Food vouchers improve rates of medical circumcision for HIV prevention in Kenya

July 18, 2014

Medical male circumcision has been shown to be an effective intervention for preventing HIV in sub-Saharan Africa. Now, a UNC researcher has led a team in discovering that small financial incentives can dramatically increase participation in programs that encourage men to seek circumcision.

Dr. Harsha Thirumurthy

Dr. Harsha Thirumurthy

Harsha Thirumurthy, PhD, assistant professor of health policy and management at the Gillings School of Global Public Health, led the study, “Effect of Providing Conditional Economic Compensation on Uptake of Voluntary Medical Male Circumcision in Kenya,” published July 20 in the Journal of the American Medical Association. Thirumurthy is also a faculty fellow at UNC’s Carolina Population Center.

While studies have demonstrated that circumcision can reduce HIV risk by as much as 60 percent, economic barriers and behavioral factors have limited men’s taking advantage of the voluntary procedure that has become widely available in Kenya and other countries.

Thirumurthy’s study, conducted with support from the Bill and Melinda Gates Foundation and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, found that modest economic incentives could partially overcome reluctance to seek circumcision and significantly increase the number of men getting circumcised.

The randomized clinical trial in Kenya involved more than 1,500 men between the ages of 25 and 49 years. The vast majority of men reported that their greatest concern about getting circumcised was being unable to work, and thus losing wages, during the procedure and recuperation period. As an incentive in the trial, food vouchers were used to compensate men for the cost of transportation to the clinic and up to three days’ lost wages.

The voucher amounts were modest by U.S. – and even by local – standards.

Uncircumcised men were divided into four groups. Three groups received food vouchers worth $2.50, $8.75, or $15 (200, 700, and 1,200 Kenya shillings) upon completion of the circumcision procedure, and one group was not offered any compensation.

The study was conducted in the Nyanza region of western Kenya, where primary occupations are subsistence farming, fishing and various forms of casual labor. Participants were from the region’s largest ethnic group, which traditionally has been non-circumcising.

The study results showed that economic incentives of $8.75 and $15 significantly increased the likelihood that men have the procedure, a fourfold to sixfold increase compared to the groups offered no incentive or the smallest incentive. The intervention is likely to be highly cost-effective given estimates that one HIV infection can be averted for every five to 15 procedures performed and in light of the cost of lifetime treatment for HIV.

Joining lead author Thirumurthy on the research team were Samuel H. Masters, MPH, doctoral candidate in the Gillings School’s Department of Health Policy and Management; Megan A. Bronson, MPH, of UNC’s Carolina Population Center; Samwel Rao, MPH, Kawango Agot, PhD, and Eunice Omanga, PhD, of the Impact Research and Development Organization of Kisumu, Kenya; and Emily Evens, PhD, and Michele Lanham, MPH, of FHI 360 in Durham, N.C.

Listen to an audio interview with Thirumurthy, available on the JAMA website.


Gillings School of Global Public Health contact: David Pesci, director of communications, (919) 962-2600 or dpesci@unc.edu.