MELBOURNE, Australia -- Modest economic incentives appeared to increase the chance that uncircumcised men in HIV-endemic areas would undergo circumcision within a couple of months, researchers reported here.
In a study done in over 1,500 uncircumcised Kenyan men, circumcision uptake was 6.6% among those offered food vouchers worth about $8.75 and 9% among those offered food vouchers worth about $15 when compared with men who were given vouchers of lesser values or no vouchers at all, reported Harsha Thirumurthy, PhD, from the University of North Carolina at Chapel Hill, and colleagues.
Circumcision uptake in those who were offered $2.50 in food vouchers was 1.9%; the uptake rate was 1.6% in those given no vouchers, the authors stated in a presentation at the International AIDS Conference and in the Journal of the American Medical Association.
"Further testing is necessary to determine the generalizability of our intervention and results to settings outside Kenya, "the authors wrote. "It is important to emphasize, for example, that the intervention would need to be accompanied by an adequate supply of voluntary medical male circumcision services and that a high background level of general knowledge and acceptability of circumcision, as was the case in our study setting due to prior efforts of the government and circumcision-implementing organizations, may be required."
Following randomized trials that demonstrated that medical male circumcision reduced men's risk of HIV acquisition by 50% to 60%, the Joint United Nations Programme on HIV and the World Health Organization recommended the scale-up of voluntary medical male circumcision 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 uptake, but potential barriers include concerns about lost wages during and after the procedure, the researchers suggested.
"To the extent that economic and behavioral barriers to circumcision uptake exist for many men, however, the results from this study should apply in these other settings," Thirumurthy's group reported.
The authors administered baseline questionnaires to 1,502 uncircumcised men, ages 25 to 49 (mean age 34.4), in the Nyanza province of Kenya. They were randomly assigned to three intervention groups and one control group (no compensation).
The participants self-reported working about 48 hours in the previous week with a daily wage of around $5. Eighty-four percent reported being married.
The one-time compensation amounts in the study equaled about 1 to 3 days of wages and transportation costs.
A mean of 26 days elapsed between enrollment in the study and circumcision uptake.
Among 370 men who received no compensation, six underwent circumcision. Among 376 men given vouchers worth $2.50, seven underwent the procedure. For the 381 men and 377 men who received vouchers worth $8.75 and $15, respectively, 25 and 34 underwent circumcision.
Based on logistic regression analysis, the likelihood of uptake had an adjusted odds ratio of 4.3 (95% CI 1.7-10.7) for those in the $8.75 group and 6.2 (95% CI 2.6-15.0) for the $15 group, the authors reported.
However, effect sizes for the $8.75 and $15 groups did not differ significantly (P=0.20).
While there were no adverse events reported among any of the study groups, many of the participants stated that the appropriate voucher amounts to offset the economic costs associated with male circumcision were even higher than the amounts given in the study.
Nevertheless, the authors found "a significant increase in voluntary medical male circumcision 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 study had some limitations, including the inability to compare the interventions' effect in different subgroups because of the small sample size and limited statistical power. Also, the authors did not explore if alternative forms of conditional economic compensation could be equally or more effective in increasing uptake.
The authors acknowledged that there were ethical considerations when using economic incentives to promote health behaviors, but stated that the intervention in this study was "ethically sound."
"Based on participants' reported wages, the modest amounts we used compensated participants for only part of the costs they would likely incur as a result of becoming circumcised," they explained. "In light of the health externality benefits of male circumcision such as secondary HIV prevention, the provision of modest incentives in this case has a more compelling rationale than it would for behaviors with no externality benefits."
The study was funded by the Bill and Melinda Gates Foundation. Thirumurthy disclosed support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
The authors disclosed no relevant relationships with industry.
Journal of the American Medical AssociationSource Reference: Thirumurthy H, et al "Effect of providing conditional economic compensation on uptake of voluntary medical male circumcision in Kenya: a randomized clinical trial" JAMA 2014; DOI: 10.1001/jama.2014.9087.