Embe Halijamenywa: The Unpeeled Mango - A Qualitative Assessment of Views and Preferences Concerning Voluntary Male Circumcision in Iringa Region, Tanzania

This report presents the results of a qualitative assessment of people's understanding of the voluntary medical male circumcision (VMMC) programme implemented in Iringa, Tanzania by the Ministry of Health and Social Welfare with support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the Maternal and Child Health Integrated Programme (MCHIP) (managed by Jhpiego). The assessment was done in February 2011 in three districts in the Iringa region.

The assessment found that men's decisions about seeking voluntary medical male circumcision (VMMC) services are complex, influenced by culture and history, traditional beliefs, education, sexuality, gender relations, economic and marital status, exposure to urban or modern culture, past experiences with health care services, and many more factors. Because VMMC for HIV prevention will have the greatest immediate impact if adult males are also accessing male circumcision (MC) services, the report summarises key findings into strategies for improving future MC rates.

Men and women who participated in the study identified the following reasons to seek VMMC services: 1) prevention of disease; 2) women's preferences; 3) cleanliness; 4) peer pressure; 5) education on VMMC; 6) better sex; and 7) religious motivation. Participants almost unanimously preferred VMMC to be done in the colder months of May, June, July, and August due to perceptions that healing is facilitated by the colder weather and because school vacations occur at this time. Most participants also felt that circumcision is best performed before a young man reaches puberty. Participants felt that the right combination of education could convince older men to seek VMMC services as a preventative measure. Participants also felt that the most important components of service delivery were to ensure that male medical personnel performed MCs and that MC for older men and younger men be provided in separate delivery settings.

According to the research findings, almost all participants in this study could describe what circumcision is and its benefits. Benefits named included cleanliness, disease prevention (including HIV/AIDS), and perceptions of increased virility. It was not clear where this knowledge came from. Many participants identified circumcision as being a disease prevention measure. According to the report, the familiarity of participants with the benefit of HIV prevention is good, but also must be viewed with caution. This is especially true since the concept that VMMC provides only partial protection against HIV was not fully explored in this assessment. Multiple concurrent partnerships were described as a norm for both men and women, but especially for men. Also, low levels of discussion and involvement of partners in decision-making about sexuality were described almost universally. In this context, it will be important for educational campaigns to stress the importance of testing and continuing other prevention measures, so that, for example, people do not start equating circumcision with full protection against HIV. In addition, further exploration is needed to understand to what extent people understand that VMMC provides only partial protection against HIV transmission.

The report highlights the need for the following in order to increase the success of VMCC campaigns:

• Information on the benefits, drawbacks, and advantages of circumcision at different ages, focusing on the fact that occasional erections do not generally interfere with the healing process.
• Information and supporting evidence discussing the risks, benefits, and advantages of circumcisions done at times other than May-August.
• Most large-scale campaigns should be run during the months of May-August because public perception is that healing occurs best during these months.
• Information emphasising the importance of preventative measures for men who are over 20 years old, and/or who are married, and/or who have children.
• Life-skills training for older clients about communication within relationships when promoting VMMC among older clients.
• Emphasise the benefits of VMMC to women.
• Use widespread media campaigns in a variety of media to promote service availability, when services can be provided for older men and younger men in different facilities or on different days.