Conditional economic compensation to increase uptake of voluntary medical male circumcision: a randomized controlled trial

Harsha Thirumurthy1, Emily Evens2, Samwel Rao3, Michele Lanham2, Eunice Omanga3, Kawango Agot3

1University of North Carolina at Chapel Hill and Carolina Population Center; 2FHI 360; 3Impact Research and Development Organization

Presented by Kawango Agot

20th International AIDS Society Conference

Limited progress in VMMC scale-up

UNAIDS 2013

• Sustained demand for VMMC key challenge

• Getting men ≥25 years even bigger challenge, even though HIV risk is high in this group

• CDC data: Between 2008-11, only 14.4% of VMMC clients aged ≥25 years (but 57% of the 15-49 population)

Barriers to VMMC uptake & promise of economic interventions to create demand

Barriers faced by older men may differ from those for younger men Several studies have identified financial concerns and fear of pain as

primary barriers to uptake among older men

Strong rationale for use of economic interventions (such as provision of incentives and compensation) to change behavior Conditional cash transfer (CCT) programs have had positive effects Behavioral economics also provides rationale for using incentives

RCT of conditional economic compensation

Overall objective: Increase VMMC uptake among men aged 25-49 years by offering conditional in-kind compensation for transport costs and lost wages

Specific aim: Determine impact of offering different amounts of compensation (in the form of food vouchers) on VMMC uptake over a 2 month period

Study design

Design: Randomized controlled trial

4 study groups Control (0 KES) 200 KES (US $2.50) 700 KES (US $8.75) 1,200 KES(US $15.00)

Intervention sought to reduce costs associated with VMMC Amounts of 700 and 1,200 KES represent 2-3 days wages Goal is to bring full costs of procedure down to zero

Outcome: Uptake of VMMC within 2 months of enrollment

Main result: VMMC uptake within 2 months

1,504 uncircumcised men randomized to 4 groups Mean age 34 years, all Luo, 84% married Median earnings US $5/day 25% reported strong interest in getting circumcised in future

Higher VMMC uptake among participants receiving conditional food vouchers of US$8.75 and US$15.00 (6.6% and 9.0%)

Adjusted logistic regression analysis of VMMC uptake 4.3 times higher odds for participants offered US$8.75 (KES 700) 6.2 times higher odds for participants offered US$15.00 (KES 1,200)

Main result: VMMC uptake within 2 months

Study group

Control US$2.5 US$8.75 US$15 No. of participants 370 374 381 377 Circumcised, No. (%) 6 (1.6) 7 (1.9) 25 (6.6) 34 (9.0) 95% CI 0.6%-3.5% 0.8%-3.8% 4.3%-9.5% 6.3%-12.4%

Logistic regression Adj. Odds Ratio 1 (Reference) 1.1 4.3 6.2

95% CI - 0.4 - 3.3 1.7 - 10.7 2.6 - 15.0 P-value - 0.869 0.002 <0.001

Conclusion and policy implications

Provision of small amounts of compensation effective in promoting VMMC uptake among men aged 25-49 years within 2 month period

Absolute increase in uptake was relatively modest From ~2% in control group to 9% in US$15.00 group However, increase is large given ~35% MC prevalence among older

men after 5 years of rollout

Scaling-up intervention could result in larger effect on VMMC uptake Greater promotion likely to encourage more men (no reminders in study) Longer VMMC uptake window likely to result in higher uptake as well

Countries could consider the intervention as a model for reaching those who have yet become circumcised.

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H Thirumurthy and coauthors

Effect of Providing Conditional Economic Compensation on Uptake of Voluntary Medical Male Circumcision in Kenya: A Randomized Clinical Trial

Published online July 20, 2014

Acknowledgements

Partnership Kenya Ministry of Health UNC Chapel Hill Impact-RDO

Financial support BMGF NIH K01HD061605

ODK support at UNC David Perrin Tim Van Acker

Collaborators Sam Masters Megan Bronson Kate Murray