Title: Male Circumcision for HIV Prevention in Kenya: Seeking effective strategies to recruit older men Background: In Kenya, 1.4-1.6 million people are living with HIV, with an adult prevalence of 6.3%. Nyanza, one of the eight provinces, has the highest prevalence, at 13.9%. Within Nyanza, HIV prevalence in the districts occupied by the Luo - the dominant ethnic community in the province and third nationally - was 20.2% (17.1% in men and 22.8% in women). Several drivers of the rapid spread of HIV in the province have been identified as, among other factors, lack of male circumcision. A large number of observational studies and three randomized controlled trials concurred in their findings, that male circumcision reduces the risk of acquiring HIV by about 60%. Following the publications of these results and subsequent endorsement by the World Health Organization, Kenya rolled out male circumcision (MC) services from October 2008, and by March 2011, had circumcised 250,807 people in Nyanza province, 115,196 of these performed by our organization. However, uptake of services by older men (aged >25 years) who are more at risk of acquiring HIV has been elusive. We propose to evaluate different strategies to recruit men aged 25-39 years - Inter-Personal Communication (IPC), Conditional Cash Transfer (CCT), and a combination of IPC and CCT - in terms of uptake and cost of MC in Nyanza. Goal and Aims: With a goal of getting 80% of men aged 25-39 years circumcised, the specific aims are to: i) assess the rate of uptake of MC services among four categories of men aged 25-39 years: those exposed CCT vs. those exposed to IPC vs. those exposed to both interventions combined vs. those receiving no intervention;ii) determine the cost of providing MC among the three interventions vs. no intervention;iii) determine, through anonymous testing blood from the excised foreskin, the proportion of men who decline pre-operative testing who are HIV infected; and iv) link 80% of those who test positive in MC settings to HIV care and treatment programs. Methods: Three recruitment approaches will be implemented and evaluated: IPC, CCT and a combination of the two. Under IPC, we will engage those who have been circumcised, female champions, work-place champions, and opinion leaders to conduct one-on-one and small-group recruitment and referrals to our MC service sites;Under CCT, spouses or adult family members will accompany clients for MC services and couple HTC and MC education will be offered to clients with spouses. After surgery, the spouse/family member will be given a food stamp worth KShs. 1,750 (USD 23) per day for one week. The stamp will be presented to a designated shop in exchange of food stuff for use by the family when the bread-winner is recovering;Under Combined IPC and CCT, the effect of both interventions implemented together will be examined;In the Control District, no intervention will be implemented. The proposed study is unique in several ways: given MC is a one-off intervention, using cash incentives to increase the uptake of the services would pay off in terms of achieving faster population level impact; utilizing local resources and existing community structures to promote public health will ensure sustainability;and cash transfer to the spouse will promote women's involvement in decision- making around circumcision of their spouses. We anticipate doubling, in one year, the number of men age 25-39 years circumcised over the last 21/2 years, from 10,519 to 21,038, with a contributory ratio of 1:1.5:2 by IPC, CCT and IPC/CCT interventions, respectively.
Over two and a half years into rolling out male circumcision for HIV prevention in Kenya, less than 10% of those circumcised to date (n=250,807) are in the critical age (25-39 years) that would translate into a more immediate impact on population-level HIV incidence. The proposed evaluation study will identify effective approaches to getting older men to take up male circumcision services in order to realize the impact of the intervention sooner than would otherwise be the case if the current trend of circumcising under 24-year-olds continue.