Toward a Systematic Approach to Generating Demand for Voluntary Medical Male Circumcision: Insights and Results From Field Studies

By the end of 2014, an estimated 8.5 million men had undergone voluntary medical male circumcision (VMMC) for HIV prevention in 14 priority countries in eastern and southern Africa, representing more than 40% of the global target. However, demand, especially among men most at risk for HIV infection, remains a barrier to realizing the program's full scale and potential impact. We analyzed current demand generation interventions for VMMC by reviewing the available literature and reporting on field visits to programs in 7 priority countries. We present our findings and recommendations using a framework with 4 components: insight development; intervention design; implementation and coordination to achieve scale; and measurement, learning, and evaluation. Most program strategies lacked comprehensive insight development; formative research usually comprised general acceptability studies. Demand generation interventions varied across the countries, from advocacy with community leaders and community mobilization to use of interpersonal communication, mid- and mass media, and new technologies. Some shortcomings in intervention design included using general instead of tailored messaging, focusing solely on the HIV preventive benefits of VMMC, and rolling out individual interventions to address specific barriers rather than a holistic package. Interventions have often been scaled-up without first being evaluated for effectiveness and cost-effectiveness. We recommend national programs create coordinated demand generation interventions, based on insights from multiple disciplines, tailored to the needs and aspirations of defined subsets of the target population, rather than focused exclusively on HIV prevention goals. Programs should implement a comprehensive intervention package with multiple messages and channels, strengthened through continuous monitoring. These insights may be broadly applicable to other programs where voluntary behavior change is essential to achieving public health benefits

Modeling Impact and Cost-Effectiveness of Increased Efforts to Attract Voluntary Medical Male Circumcision Clients Ages 20–29 in Zimbabwe

<div><p>Background</p><p>Zimbabwe aims to increase circumcision coverage to 80% among 13- to 29-year-olds. However, implementation data suggest that high coverage among men ages 20 and older may not be achievable without efforts specifically targeted to these men, incurring additional costs per circumcision. Scale-up scenarios were created based on trends in implementation data in Zimbabwe, and the cost-effectiveness of increasing efforts to recruit clients ages 20–29 was examined.</p><p>Methods</p><p>Zimbabwe voluntary medical male circumcision (VMMC) program data were used to project trends in male circumcision coverage by age into the future. The projection informed a base scenario in which, by 2018, the country achieves 80% circumcision coverage among males ages 10–19 and lower levels of coverage among men above age 20. The Zimbabwe DMPPT 2.0 model was used to project costs and impacts, assuming a US$109 VMMC unit cost in the base scenario and a 3% discount rate. Two other scenarios assumed that the program could increase coverage among clients ages 20–29 with a corresponding increase in unit cost for these age groups.</p><p>Results</p><p>When circumcision coverage among men ages 20–29 is increased compared with a base scenario reflecting current implementation trends, fewer VMMCs are required to avert one infection. If more than 50% additional effort (reflected as multiplying the unit cost by >1.5) is required to double the increase in coverage among this age group compared with the base scenario, the cost per HIV infection averted is higher than in the base scenario.</p><p>Conclusions</p><p>Although increased investment in recruiting VMMC clients ages 20–29 may lead to greater overall impact if recruitment efforts are successful, it may also lead to lower cost-effectiveness, depending on the cost of increasing recruitment. Programs should measure the relationship between increased effort and increased ability to attract this age group.</p></div

Sensitivity Analysis of Unit Cost for Circumcising Males Ages 20–29 in Scenario A¹.

<p>Sensitivity Analysis of Unit Cost for Circumcising Males Ages 20–29 in Scenario A<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0164144#t003fn001" target="_blank">¹</a>.</p

Cost and Impact of the Four Scenarios, 2015–2029.

<p>Cost and Impact of the Four Scenarios, 2015–2029.</p

Age distribution of VMMC clients compared with the age distribution of potential clients.

<p>VMMC clients are shown in white bars; the age distribution of uncircumcised males in the overall population of 10- to 49-year-old males (potential clients) is shown in black bars.</p

Reduction in HIV incidence with provision of VMMC to males, by age group, 2014–2050.

<p>The HIV incidence ratio represents the incidence in the scale-up scenario divided by the incidence in a population where circumcision is not scaled up over baseline levels. HIV incidence is in the entire population—males and females. Each line represents the HIV incidence ratio under a scenario in which only the indicated five-year age group is circumcised. In each age group, MC is scaled up to 80% coverage 2014–2018 and maintained at that level from 2018 forward. The dashed vertical line represents a 15-year period from the base year.</p

Trends in the proportion of each age group among VMMC clients over time.

<p>Trends in the proportion of each age group among VMMC clients over time.</p

Target Coverage by 2018 for Three Scenarios.

<p>Target Coverage by 2018 for Three Scenarios.</p