Background: Since 2013, the ZAZIC Consortium implemented an integrated voluntary medical male circumcision (VMMC) program jointly with Ministry of Health and Child Care in 21 districts in Zimbabwe. ZAZIC''s integrated VMMC approach used existing healthcare workers and MOHCC infrastructure. From October 2013 through September 2015, ZAZIC expanded from 2 to 36 static VMMC sites and performed a total of 84,708 VMMCs, averaging 3530 per month and exceeding donor targets. More than 85% of all VMMCs were completed independently by existing MOHCC staff in health facilities; approximately two-thirds occurred in outreach settings.
Description: In 2015, the U.S. President''s Emergency Plan for AIDS Relief (PEPFAR) 3.0 required a strategic pivot in Zimbabwe''s VMMC program, transitioning from national coverage to focused scale-up in areas of highest disease burden. Under the pivot, ZAZIC''s VMMC implementation was limited to 10 scale-up districts beginning in October 2015. Ambitious targets were maintained, translating to a 40% increase in circumcisions within these districts. By January 2016, implementation was discontinued outside of PEPFAR scale-up districts. From October 2015-March 2016, ZAZIC performed 20,241 VMMCs, a monthly average of 3374, demonstrating an impressive transition in accordance with the pivot requirements.

Male circumcisions in priority versus non priority districts, pre- and post-pivot
[Male circumcisions in priority versus non priority districts, pre- and post-pivot]

Lessons learned: The pivot necessitated immediate redirection from program breadth to depth. Due to MOHCC human resource constraints and the dramatic rise in targets, this mandate was accompanied by a rapid ZAZIC shift from integrated service delivery to a mixed implementation approach employing additional mobile teams using non-MOHCC staff.
Conclusions/Next steps: ZAZIC''s locally-led consortium successfully transitioned its program to meet changing PEPFAR priorities. Momentum indicates continued future achievements. There is need to evaluate the implications of the pivot on VMMC cost, quality, population-level HIV reduction benefit, and impact on the health system as a whole.

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