Sexual risk reduction and behavioural programme increases uptake of circumcision in hard-to-reach men

A cluster randomized controlled trial to increase the availability and acceptability of voluntary medical male circumcision in Zambia: the Spear and Shield Project.

Weiss SM, Zulu R, Jones DL, Redding CA, Cook R, Chitalu N. Lancet HIV. 2015 May 1;2(5):e181-e189.

Background: Widespread voluntary medical male circumcision in Africa could avert an estimated 3.436 million HIV infections and 300 000 deaths over the next 10 years. Most Zambian men have expressed little interest in the procedure. We tested the effect of the Spear and Shield intervention designed to increase demand for voluntary medical male circumcision among these hard-to-reach men.

Methods: This cluster randomised controlled trial was done between Feb 1, 2012, and Oct 31, 2014, in Lusaka, Zambia, where HIV prevalence is 20.8%. 13 community health centres were stratified by HIV voluntary counselling and testing rates and patient census, and randomly assigned (5:5:3) to experimental (the intervention), control, or observation-only conditions. Community health centre health-care providers at all 13 sites received training in voluntary medical male circumcision. Eligible participants were aged at least 18 years, HIV-negative, uncircumcised, and had not proactively requested or planned for voluntary medical male circumcision at the time of enrolment. Trial statisticians did not participate in randomisation. After voluntary counselling and HIV testing, participants were recruited; female partners were invited to participate. The primary outcomes at the individual level were the likelihood of voluntary medical male circumcision by 12 months post intervention, and condom use after voluntary medical male circumcision among participants receiving the intervention. The trial is registered with, number NCT01688167.

Findings: 800 uncircumcised HIV-negative men (400 in the experimental group, 400 in the control group) were enrolled. 161 participants in the experimental group and 96 in the control group had voluntary medical male circumcision (adjusted odds ratio 2.45, 95% CI 1.24–4.90; p=0.02). Condom use was examined in participants who had voluntary medical male circumcision and reported sexual activity within 1 month of a post-circumcision assessment (88 in the experimental group and 64 in the control group). Condom use over time increased in the experimental group (p=0.03) but not in the control group (p=0.2). One patient died in each group; no adverse events related to study participation were reported.

Interpretation: Comprehensive HIV prevention programmes can increase the demand for and uptake of voluntary medical male circumcision services.

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Editor’s notes: Voluntary medical male circumcision reduces the risk of HIV acquisition in men by approximately 60%, yet in some high-prevalence countries uptake is low. This presents challenges in meeting WHO targets of 80% coverage. In Zambia, only 37% of the national target has been achieved. In this cluster randomised trial, 13 community health centres were randomised to receive training in the “Spear and Shield” programme, control (training for an equivalent period of time on general disease prevention strategies) or observation only. The Spear and Shield programme consisted of four weekly 90 minute group sessions. Men in the programme group had about 2.5 times the odds of having male circumcision, compared to the control group participants. This increase in uptake of male circumcision was not associated with an increase in sexual risk behaviours. In fact there was an increase in condom use in the programme group. According to WHO, demand creation continues to be the major challenge in meeting male circumcision coverage goals. The authors propose that scaling up an evidence-informed programme such as Spear and Shield, while training community health care workers to perform circumcisions, might be one of the best and most cost-effective ways to significantly reduce HIV rates in high-incidence settings.

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