Study examines incentives to increase medical male circumcision to help reduce risk of HIV

July 20, 2014

Among uncircumcised men in Kenya, compensation in the form of food vouchers worth approximately U.S. $9 or $15, compared with lesser or no compensation, resulted in a modest increase in the prevalence of circumcision after 2 months, according to a study published by JAMA. The study is being released to coincide with its presentation at the International AIDS Conference.

Following randomized trials that demonstrated that medical male circumcision reduces men's risk of HIV acquisition by 50 percent to 60 percent, UNAIDS and the World Health Organization recommended the scale-up of voluntary medical male circumcision (VMMC) in 14 countries in eastern and southern Africa. Despite considerable scale-up efforts, most countries are far short of target goals. Novel strategies are needed to increase VMMC uptake. Potential barriers include concerns about lost wages during and after the procedure, according to background information in the article.

Harsha Thirumurthy, Ph.D., of the University of North Carolina at Chapel Hill, and colleagues studied 1,504 uncircumcised men (25 to 49 years of age) in Nyanza region, Kenya, who were randomly assigned to 1 of 3 intervention groups or a control group. Participants in the intervention groups received varying amounts of compensation conditional on VMMC uptake at 1 of 9 study clinics within 2 months of enrollment. Compensation took the form of food vouchers worth approximately U.S. $2.50, $8.75, or $15, which reflected a portion of transportation costs and lost wages associated with getting circumcised. The control group received no compensation.

The researchers found VMMC uptake within 2 months was higher in the $8.75 group (6.6 percent [25 of 381]) and the $15 group (9.0 percent [34 of 377]) than in the $2.50 group (1.9 percent [7 of 374]) and the control group (1.6 percent [6 of 370]). Further analysis indicated that compared with participants in the control group, those in the $15 and $8.75 groups were significantly more likely to get circumcised; those enrolled in the $2.50 group were not. The difference in VMMC uptake between the $8.75 and $15 groups was not significant.

"There was also a significant increase in VMMC uptake among married and older participants, groups that have been harder to reach previously. The interventions also significantly increased the likelihood of circumcision uptake among participants at higher risk of acquiring HIV. This latter result is especially promising from an HIV prevention standpoint," the authors write.

"The overall increase in VMMC uptake within 2 months, as a result of providing compensation, was modest, with an increase of at most 7.4 percent in the U.S. $15.00 group. This increased uptake was in a population with an estimated circumcision prevalence of 35.6 percent. Evaluation of scaled-up implementation of the intervention is needed to determine whether it will help achieve higher circumcision coverage over longer periods of time."
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(doi:10.1001/jama.2014.9087; Available pre-embargo to the media at http://media.jamanetwork.com)

Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

The JAMA Network Journals

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