An implementation science study investigating profiles of men interested in medical male circumcision (MMC), barriers and methods to increase the uptake of MMC among older men in South Africa (IMBIZO)

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Title: Evaluating the impact of conditional cash transfers to increase uptake of medical male circumcision among South African men. PI of the project Mary H. Latka, PhD MPH Other Key Personnel Gavin J. Churchyard Mpho Maraisane Gillian Gresak Katherine Fielding Abstract/ Project Summary The purpose of this implementation science study is to evaluate the impact of providing men aged 20-49 with a monetary incentive to undergo medical male circumcision (MC) on MC uptake. MC reduces men's risk of HIV acquisition by approximately 60%. Globally, roll out of MC is being prioritized among adult men in countries with high HIV prevalence and low MC prevalence. Despite high volume, high quality services available for this procedure, demand for MC is not guaranteed. Conditional cash transfer (CCT) programmes involve paying a defined cash amount to persons who enact a health-enhancing service or behaviour. CCT programmes have been used extensively in Latin America, but not Africa. To test the CCT approach on MC uptake, we will conduct two years of implementation science at our PEPFAR-funded MC clinic in the Ekurhuleni North sub-district of Johannesburg, South Africa. First we will conduct a pilot study where the cash transfer amounts to be tested will be identified. We will then conduct a trial where 4488 men aged 20-49 encountered during service delivery outreach who are interested in MC will give their consent to be randomized to one of two possible cash transfer amounts(1122 each), or a control condition (2244) involving receipt of a nominal item (i.e. water bottle/cap). All men, regardless of randomization status, will be able to access our MC service for free. To measure effectiveness, we will compare the MC yield (number in for MC over the number of vouchers delivered) for each cash transfer amount with yield in the control condition. We have >90% statistical power, even under worst case assumptions about MC uptake in the control and intervention conditions. To describe men who respond to incentives we will measure the socio- demographics, cultural beliefs, HIV risk profile and HIV status of men who come in for MC, and compare these characteristics between cash transfer arms and control. To evaluate any possible untoward effect of this programme on men just short of the age range, we will measure MC uptake among men aged 18-19 immediately before, during and after the intervention period. To identify perceptions that may inhibit or facilitate the subsequent transfer of a CCT for MC to other settings, including cultural beliefs and traditions, we will conduct focus groups with outreach and clinic staff involved in MC service delivery before and during the trial, Findings from this research will have timely and direct relevance to MC roll-out. If conditional cash transfers are effective in increasing demand among adult men, this approach could be expanded to hasten the uptake MC in Southern Africa where rapid uptake is needed to achieve population- level impacts.