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

Webster Mavhu; Melissa Neuman; Karin Hatzold; Stephen Buzuzi; Galven Maringwa; Sungai T. Chabata; Collin Mangenah; Noah Taruberekera; Ngonidzashe Madidi; Malvern Munjoma; Getrude Ncube; Sinokuthemba Xaba; Owen Mugurungi; Cheryl C. Johnson; Elizabeth L. Corbett; Helen A. Weiss; Katherine Fielding; Frances M. Cowan

doi:10.1136/bmjgh-2021-006141

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

Webster Mavhu^*, Melissa Neuman, Karin Hatzold, Stephen Buzuzi, Galven Maringwa, Sungai T. Chabata, Collin Mangenah, Noah Taruberekera, Ngonidzashe Madidi, Malvern Munjoma, Getrude Ncube, Sinokuthemba Xaba, Owen Mugurungi, Cheryl C. Johnson, Elizabeth L. Corbett, Helen A. Weiss, Katherine Fielding, Frances M. Cowan

^*Corresponding author for this work

Research output: Contribution to journal › Article › Academic › peer-review

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Abstract

Introduction:

Reaching 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).

Methods:

We 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.

Results:

We 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.

Conclusion:

This 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 number:

PACTR201804003064160.

Original language	English
Article number	e006141
Journal	BMJ Global Health
Volume	6
DOIs	https://doi.org/10.1136/bmjgh-2021-006141
Publication status	Published - 18 Jul 2021
Externally published	Yes

Bibliographical note

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© 2021 BMJ Publishing Group. All rights reserved.

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Mavhu, W., Neuman, M., Hatzold, K., Buzuzi, S., Maringwa, G., Chabata, S. T., Mangenah, C., Taruberekera, N., Madidi, N., Munjoma, M., Ncube, G., Xaba, S., Mugurungi, O., Johnson, C. C., Corbett, E. L., Weiss, H. A., Fielding, K., & Cowan, F. M. (2021). Innovative demand creation strategies to increase voluntary medical male circumcision uptake: A pragmatic randomised controlled trial in Zimbabwe. BMJ Global Health, 6, Article e006141. https://doi.org/10.1136/bmjgh-2021-006141

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abstract = "Introduction: Reaching 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). Methods: We 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. Results: We 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. Conclusion: This 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 number:PACTR201804003064160.",

author = "Webster Mavhu and Melissa Neuman and Karin Hatzold and Stephen Buzuzi and Galven Maringwa and Chabata, {Sungai T.} and Collin Mangenah and Noah Taruberekera and Ngonidzashe Madidi and Malvern Munjoma and Getrude Ncube and Sinokuthemba Xaba and Owen Mugurungi and Johnson, {Cheryl C.} and Corbett, {Elizabeth L.} and Weiss, {Helen A.} and Katherine Fielding and Cowan, {Frances M.}",

year = "2021",

month = jul,

day = "18",

doi = "10.1136/bmjgh-2021-006141",

language = "English",

volume = "6",

journal = "BMJ Global Health",

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Mavhu, W, Neuman, M, Hatzold, K, Buzuzi, S, Maringwa, G, Chabata, ST, Mangenah, C, Taruberekera, N, Madidi, N, Munjoma, M, Ncube, G, Xaba, S, Mugurungi, O, Johnson, CC, Corbett, EL, Weiss, HA, Fielding, K & Cowan, FM 2021, 'Innovative demand creation strategies to increase voluntary medical male circumcision uptake: A pragmatic randomised controlled trial in Zimbabwe', BMJ Global Health, vol. 6, e006141. https://doi.org/10.1136/bmjgh-2021-006141

TY - JOUR

T1 - Innovative demand creation strategies to increase voluntary medical male circumcision uptake

T2 - A pragmatic randomised controlled trial in Zimbabwe

AU - Mavhu, Webster

AU - Neuman, Melissa

AU - Hatzold, Karin

AU - Buzuzi, Stephen

AU - Maringwa, Galven

AU - Chabata, Sungai T.

AU - Mangenah, Collin

AU - Taruberekera, Noah

AU - Madidi, Ngonidzashe

AU - Munjoma, Malvern

AU - Ncube, Getrude

AU - Xaba, Sinokuthemba

AU - Mugurungi, Owen

AU - Johnson, Cheryl C.

AU - Corbett, Elizabeth L.

AU - Weiss, Helen A.

AU - Fielding, Katherine

AU - Cowan, Frances M.

PY - 2021/7/18

Y1 - 2021/7/18

N2 - Introduction: Reaching 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). Methods: We 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. Results: We 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. Conclusion: This 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 number:PACTR201804003064160.

AB - Introduction: Reaching 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). Methods: We 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. Results: We 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. Conclusion: This 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 number:PACTR201804003064160.

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U2 - 10.1136/bmjgh-2021-006141

DO - 10.1136/bmjgh-2021-006141

M3 - Article

AN - SCOPUS:85110806925

SN - 2059-7908

VL - 6

JO - BMJ Global Health

JF - BMJ Global Health

M1 - e006141

ER -

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

Abstract

Bibliographical note

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