title: Voluntary medical male circumcision (VMMC) in Tanzania and Zimbabwe: service delivery intensity and modality and their influence on the age of clients.
abstract: BACKGROUND
  Scaling up voluntary medical male circumcision (VMMC) to 80% of men aged 15-49 within five years could avert 3.4 million new HIV infections in Eastern and Southern Africa by 2025. Since 2009, Tanzania and Zimbabwe have rapidly expanded VMMC services through different delivery (fixed, outreach or mobile) and intensity (routine services, campaign) models. This review describes the modality and intensity of VMMC services and its influence on the number and age of clients.
  
  
  RESULTS
  Program reviews were conducted using data from implementing partners in Tanzania (MCHIP) and Zimbabwe (PSI). Key informant interviews (N = 13 Tanzania; N = 8 Zimbabwe) were conducted; transcripts were analyzed using Nvivo. Routine VMMC service data for May 2009-December 2012 were analyzed and presented in frequency tables. A descriptive analysis and association was performed using the z-ratio for the significance of the difference. Key informants in both Tanzania and Zimbabwe believe VMMC scale-up can be achieved by using a mix of service delivery modality and intensity approaches. In Tanzania, the majority of clients served during campaigns (59%) were aged 10-14 years while the majority during routine service delivery (64%) were above 15 (p<0.0001). In Zimbabwe, significantly more VMMCs were done during campaigns (64%) than during routine service delivery (36%) (p<0.00001); the difference in the age of clients accessing services in campaign versus non-campaign settings was significant for age groups 10-24 (p<0.05), but not for older groups.
  
  
  CONCLUSIONS
  In Tanzania and Zimbabwe, service delivery modalities and intensities affect client profiles in conjunction with other contextual factors such as implementing campaigns during school holidays in Zimbabwe and cultural preference for circumcision at a young age in Tanzania. Formative research needs to be an integral part of VMMC programs to guide the design of service delivery modalities in the face of, or lack of, strong social norms.
authors.affiliation: Maternal and Child Health Integrated Program (MCHIP), Washington, District of Columbia, United States of America; Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Tigistu Adamu
authors.initials: TA
authors.lastname: Ashengo
authors.affiliation: Population Services International (PSI), Harare, Zimbabwe.
authors.forename: Karin
authors.initials: K
authors.lastname: Hatzold
authors.affiliation: MCHIP Tanzania, Dar es Salaam, Tanzania.
authors.forename: Hally
authors.initials: H
authors.lastname: Mahler
authors.affiliation: JSI Research & Training Institute, Inc., Boston, Massachusetts, United States of America.
authors.forename: Amelia
authors.initials: A
authors.lastname: Rock
authors.affiliation: JSI Research & Training Institute, Inc., Boston, Massachusetts, United States of America.
authors.forename: Natasha
authors.initials: N
authors.lastname: Kanagat
authors.affiliation: JSI Research & Training Institute, Inc., Boston, Massachusetts, United States of America.
authors.forename: Sophia
authors.initials: S
authors.lastname: Magalona
authors.affiliation: Maternal and Child Health Integrated Program (MCHIP), Washington, District of Columbia, United States of America; Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Kelly
authors.initials: K
authors.lastname: Curran
authors.affiliation: Maternal and Child Health Integrated Program (MCHIP), Washington, District of Columbia, United States of America.
authors.forename: Alice
authors.initials: A
authors.lastname: Christensen
authors.affiliation: United States Agency for International Development, Washington, District of Columbia, United States of America.
authors.forename: Delivette
authors.initials: D
authors.lastname: Castor
authors.affiliation: Ministry of Health and Child Welfare, Harare, Zimbabwe.
authors.forename: Owen
authors.initials: O
authors.lastname: Mugurungi
authors.affiliation: Population Services International (PSI), Harare, Zimbabwe.
authors.forename: Roy
authors.initials: R
authors.lastname: Dhlamini
authors.affiliation: Ministry of Health and Child Welfare, Harare, Zimbabwe.
authors.forename: Sinokuthemba
authors.initials: S
authors.lastname: Xaba
authors.affiliation: United States Agency for International Development, Washington, District of Columbia, United States of America.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Njeuhmeli
mesh_terms: D000293:Adolescent; D002648:Child; D002944:Circumcision, Male / Q000706:statistics & numerical data*; D003695:Delivery of Health Care / Q000379:methods / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D010045:Outpatients / Q000706:statistics & numerical data*; D013636:Tanzania; D055815:Young Adult; D015030:Zimbabwe