Conditional economic compensation to increase uptake of voluntary medical male circumcision: a randomized controlled trial Harsha Thirumurthy 1, Emily Evens 2, Samwel Rao 3, Michele Lanham 2, Eunice Omanga 3, Kawango Agot 3 1 University of North Carolina at Chapel Hill and Carolina Population Center; 2 FHI 360; 3 Impact Research and Development Organization Presented by Kawango Agot 20 th 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 , only 14.4% of VMMC clients aged ≥25 years (but 57% of the 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 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

Conclusion and policy implications Provision of small amounts of compensation effective in promoting VMMC uptake among men aged 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 K01HD ODK support at UNC  David Perrin  Tim Van Acker Collaborators  Sam Masters  Megan Bronson  Kate Murray