Feasibility and Effectiveness of a Peer Referral Incentive Intervention to Promote Male Circumcision Uptake in Zambia.

BACKGROUND: Medical male circumcision is a promising HIV prevention tool in countries with generalized HIV epidemics, but demand creation interventions are needed to support scale-up. We piloted a peer referral intervention in which circumcision clients were offered incentives for referring their peers for circumcision. METHODS: The intervention was implemented between June 2014 and February 2015 in 6 randomly selected health facilities in Southern Province, Zambia. For the first 5 months, circumcision clients ≥18 years of age were given referral vouchers that allowed them to refer up to 5 peers for circumcision within a 3-month period. An incentive of US$2 was offered for each referral. The primary outcome was the number of circumcisions performed per month in each facility. To assess the effect of the intervention, a difference-in-difference analysis was performed using longitudinal data from the intervention facilities and 22 nonintervention facilities. A questionnaire was also implemented to understand men's perceptions of the intervention. RESULTS: During the 8-month intervention period, 1222 men over 18 years of age were circumcised in intervention facilities. In the first 5 months, 699 circumcision clients were enrolled and 385 clients brought a referral voucher given to them by an enrolled client. Difference-in-difference analyses did not show a significant increase in circumcisions performed in intervention facilities. However, circumcision clients reported that the referral incentive motivated them to encourage their friends to seek male circumcision. Peer referrals were also reported to be an important factor in men's decisions because 78% of clients who were referred reported that talking with a circumcised friend was important for their decision to get circumcised. CONCLUSIONS: The peer referral incentive intervention for male circumcision was feasible and acceptable. However, the intervention did not have a significant effect on demand for male circumcision. Barriers to circumcision and features of the intervention may have limited the effect of the intervention. Further efforts regarding encouraging male-to-male communication and evaluations with larger sample sizes are needed.

Safety and Efficacy of the PrePex Male Circumcision Device: Results From Pilot Implementation Studies in Mozambique, South Africa, and Zambia.

BACKGROUND: Fourteen countries in East and Southern Africa have engaged in national programs to accelerate the provision of voluntary medical male circumcision (VMMC) since 2007. Devices have the potential to accelerate VMMC programs by making the procedure easier, quicker, more efficient, and widely accessible. METHODS: Pilot Implementation studies were conducted in Mozambique, South Africa, and Zambia. The primary objective of the studies was to assess the safety of PrePex device procedures when conducted by nurses and clinical officers in adults and adolescent males (13-17 years, South Africa only) with the following end points: number and grade of adverse events (AEs); pain-related AEs measured using visual analog score; device displacements/self-removals; time to complete wound healing; and procedure times for device placement and removal. RESULTS: A total of 1401 participants (1318 adult and 83 adolescent males) were circumcised using the PrePex device across the 3 studies. Rates of moderate/severe AEs were low (1.0%; 2.0%; and 2.8%) in the studies in Mozambique, Zambia, and South Africa, respectively. Eight early self-removals of 1401 (0.6%) were observed, all required corrective surgery. High rates of moderate/severe pain-related AEs were recorded especially at device removal in South Africa (34.9%) and Mozambique (59.5%). Ninety percent of participants were healed at day 56 postplacement. DISCUSSION: The study results from the 3 countries suggest that the implementation of the PrePex device using nonphysician health care workers is both safe and feasible, but better pain control at device removal needs to be put in place to increase the comfort of VMMC clients using the PrePex device.

Evaluating Opportunities for Achieving Cost Efficiencies Through the Introduction of PrePex Device Male Circumcision in Adult VMMC Programs in Zambia and Zimbabwe.

BACKGROUND: Results from recent costing studies have put into question potential Voluntary Medical Male Circumcision (VMMC) cost savings with the introduction of the PrePex device. METHODS: We evaluated the cost drivers and the overall unit cost of VMMC for a variety of service delivery models providing either surgical VMMC or both PrePex and surgery using current program data in Zimbabwe and Zambia. In Zimbabwe, 3 hypothetical PrePex only models were also included. For all models, clients aged 18 years and older were assumed to be medically eligible for PrePex and uptake was based on current program data from sites providing both methods. Direct costs included costs for consumables, including surgical VMMC kits for the forceps-guided method, device (US $12), human resources, demand creation, supply chain, waste management, training, and transport. RESULTS: Results for both countries suggest limited potential for PrePex to generate cost savings when adding the device to current surgical service delivery models. However, results for the hypothetical rural Integrated PrePex model in Zimbabwe suggest the potential for material unit cost savings (US $35 per VMMC vs. US $65-69 for existing surgical models). CONCLUSIONS: This analysis illustrates that models designed to leverage PrePex's advantages, namely the potential for integrating services in rural clinics and less stringent infrastructure requirements, may present opportunities for improved cost efficiency and service integration. Countries seeking to scale up VMMC in rural settings might consider integrating PrePex only MC services at the primary health care level to reduce costs while also increasing VMMC access and coverage.