and link them to care if needed.

HIV counseling and testing

Urological referral Addressing gender-based violence

Methods
n A review was done of all client records entered into a VMMC database
from September 2009August 2012. results and marital status.
STI screening Chronic diseases

n Data were analyzed using STATA and disaggregated by age, HIV test n Sources of referral for clients who came to seek services were analyzed. n Commonly presenting symptoms for clients with STIs were also retrieved. n Where appropriate, a chi-square test was applied to determine the level
of significance.
(e.g., hypertension)

VMMC

Reported STIs
ART

Number with STI 64 178 55 3 300

Total Number 63,479 26,077 5,055 89 94,700 49

Percentage p-value with STI 0.10% 0.68% <0.001 1.09% 3.37%

TB screening and treatment

Description Number Percentage Urethral Discharge 69 0.07% Genital Ulcer 87 0.09% Dysuria 121 0.13% Genital Warts 69 0.07% Confirmed HIV 1,296 1.37%

Urethral discharge Genital ulcer 4% 5%

Confirmed HIV 79%

This poster was funded by the United States Presidents Emergency Plan for AIDS Relief (PEPFAR) through the United States Agency for International Developments (USAIDs) Maternal and Child Health Integrated Program (MCHIP), under Cooperative Agreement #GHS-A-00-08-00002-000. The opinions herein are those of the authors and do not necessarily reflect the views of USAID.