1. Figure 1. Food voucher given to VMMC clients H. Thirumurthy 1,2, E. Evens 3, S. Rao 4, M. Lanham 3, E. Omanga 4, K. Agot 4 1 Dept. of Health Policy and Management, University of North Carolina at Chapel Hill, United States; 2 Carolina Population Center, Chapel Hill, United States; 3 FHI 360, Durham, United States; 4 Impact Research and Development Organization, Kisumu, Kenya Presented by Kawango Agot The effect of conditional economic compensation on uptake of voluntary medical male circumcision in Kenya: a randomized controlled trial Background o Since male circumcision reduces the risk of female-to-male HIV transmission by up to 60%, WHO/UNAIDS have recommended scale-up of voluntary medical male circumcision (VMMC) services in 14 countries in sub-Saharan Africa o However, low VMMC uptake has been a major challenge to the scale-up of male circumcision in many countries and novel strategies are needed to increase VMMC uptake o Kenya has made progress toward achieving 80% circumcision prevalence, but uptake among men aged 25-49 years is low o A commonly reported barrier to VMMC uptake, particularly among older men, has been concern about lost wages o Incentive-based interventions have been shown to increase uptake of other health interventions, but there is a lack of evidence on their effectiveness in promoting VMMC uptake Objective o To determine whether providing small amounts of compensation conditional on undergoing circumcision can increase VMMC uptake by addressing reported economic barriers Specific Aims o Assess the impact of conditional economic compensation on VMMC uptake over a short duration of time o Determine optimal size of compensation o Explore men’s perceptions of the intervention Methods Intervention : Compensation in the form of food vouchers was given to participants who underwent medical male circumcision; amounts reflected a portion of transportation costs and 2-4 days of lost wages associated with getting circumcised Study design: Randomized controlled trial with 4 groups Outcome variable: VMMC uptake within 2 months of enrollment Participants: Men aged 25-49 years who reported being uncircumcised were enrolled from June-December 2013 Location: 9 Sublocations within Nyanza region, western Kenya Presented at AIDS 2014 – Melbourne, Australia Figure 2. Study area in western Kenya Results o 1,502 participants enrolled and randomized to 4 study groups o Participant characteristics similar in all study groups (Table 1) o Sexual behavior and circumcision attitudes similar in all study groups o Majority (68%) reported possibility of being unable to work temporarily as their greatest concern about getting circumcised; 15% reported fear of pain; 16% reported other factors Table 1. Baseline characteristics of study participants Study group Control (n=370) US$2.5 (n=374) US$8.75 (n=381) US$15 (n=377) Full sample (n=1502) Age, mean (SD)34.1 (6.7)34.2 (6.7)34.8 (6.5)34.4 (6.7) Wealth based on asset index*, mean (SD)3.0 (1.5) 3.1 (1.5)3.0 (1.5) Hours worked in past week, mean (SD)46.9 (20.1)46.6 (19.5)48.0 (19.4)47.1 (19.8) Daily earnings (US$), median (IQR)5.0 (3.8-7.1)5.0 (3.1-7.5)6.3 (3.8-7.5)5.0 (3.8-7.5) Distance to nearest clinic (km), median (IQR)5.6 (4.6-7.3)5.7 (4.6-7.6)5.8 (4.6-7.8)6.0 (4.6-7.9)5.7 (4.6-7.7) Education Some primary education or none, No. (%)113 (31)99 (26)104 (27)99 (26)415 (28) Completed primary education, No. (%)112 (30)125 (33)122 (32)124 (33)483 (32) Some secondary education, No. (%)49 (13)53 (14)46 (12)48 (13)196 (13) Completed secondary or greater, No. (%)96 (26)97 (26)109 (29)106 (28)408 (27) Married, No. (%)317 (86)293 (78)332 (87)324 (86)1266 (84) Luo ethnicity, No. (%)370 (100)373 (100)381 (100)375 (99)1499 (100) *Notes: wealth was measured using an asset index defined as the sum of affirmative responses to questions about ownership of 11household items. Table 2. Effects of conditional economic compensation on VMMC uptake within 2 months Study group ControlUS$2.50US$8.75US$15 P-value for test of equality*** No. of participants370374381377 Circumcised, No. (%) 95% CI 6 (1.6) 0.6%-3.5% 7 (1.9) 0.8%-3.8% 25 (6.6) 4.3%-9.5% 34 (9.0) 6.3%-12.4% Unadjusted* OR 95% CI P-value 1 (Ref) - 1.2 0.4-3.5 0.802 4.3 1.7-10.5 0.002 6.0 2.5-14.5 <0.001 0.21 Adjusted** OR 95% CI P-value 1(Ref) - 1.1 0.4-3.3 0.869 4.3 1.7-10.7 0.002 6.2 2.6-15.0 <0.001 0.20 Notes: *Results from logistic regression model of VMMC uptake with indicators of study group (control group as reference group). **Results from logistic regression model with indicators of study group and controls for age, education, wealth, and marital status. ***P-value from Wald test of equality between US$8.75 group and US$15 group. Logistic regression analysis of VMMC uptake Compared to participants in the control group: o Participants in the US$15 group were 6 times more likely to uptake VMMC o Participants in the US$8.75 group were 4 times more likely to uptake VMMC o Participants in the US$2.50 group were not significantly more likely to uptake VMMC o Effect sizes for the US$8.75 and US$15 groups did not differ significantly (P=0.20) Control (0 KES) 200 KES (US $2.50) 700 KES (US $8.75) 1,200 KES (US $15) VMMC uptake within 2 months was significantly higher among participants in the US $8.75 and US $15 groups than in the US $2.5 and control groups Subgroup analyses Higher amounts of compensation had a significant effect in all of the sub-groups we examined, including: o Older and younger participants o Married and unmarried participants o Strong and weak intentions of getting circumcised in future Qualitative sub-study o 45 in-depth interviews with study participants supported main study results o None of the interviewees perceived the vouchers as coercive o Many viewed the voucher amounts as inadequate and called for higher amounts of compensation Conclusions & policy implications o Providing compensation with low-cost food vouchers (US$8.75 or US$15) to men who undergo circumcision was effective in increasing VMMC uptake within 2 months o Compared to the control group, the absolute increase in VMMC uptake as a result of providing higher compensation was modest o The effects of more intense promotion of the intervention or prolonged implementation requires further investigation o Compensation amounts may need to be higher in order to more adequately compensate for costs associated with VMMC; this is supported by lower effect size among participants with above median earnings and qualitative findings o The intervention is likely to be highly cost-effective since the bulk of intervention costs (compensation to VMMC clients) are only incurred when VMMC uptake occurs Acknowledgments: Sam Masters, Megan Bronson, Kate Murray Funding: Bill and Melinda Gates Foundation (OPP1069673), National Institute for Child Health and Human Development (K01HD061605) ClinicalTrials.gov Identifier: NCT01857700 Contact: kawango@impact-rdo.org harsha@unc.edu “[The food voucher] changed my mind [...] looking at the duties that I do in a day, I earn [US$2.50] out of them. So that means that the [US$15] [voucher] was enough to cover roughly six days and for the other days, I would see what to do. So that is how the voucher changed my mind and influenced me.” - Casual laborer, became circumcised, US$15 group “1200 shillings is not enough for even two days, and somebody like me who… can even make more than [US$50] from morning to mid-day, now 1200 shillings cannot make me go for circumcision.” - Fisherman, did not become circumcised, US$15 group “[The food voucher] changed my mind [...] looking at the duties that I do in a day, I earn [US$2.50] out of them. So that means that the [US$15] [voucher] was enough to cover roughly six days and for the other days, I would see what to do. So that is how the voucher changed my mind and influenced me.” - Casual laborer, became circumcised, US$15 group “1200 shillings is not enough for even two days, and somebody like me who… can even make more than [US$50] from morning to mid-day, now 1200 shillings cannot make me go for circumcision.” - Fisherman, did not become circumcised, US$15 group Intervention was most effective among participants engaged in higher-risk sexual behaviors (AOR 11.8, 95% CI 1.4-98.7)