Policy Environment and Male Circumcision for HIV Prevention: Findings from a Situation Analysis Study in Tanzania

This Tanzanian study is part of a situation analysis to understand the attitudes of policy makers and other key community and health authority decision makers towards male circumcision (MC), the policy and regulatory environment, and the readiness of a health system to accommodate scaling up of MC services. MC has been shown to be effective against heterosexual acquisition of HIV infection and is being scaled up as an additional strategy against HIV in several countries of Africa. [Footnotes removed throughout by the editor.]

Because the government of Tanzania is keen to undertake MC on a large scale, it has established policy for promotion and scaling up in the National Multi-Sectoral HIV Prevention Strategy (2009-2012), yet the Health Sector HIV and AIDS Strategic Plan II (2008-2012) notes that MC has not been integrated in current HIV prevention services and has, as one of the strategic objectives, the promotion of medically performed safe, acceptable MC for health benefits and as a preventive measure against HIV transmission.

Between 2008 and 2009, researchers conducted a situation analysis of MC in Dar es Salaam City, one traditionally circumcising district (Tarime district in Mara region), which chooses to circumcise youth for religious and/or cultural reasons, and two traditionally non-circumcising districts, using interviews to obtain detailed information about attitudes, beliefs, and practices regarding circumcision and the policy environment from the perspective of the informants. Key informants (KIs) were chosen from community, district, regional, and national levels.

Results include the following:

• Most of KIs (94%) were aware of the availability of MC services at the health facilities in their areas including the district hospitals.
• Male informants from traditionally non-circumcising districts were generally supportive of medical male circumcision (MMC).
• Almost all KIs 97% showed willingness to support the scale up of MC services. 
• In order to increase demand for circumcision services, all KIs suggested that the services must be affordable - possibly a free government service or one with payment in kind (possibly with farm produce).
• "With regard to culture, almost all informants echoed the adherence to traditional customs as the most important factor which influences people to undergo circumcision in traditionally circumcising communities such as the Kurya of Mara region. This view was explicit in almost all interviews."
• "It was reported that both Muslims and Christians are required by their religious faiths to get circumcised so as to adhere to religious purity."
• In non-circumcising communities, "with the influence of the so called 'forces of modernity' (e.g. schooling, religion, modern health care, and exposure to other cultures), traditionally non-circumcising communities are increasingly accepting MC."

Though there is awareness and willingness to use the procedure, "the legal, regulatory and policy framework governing MC in Tanzania is weak and there is no law dealing specifically with circumcision....Appropriate by laws and regulations are needed so that MC services are accessible and provided safely without discrimination and that different stakeholders are guided and protected by law." In addition, there is a need for increased healthcare, including the availability of: adequate health facilities, human resources, equipment, and materials. Informants (94%) favoured integrating the surgery into the existing healthcare system and integrating traditional MC into hospital services, due to complications when done outside the medical system, including the comment: "I urge health care providers to work closely with traditional circumcisers (locally known as Omusari in Kurya language) because they together with clan leaders are the custodian of Kurya traditions and chief spokesmen and decision makers on when and who has to undergo circumcision."

Quality assurance was raised as an issue by 17% of KIs. Ninety-seven percent of the KIs mentioned advocacy and mass education as critical issues. "With regard to education, it was pointed out that advantages and disadvantages of medically performed MC need to be communicated to the people to raise their levels of knowledge and awareness on the issue and to dispel fears, misconceptions and stigma. The most common approach mentioned was to educate people through public meetings and other such gatherings."

The researchers conclude that, for successful implementation of the MC programme, first, there is a need for a favourable policy environment and, then, the necessary support at different levels of authority and the meaningful involvement of all stakeholders in the process. "Secondly, although there is no stand alone (formal/specific) policy on MC in Tanzania, basic elements of enabling policy environment at national, regional, district and community levels are in place (i.e. existence of effective regulations and enabling HIV/AIDS prevention policies which are sensitive to context: political, cultural and practical) and can be adapted for implementation of [an] MC scale up programme."