Scaling An Evidence-Based Voluntary Medical Male Circumcision Demand Creation Intervention For Adolescents In Sub-Saharan Africa

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  • March 21, 2019
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  • DeCelles, Jeff
    • Affiliation: Gillings School of Global Public Health, Department of Health Policy and Management
Abstract
  • Approximately 70% of all new HIV infections occur in Sub-Saharan Africa, where more than 25 million people are living with HIV. Clinical trials have shown that voluntary medical male circumcision (VMMC) can reduce female-to-male transmission of HIV in sub-Saharan African countries by up to 60%. UNAIDS and the World Health Organization (WHO) have identified 14 countries in sub-Saharan Africa as VMMC priority countries, as these nations have generally low circumcision coverage and high HIV prevalence rates. Since 2007, nearly 11.6 million males in these countries have undergone VMMC, demonstrating great progress has been made in scaling up VMMC services. However, an estimated 9.4 million circumcisions are still needed to achieve the 80% coverage target. To fill this gap, demand creation interventions are needed to provide education, motivation, and support to encourage men and adolescent boys to undergo the procedure. This study includes a literature review of all completed randomized controlled trials on VMMC demand creation. This review found interventions such as interpersonal communication, incentives, and sport-based approaches have produced encouraging evidence of increased demand for VMMC; however, none of these evidence-based interventions appear to have been scaled to regional or national levels beyond the successful trials. Building on these findings, this study utilized key informant interviews (n=26) with a range of stakeholders to establish key criteria for scaling evidence-based VMMC demand creation interventions, with an emphasis on scaling adolescent interventions. This study generated findings useful to policymakers, donors, and implementing organizations as they design strategies for scaling VMMC demand-creation interventions. Findings suggest that scalable VMMC demand creation interventions should: (1) utilize ongoing collection of programmatic data to become more affordable, reach larger numbers, and iteratively improve quality; (2) implement a targeted approach to address individual barriers to VMMC uptake; and (3) continually evolve and innovate to stay relevant and effective. This study found it is critical to take a “consortium approach” to scaling VMMC demand creation interventions. In the consortium approach, African government ministries, community members, implementing organizations, and donors participate in meaningful engagement from the “pre-planning” phase through scale-up. The Ministry of Education and parents were identified as important stakeholders when scaling adolescent interventions. VMMC conversion rate, absolute VMMC uptake, cost effectiveness, ongoing quality assurance, and changes in norms and values were identified as key metrics to assess impact and effectiveness of VMMC demand creation interventions at scale. Key informants identified barriers to scaling VMMC demand creation interventions including difficult funding structures, challenges engaging government, and supply side barriers related to availability and quality of services. Parental consent was identified as a key barrier to scaling of adolescent VMMC demand creation interventions. Key informants described VMMC strategies as transitioning from an emergency approach to a maintenance approach as several countries make progress towards VMMC coverage and VMMC becomes integrated into a wider package of health services. To sustain current circumcision coverage, circumcision strategies will likely shift focus from the general population of males to adolescent boys and infants. Additionally, government adoption was identified as a pathway to sustainability of VMMC demand creation interventions, yet key informants were skeptical that governments would fully take on all activities, including funding, implementation and evaluation. Furthermore, funding for VMMC is likely to change in the coming years; in response, demand creation interventions will need to find new funding sources outside PEPFAR, including private sector funding. Findings from this study have informed a Plan For Change for Grassroot Soccer, a sport-based adolescent health organization that seeks to scale its evidence-based VMMC demand creation intervention for adolescents in sub-Saharan Africa.
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  • In Copyright
Advisor
  • Greene, Sandra
  • Harrison, Abigail
  • Powell, Byron
  • Pettifor, Audrey
  • Thirumurthy, Harsha
Degree
  • Doctor of Public Health
Degree granting institution
  • University of North Carolina at Chapel Hill Graduate School
Graduation year
  • 2018
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