Innovative demand creation strategies to increase voluntary medical male circumcision uptake: a pragmatic randomised controlled trial in Zimbabwe

Abstract

IntroductionReaching men aged 20–35 years, the group at greatest risk of HIV, with voluntary medical male circumcision (VMMC) remains a challenge. We assessed the impact of two VMMC demand creation approaches targeting this age group in a randomised controlled trial (RCT).MethodsWe conducted a 2×2 factorial RCT comparing arms with and without two interventions: (1) standard demand creation augmented by human-centred design (HCD)-informed approach; (2) standard demand creation plus offer of HIV self-testing (HIVST). Interpersonal communication (IPC) agents were the unit of randomisation. We observed implementation of demand creation over 6 months (1 May to 31 October 2018), with number of men circumcised assessed over 7 months. The primary outcome was the number of men circumcised per IPC agent using the as-treated population of actual number of months each IPC agent worked. We conducted a mixed-methods process evaluation within the RCT.ResultsWe randomised 140 IPC agents, 35 in each arm. 132/140 (94.3%) attended study training and 105/132 (79.5%) reached at least one client during the trial period and were included in final analysis. There was no evidence that the HCD-informed intervention increased VMMC uptake versus no HCD-informed intervention (incident rate ratio (IRR) 0.87, 95% CI 0.38 to 2.02; p=0.75). Nor did offering men a HIVST kit at time of VMMC mobilisation (IRR 0.65, 95% CI 0.28 to 1.50; p=0.31). Among IPC agents that reported reaching at least one man with demand creation, both the HCD-informed intervention and HIVST were deemed useful. There were some challenges with trial implementation; <50% of IPC agents converted any men to VMMC, which undermined our ability to show an effect of demand creation and may reflect acceptability and feasibility of the interventions.ConclusionThis RCT did not show evidence of an effect of HCD-informed demand intervention or HIVST on VMMC uptake. Findings will inform future design and implementation of demand creation evaluations.Trial registration numberPACTR201804003064160.

Relative efficiency of demand creation strategies to increase voluntary medical male circumcision uptake: a study conducted as part of a randomised controlled trial in Zimbabwe

“…The trial design is described in more detail elsewhere. 25 In short, Population Services International (PSI) Zimbabwe redesigned their interpersonal communication (IPC) demand creation approaches drawing on market research and using HCD-informed methods as discussed above. HCD approaches develop solutions to problems by involving the human perspective in all steps of the problem-solving process.…”

“…HCD approaches develop solutions to problems by involving the human perspective in all steps of the problem-solving process. [23][24][25] A 2×2 factorial pragmatic RCT compared arms with and without two interventions implemented by VMMC mobilisers known as IPC agents: (i) standard demand creation (SDC) augmented by HCD-informed approach; (ii) standard demand creation plus offer of HIVST across five rural districts (Buhera, Gokwe North, Mangwe, Mutasa, Zvimba) in 4 of 10 provinces in Zimbabwe, where neither the HCD-informed nor HIVST intervention had previously been implemented (table 1). 25 IPC agents, the unit of randomisation, were assigned 1:1:1:1 to four arms, using restricted randomisation.…”

“…All mobilised clients received a referral card to link the client to the IPC agent at the VMMC site. 25 Circumcised clients were therefore directly linked to their respective arm through the IPC agents who mobilised them. Online supplemental file 1 provides additional detailed narrative description of the demand creation models and mobilisation strategy.…”

“…21 22 Demand-side barriers include poor HIV risk perception and healthcare seeking among men; fear of pain associated with the surgical procedure and local anaesthesia; fear of surgical complications; fear of preoperative HIV testing, lengthy healing and sexual abstinence period and perceived threats to masculinity. [23][24][25][26][27][28][29][30][31] Low demand has also been associated with perceived high opportunity costs of seeking VMMC services including transport and productivity losses. 20 25 32 33 For Zimbabwe, one of the countries' worst affected by HIV, with a prevalence of 12.9%, modelling studies suggested that the greatest reduction in new infections could have been achieved if 1.3 million (80% of 13-29-year-old men) had been circumcised by 2017.…”

“…25 44 In this paper, we present results of an economic analysis to assess the relative efficiency of demand creation models as part of a RCT which assessed the effectiveness of a human-centred design (HCD)-informed approach combined with HIV self-testing (HIVST) in motivating men (15-29 years) to take up VMMC. 25 HIVST has been shown to increase testing coverage among previously unreached populations, such as men, than conventional HIV testing services and might help overcome men's fear of preoperative HIV testing and a positive result, allowing them to test in private prior to going to a VMMC health facility (even if it meant being tested again). 45…”