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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.
jamanetwork.com
Available at jama.com and on The JAMA Network Reader at
mobile.jamanetwork.com
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