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Limited progress in VMMC scale-up

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

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Limited progress in VMMC scale-up

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  1. 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 Agot31University of North Carolina at Chapel Hill and Carolina Population Center; 2FHI 360; 3Impact Research and Development Organization Presented by KawangoAgot 20th International AIDS Society Conference

  2. Limited progress in VMMC scale-up • 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) UNAIDS 2013

  3. 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

  4. 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

  5. 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

  6. 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%)

  7. Main result: VMMC uptake within 2 months • Adjusted logistic regression analysis of VMMC uptake • 4.3times higher odds for participants offered US$8.75 (KES 700) • 6.2times higher odds for participants offered US$15.00 (KES 1,200)

  8. 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.

  9. 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

  10. 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

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