The Spear and Shield intervention to increase the availability and acceptability of voluntary medical male circumcision in Zambia: a cluster randomised controlled trial

Abstract

BackgroundWidespread voluntary medical male circumcision (VMMC) in Africa could avert an estimated 3·436 million HIV infections and 300,000 deaths over the next 10 years. Most Zambian men, however, have expressed little interest in undergoing VMMC. This study tested the effect of an intervention designed to increase demand for VMMC among these “hard to reach” men.MethodsThis cluster randomized controlled trial was conducted from 2012 to 2014 in Lusaka, Zambia (HIV prevalence = 20·8%). 13 Community Health Centers (CHCs) were stratified by HIV voluntary counseling and testing (VCT) rates and patient census and randomly assigned (5:5:3) to Experimental, Control or Observation Only conditions. CHC health care providers at all 13 sites received VMMC training. Trial statisticians did not participate in randomization. 800 uncircumcised HIV-, post-VCT men, 400 per condition, were recruited; female partners were invited to participate. The primary outcome was the likelihood of VMMC by 12 months post-intervention. The trial registration is NCT 01688167.Findings161 participants in the Experimental condition underwent VMMC as compared to 96 Control participants [adjusted odds ratio = 2·45, 95% CI = (1·24, 4·90) p = ·0166]. Post-VMMC condom use among Experimental condition participants increased compared to baseline, with no change among Control participants. No adverse events related to study participation were reported.InterpretationThe Spear and Shield intervention combined with VMMC training was associated with a significant increase in the number of VMMCs performed as well as in condom use among “hard to reach” Zambian men. Results support the importance of comprehensive HIV prevention programs that increase supply of and demand for VMMC services.FundingNIH/NIMH R01MH095539.

Increasing voluntary medical male circumcision uptake among adult men in Tanzania

“…The study contributes to the growing evidence on effective demand-creation strategies for VMMC [17,18]. The increase in the number of men of all ages attending VMMC in the intervention arm reflects that many messages in the intervention strategy were attractive to younger as well as older men, and incorporating these elements should be of benefit to general VMMC campaigns.…”

“…The increase in the number of men of all ages attending VMMC in the intervention arm reflects that many messages in the intervention strategy were attractive to younger as well as older men, and incorporating these elements should be of benefit to general VMMC campaigns. To our knowledge, only three randomized controlled clinical trials in SSA have assessed the effect of a targeted intervention on VMMC uptake among men aged at least 18 years: an economic incentive trial in Kenya [17] and Tanzania [31], and a CRT in Zambia [18]. There are notable differences between these studies and our study.…”

Circumcision Status and Time to Sexual Debut Among Youth in Sub-Saharan Africa: Evidence from Six Demographic and Health Surveys

“…We also acknowledge the influence of contextual factors on VMMC decision-making which our study could not account for. For instance, [37] indicate that men participating in a comprehensive sexual risk reduction program were more likely to reduce other sexual risk behaviors following VMMC compared to those receiving only VMMC. Also, our data spans countries that historically shared similar cultural and ethnic practices (Rwanda and Uganda) that could potentially bias our results.…”

Stages of Change for Voluntary Medical Male Circumcision and Sexual Risk Behavior in Uncircumcised Zambian Men: The Spear and Shield Project

“…Clinics were selected in consultation with the Lusaka Provincial Health Office based on: 1) ≥ 50 HIV voluntary counseling and testing (VCT) participants per month, 2) no trained CHC personnel currently performing circumcisions on a regular basis, 3) at least 3 health care providers available at each site for circumcision training, and 4) a minimum of 2 VCT counselors (or equivalent) available at each site for sexual risk reduction training. More details on this project and outcomes are described elsewhere [28]. …”

“…VMMC knowledge and attitudes were assessed using a measure adapted from the Uganda National Serosurvey [23,28,29]. Participants reported both methods they currently used to prevent HIV and the methods they believed were effective.…”