Engaging women in the dialogue on VMMC can have broad impacts on voluntary medical male circumcision (VMMC) programs, especially when women become aware that circumcision can reduce HIV risk. In Tanzania, the Strengthening High-Impact Interventions for an AIDS-free Generation (AIDSFree) Project found that women can influence men’s decisions to undergo VMMC and impact men’s willingness to get circumcised. An initiative to examine the role of women in demand creation resulted in changing the gender distribution of health promoters—by increasing the number of females to provide a more balanced perspective and approach to VMMC uptake.
This shift in focus to engage more women began with the 2014 implementation of an enhanced VMMC demand creation package, including increased participation of women, by the Maternal and Child Health Integrated Program (MCHIP) and partners. Intervention findings confirmed that women influence men on their decisions about VMMC, especially among couples.
As a result, in 2015, AIDSFree began incorporating these findings within its VMMC program in Tanzania and trained women to become ‘health promoters’ as part of the demand creation team (21 women and 27 men) to promote VMMC to potential VMMC customers and their partners among communities in Iringa, Njombe, and Tabora regions. By April 2016, even more women were included in demand creation activities—34 women and 48 men—these women, designated as “community advocates,” come from the communities in which they work to educate and inform their communities on VMMC, working with both potential male clients and/or their partners.
Under this new community-driven demand creation strategy, female community advocates lead the outreach activities to raise awareness of the benefits of VMMC for women as well as their male partners, including reducing the risk of HIV. Five demand creation outreach teams made up of three women each—a trained female promoter, a community advocate, and female VMMC provider—travel among their assigned communities providing information specifically to women, and spreading the word about the benefits of VMMC for both men and women. AIDSFree’s demand creation outreach activities also include women-focused information booths (large tents, placed in high-traffic areas) where a trained female health promoter is available to provide information and answer questions.
I am very grateful for this service, because it has rescued [my] relationship with my lover who threatened to leave because I was not circumcised.
The Tanzania experience shows that women can influence their partners in health promotion practices. In the AIDSFree documentary on VMMC, “It’s About the People,” Maria Mwinuka, 30, said: “We heard about tohara (male circumcision) on the radio...I decided to talk to my husband and encouraged him to get circumcised at the clinic. My husband made a decision to get circumcised, and so did my child [aged 10].” By discussing circumcision, women eliminate the stigma attached to VMMC in some communities, and give men confidence that circumcision is acceptable.
Female health promoters can also influence men directly. Wawa, a female health promoter, recalled that a man in his 20s talked to her privately after she spoke to a group of patrons on a bodaboda (public-transport motorcycle). “I educated him and he said he was presently busy but would attend later.” Wawa kept in touch with the man and learned that he received VMMC services at a center in Tabora several months after they spoke.
Engaging women in the dialogue on VMMC has had broad social impacts, especially when women learn that circumcision can reduce HIV risk and women’s risk of cervical cancer. In some communities, circumcision has become a norm. “Nowadays girls are refusing to court men who are not circumcised, as they might get infected with diseases,” one VMMC client said. Another added, “I am very grateful for this service, because it has rescued [my] relationship with my lover who threatened to leave because I was not circumcised.” Overall, AIDSFree’s experience in Tanzania illustrates the potential to mobilize women, as well as men, as agents of community change to increase VMMC uptake for HIV prevention.