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Sexual Prevention and Adolescents Attending Voluntary Medical Male Circumcision (VMMC) Services in Tanzania: A Golden Opportunity to Offer

Adolescent-Targeted Services
by: Augustino Hellar1, Dorica Boyee1, Marya Plotkin3, Hally Mahler1, Yusuph Kulindwa1, Tigistu Adamu Ashengo1,3, Kelly Curran2,3, Mbaraka Amuri1, Seth Greenberg4 and Paul Luvanda5 affiliate: 1Maternal and Child Health Integrated Program (MCHIP)/Jhpiego, an affiliate of Johns Hopkins University; 2 Jhpiego, an affiliate of Johns Hopkins University; 3Johns Hopkins Bloomberg School of Public Health; 4United States Agency for International Development (USAID)/Tanzania; 5Ministry of Health and Social Welfare, Iringa Region

Background
n In Tanzania, an estimated 670,000 clients have received VMMC services in 12 priority regions. Priority regions are those with high HIV rates and low MC prevalence. n The Maternal and Child Health Integrated Program (MCHIP) supports the Ministry of Health and Social Welfare to implement VMMC in three priority regionsIringa, Njombe and Tabora. n The World Health Organization (WHO)recommended VMMC package of services includes:
n n n n n n

Adolescent VMMC clients waiting for services

Number of lifetime partners reported by sexually active clients


6,000 No response More than two partners 5,000 1,456 283 529 3,000 26.7% 5.1% 9.7% Two partners One partner

4,000

2,000

3,198

58.5%

1,000

HIV testing and counseling (HTC) VMMC counseling Screening and treatment for sexually transmitted infections (STIs) VMMC procedure Post-operative counseling

Methods
n Conducted a secondary analysis of client-level data from January 2011December 2012 using the MCHIP VMMC database. n Reviewed self-reported sexual behaviors 3 months prior to date of circumcision. n Calculated the HIV and STI prevalence by age group.

1014 years* *The number of partners reported in this age group is too small for comparison.

1519 years

Clients reporting sex in exchange for money


6,000 No response No 5,000 1,305 23.9% Yes

2-day and 7-day postoperative follow-up n This package was developed with adult clients in mind. VMMC counseling, HTC and prevention messages are not specifically targeted to youth/adolescents in the VMMC reference materials.

Results
n A total of 118,977 client records were reviewed. n Of those, 97,302 (82%) clients were aged 1019 years and 94% (91,373) of those responded to questions about their sexual activities. n Of the respondents, 58,046 (49%) were 10 14 years old, while 39,256 (33%) were 1519 years old. n The record review found an HIV prevalence of 0.51% and STI prevalence of 0.40%. n There was an increase in the percentage of sexually active adolescents between the two age categories, with 0.2% of 1014 year olds being sexually active, compared with 14% of the 1519 year olds being sexually active. n Among the sexually active 1519 year olds, 14.8% reported having two or more sexual partners in their lifetime, and approximately one-quarter reported unprotected sex. n Of 1519 year olds, 3.2% reported they have had sex in exchange for money.

4,000

3,000 3,986 2,000 72.9%

1,000 175 1014 years* 1519 years 3.2%

MCHIP-Supported Regions Providing VMMC Services


n As of November 2013, more than 50,000 VMMCs have been provided in the three MCHIP regions. n HIV prevalence:
n n n n

*The number of clients reporting exchanging money for sex in this age group is too small for comparison.

Conclusions
n This review of VMMC client data from three regions of Tanzania illustrates that while 1014 year olds are rarely engaged in sexual activity, there is a substantial increase among 1519 year olds. Nevertheless, the vast majority of 1019 year olds are not yet sexually active. n Given the large number of adolescent boys seeking VMMC services, this is a unique opportunity to provide 1014 year olds with pre-sexual debut messages related to HIV prevention, risk reduction and reproductive health education. n The data also reinforce that among 1519 year olds, there is a need for counselors to conduct individualized risk assessments and provide specific and appropriate education and counseling, taking into account additional risk factors such as sex in exchange for money and multiple sex partners.

Iringa: 9.1% Njombe: 14.8% Tabora: 5.1% THMIS 2011/12

Tabora

Iringa

Njombe

Self-reported sexual activity of VMMC clients


60,000 4,475 7.7% No response Not sexually active Sexually active 50,000

Adolescents and VMMC


n Less than half of young people (aged 1524) in Tanzania have a comprehensive knowledge of HIV/AIDS. n Median age of sexual debut for men is 18.7 years.
(THMIS 2011/12)

40,000 53,467 92.1%

1,454

3.7%

Recommendations
n Given the huge number of pre-sexual adolescent boys being reached by VMMC services, key education and counseling messages must be adapted, and providers must be trained to best support adolescent needs. n Not only should adolescents be segmented from adults in VMMC education and counseling, but to the extent possible, older adolescents should be segmented so that messages tailored to those soon-to-be or newly sexually active can be addressed. n Providers will need assistance to make these changes. Adolescent-specific tools and messages for the VMMC programs in Tanzania should be developed and providers trained to use them. n Providing adolescent-specific counseling and education during VMMC services presents an unprecedented opportunity to reach large numbers of adolescent males in the fight for an HIV-free generation.

30,000

20,000

32,336

82.3%

10,000 104 0 1014 years .2% 5,466 1519 years 14%

n Clients aged 1019 years make up 79% of the VMMC clients circumcised in the MCHIP regions. n VMMC services are a unique opportunity when adolescents are in search of and engaging with health services.

Age distribution of VMMC clients in MCHIP-supported regions


2.32% 3.89% .45% .02% .5% 2.33%

Proportion of sexually active clients reporting sex in the past 3 months


1014 years
n=104 1% Yes No No response 15%

1519 years
n=5,466 0% Yes No No response

54%

45% 85%

79% of the VMMC clients are 1019 years

11.49%

45.88% 33.12%

<1 19 1014 1519 2024 2529 3034 3549 50+

Proportion of sexually active clients reporting unprotected sex with a regular partner in the past 3 months
1014 years
n=104 Yes No 22% No response

1519 years
n=5,466

Yes No 23% No response

64%

14%

50% 27%

This poster was funded by the United States Presidents Emergency Plan for AIDS Relief (PEPFAR) through 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.

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