1. A mobile app for recruiting and booking services—and more.

We worked with community volunteer agents and popular opinion leaders—trusted community members who are trained to discuss safe sexual behaviors—to disseminate the Tohara Journey mobile app. Clients can now be recruited for VMMC services using their mobile phone numbers and use the app to find service locations, make appointments, and access a range of information about VMMC.

The app counsels new VMMC clients through three stages (which we developed using a human-centered design). It also provides thorough counseling and instructions on post-operative wound care, mandatory post-operative follow-up visits, and—for VMMC clients who have tested positive for HIV—how to enroll in care and treatment centers.

If clients experience difficulties using the mobile app and SMS platform, our trained volunteers and health workers are available to help. There is also a free one-on-one call-in service to help clients throughout the VMMC process.

2. New approaches to avoid gathering crowds.

Our VMMC outreach campaigns generally attract big gatherings, so we had to suspend them due to the pandemic. This meant we needed to make the most of static facilities. So we operated even on the weekends to cater to working men and used static satellite sites to minimize congestion at other sites, using a pre-booking system to space client appointments and eliminate congestion at the health facility.

We also focused on recruiting clients 18 years and older to limit the spread of COVID-19 in these facilities. While PEPFAR guidance on circumcising clients recommends VMMC for men 15 years or older, we do not focus on clients between the ages of 15 and 17 because it requires minors’ parents or guardians to join them at the facility to provide consent, which leads to greater congestion. However, any boys 15-17 years who show up for VMMC services are not denied care.

3. Steamlined services.

To allow men to access VMMC services immediately, we started discussing VMMC with male clients who were already at the health facility receiving other routine medical services. We also placed clients who are interested but not ready on waiting lists and contact them to set their appointments later.

4. Human-centered approaches to reach more men.

Even before COVID-19, men were showing up in small numbers, partly because of the behavioral barriers that prolong their decision to receive the procedure (such as concerns about loss of income during the healing period, anticipated pain from the procedure, and shame). IntraHealth adapted a human-centered approach, which emphasizes solutions rather than problems, to fit community members’ needs.

To do this, IntraHealth:

• Engaged with community influencers such as popular opinion leaders, service providers, health workers, peer networks, satisfied clients, and local leaders to train them how to empower adult men to overcome and take control of the barriers to VMMC. 
• Worked closely with regional and council health management teams and regional and council COVID-19 rapid response teams to select sites, assess their readiness, ensure compliance with national standards and guidelines, and sustain VMMC services while avoiding the risk of COVID-19 transmission.
• Displayed mobile phone numbers of site managers or any consenting VMMC providers on posters at health facilities, local leaders’ offices, or hangout places to enable adult men to self-book their appointments.
• Provided early-morning and late-evening “flexi” time for health workers to offer VMMC services for clients before or after normal medical facility hours.
• Prepared VMMC service providers to expect and respond to potential behavioral barriers men may encounter and explore viable solutions with clients.

We also ensure health worker and client safety throughout the VMMC process by:

• Training VMMC providers on how to protect themselves and others from COVID-19, including how to identify, triage, and isolate a client or staff with symptoms of COVID-19, and how to refer clients to treatment and report suspected COVID-19 cases.
• Ensuring clients are screened for comorbidities and COVID-19 symptoms and signs, including a body temperature check using a thermo scanner, maintaining social distancing of at least two meters, and using face masks.
• Placing handwashing facilities at entrances and at all service delivery points so that everyone entering the clinic washes their hands.

These strategies have helped keep VMMC services available after the closure of large-scale campaigns. Between March and September 2020, 29,487 clients received VMMC services. While this is just 16% of the 186,014 clients who have been circumcised this year, it has helped the project achieve 117% of its annual target to reach 159,146 adolescents and adult men through IntraHealth-supported health facilities in Mwanza, Shinyanga, Simiyu and Mara regions.

IntraHealth’s Tohara Plus Project leads a consortium that includes two local partners—the Tanzania Youth Alliance (TAYOA) and IntraHealth’s local affiliate, AFYA Plus. It is funded by the US Centers for Disease Control and Prevention under the President's Emergency Plan for AIDS Relief.