Voluntary Medical Male Circumcision (VMMC) has been proven to reduce the risk of HIV acquisition in men by 50-60% in Southern and Eastern Africa. The Zambian Ministry of Health created the Operational Plan for Scale-Up of VMMC (2012-2015), with the goal of achieving 80% coverage (1.9 million circumcisions) by 2015. However, Zambia's population-based survey (2010) indicated that 80% of uncircumcised Zambian men were not interested in undergoing VMMC and as of October 2014, only 37% of the national goal had been achieved. Reaching the national goal will require not only significantly increasing the pool of health care providers qualified to perform VMMC (supply), but also to develop effective community-level behavioral change interventions to increase VMMC acceptability as a viable means to reduce HIV risk (demand creation). Our recently completed clinical trial (Weiss et al., 2015) promoted VMMC among Zambian males who initially expressed little interest in VMMC. Results demonstrated that the Spear and Shield intervention, combining qualified biomedical VMMC services with an evidence-based sexual risk reduction/VMMC promotion program, was effective in increasing the likelihood of men opting for VMMC by 2.5 times in comparison with the Control condition and by 8.5 times in comparison with the Observational-Only condition. Post-VMMC participants at experimental sites also reported increased condom use at 12 months post- intervention. The proposed competing renewal application seeks to extend these findings to 96 community health centers (CHCs) in four provincial population centers having high HIV prevalence (15-25%) and low VMMC (< 10%) rates. Using Aaron's (2011) model for evidence-based practice implementation in the public health sector, the proposed study aims to increase acceptability, availability and uptake of VMMC services at the community health center level. We anticipate that ~12,000 men presenting for HIV voluntary counseling and testing (VCT) will attend the risk reduction/VMMC service program, as well as approximately 4,000 of their female partners. This study will evaluate the effectiveness of implementation strategies in a) maximizing the number of CHCs willing to provide VMMC; b) dramatically increasing the number of men willing to undergo VMMC in clinics offering the combined risk reduction/VMMC program, in comparison to clinics offering biomedical services only; and c) implementing and sustaining the program, using innovative training structures, fidelity monitoring and implementation science strategies to identify and resolve challenges (e.g., planning, organization, scheduling, local climate, individua characteristics and logistics). Information derived from this dissemination and implementation study will provide critical guidance to the National VMMC program on strategies which may dramatically increase the uptake of VMMC in Zambia. Study outcomes will also have major implications for HIV prevention in Southern and Eastern African countries over the next ten years.
Voluntary Medical Male Circumcision (VMMC) has significantly reduced the risk of HIV infection in sub- Saharan Africa, yet the majority of Zambian men have expressed little interest in undergoing the procedure. This dissemination and implementation study proposes a biobehavioral evidence-based intervention proven effective in encouraging 'hard to reach' Zambian men to undergo VMMC. Successful outcomes from this study will provide critical guidance to the National VMMC program and will have major implications for HIV prevention in Southern and Eastern African countries over the next ten years.
