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Table 1 Voluntary medical male circumcision demand creation intervention in Tanzania

From: Using discrete choice experiments to inform the design of complex interventions

Following strong evidence for the effectiveness of voluntary medical male circumcision (VMMC) in reducing men’s risk of acquiring HIV, Tanzania was identified as one of 14 high-priority countries for VMMC scale-up [37]. Tanzania, which started rolling out VMMC in 2009, has a national adult HIV prevalence of 5.0% [38] and an adult male circumcision prevalence of 72% [39, 40]. The Tanzanian HIV and AIDS Strategic Plan prioritized scaling-up VMMC to males aged 10–34 years in eight regions (which was later increased to 12 regions due to administrative divisions), including Njombe and Tabora [41]. The National AIDS Control Programme established a target of circumcising 2.2 million eligible males aged 10–34 years in these 12 regions [40]. Significant progress has been made towards these targets: from 2009 to 2015, almost 1.2 million VMMCs were performed in the priority regions [42].
VMMC in Tanzania has predominantly attracted a young male population: As of 2012, 82% of VMMC clients in Njombe and Iringa were adolecent boys between 10-19 years old [43]. For a more immediate impact on HIV incidence, reaching an older, sexually active but not yet HIV-infected client base would be preferable. Social barriers in relation to adult men accessing VMMC services have been documented in Tanzania [44, 45]. To evaluate a model of demand creation and service delivery to increase uptake of VMMC among adult men aged ≥ 20 years, a two-phase study was implemented in the Tabora and Njombe regions. Njombe is the region with the highest HIV prevalence at 14.8% [46], and Tabora has a prevalence of 6.4%, which is higher than the national average (5.1%) [47]. In 2012, male circumcision coverage was 49% in Njombe and in Tabora, which is considerably lower than the national average of 72% [47]. Phase 1 of the study consisted of formative research to develop a package of demand creation activities designed to increase the client base of adult men (age 20–34 years).
Phase 2 was a cluster randomized trial evaluating the impact of the developed complex demand-creation intervention with a goal of increasing the proportion and number of VMMC clients aged 20–34 years whose results are published [33]. In brief, 20 outreach sites in Njombe and Tabora were randomized to receive either a demand-creation intervention package (described in Table 4) plus standard VMMC outreach, or standard VMMC outreach only. The primary outcome was defined as the increase in the proportion of 20–34 year olds among all men being circumcised in the intervention arm. Secondary outcomes compared the total increased uptake compared to the routine VMMC strategy, as well as uptake among all mature men (age ≥ 20 years).
Intervention evaluation
The RCT showed significant increases in VMMC uptake across men of all ages relative to the control arm (619 versus 393, p = 0.03) [33]. In Tabora there was a significant increase in the proportion of men aged 20–34 years (28% in the intervention arm relative to 12% in the control arm; p < 0.00), but not in Njombe (11% in the intervention arm and 15% the control arm; p = 0.44) where large increases among the younger men were also observed [33]. Further details of the intervention and its evaluation can be found in Wambura et al. [33].