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IAS 2015: Cash Encourages Circumcision, Prevention of Mother-to-Child HIV Transmission


Cash compensation can improve the uptake of key HIV prevention services in sub-Saharan Africa, according to results from 2 randomized studies presented at the 8th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention last month in Vancouver. A randomized trial conducted in Nyanza province, Kenya, showed that offering compensation in the form of food vouchers resulted in a significantly higher uptake of medical male circumcision, while a second randomized trial conducted in the Democratic Republic of Congo showed that providing modest cash incentives significantly increased retention in services for prevention of mother-to-child HIV transmission.

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Building demand for medical male circumcision is essential if national programs are to reach their targets for circumcision coverage, especially among young men over age 20, who often cite concerns about lost wages and time away from work as reasons why they have not opted for circumcision. Providing economic incentives might encourage men to opt for circumcision, but the size of the reward and the timing of the offer are likely to influence the success of any incentives.

Researchers from the University of North Carolina at Chapel Hill designed a study targeting young men aged 21-39 in which they compared the immediate incentive of compensation with the future-oriented opportunity of a large-value prize, in order to test which approach generated greater demand.

The study randomized participants to 1 of 3 groups:

  • Men offered vouchers worth $12.50 for exchange at local food shops if they underwent circumcision, as compensation for income lost while attending the clinic.
  • Men offered entry to a lottery to win much larger-value prizes if they underwent circumcision (including a 5% chance of winning a bicycle or a smartphone, or other easier-to-win rewards).
  • A control group of men who were offered circumcision and who received a food voucher worth $0.60 after circumcision.

The study enrolled 909 uncircumcised men with an average age of 29 in 8 districts in western Kenya, where a well-established service provides medical male circumcision. Median daily earnings were $3.80.

Compensation in the form of food vouchers proved to be more successful than lottery entry in encouraging men to get circumcised -- but the effect was strongest in men who were already considering whether to get circumcised. Men offered vouchers were almost 7 times more likely to get circumcised compared to the control group (adjusted odds ratio 7.1). However, uptake was still modest: 8% of those randomized to receive vouchers chose to get circumcised, compared to 1.3% of the control group (4 men). However, this increase was large relative to the annual uptake of circumcision in the local population.

Men who were not contemplating circumcision were not persuaded by the offer of compensation to come forward; rather, the intervention "nudged" those already considering circumcision, Harsha Thirumurthy of the University of North Carolina said. But interviews with men who did not seek circumcision suggest that a higher sum of compensation might have persuaded a larger number of men, and that the compensation offered was more persuasive for those with the lowest incomes.

There was no significant difference in circumcision uptake between the lottery group and the control group, probably because of what behavioral economists call "ambiguity aversion" -- aversion to the risk that there might be no reward at the end of the process.

In contrast, a study of a lottery-based intervention in Lesotho found that young women -- but not young men -- were significantly less likely to acquire HIV if they were entered into a 4-monthly lottery after testing negative for syphilis and trichomonas on a regular basis. Lottery entrants had a 40% lower incidence of HIV infection over 2 years of follow up.

Prevention of Mother-to-Child Transmission

A study conducted in the Democratic Republic of Congo found that offering women living with HIV small but escalating cash incentives for repeat attendance at antenatal clinic and uptake of prevention of mother-to-child transmission services improved retention and uptake.

The study recruited pregnant women with diagnosed HIV prior to week 32 of pregnancy and randomized them to receive either cash compensation at each clinic visit or to a control group which received standard interventions for prevention of mother-to-child transmission.

Women in the intervention group were offered $5 at the first visit, and at each subsequent visit this compensation increased by $1. Compensation was dependent on attendance at antenatal clinic visits, adherence to antiretroviral prophylaxis, and return at 6 weeks post-partum for infant HIV testing for early diagnosis. The study recruited 433 women at clinics in Kinshasa during 2013 and 2014 and randomized them equally to receive either cash compensation or standard management.

Intent-to-treat analysis showed significantly higher rates of retention in care and adherence in the intervention group (non-retention reduced by 30% and non-adherence to perinatal prevention interventions reduced by 32%), and lower rates of loss to follow-up at delivery and at 3 weeks post-partum (loss to follow-up reduced by 47%).



H Thirumurthy, S Masters, S Rao, et al. The effect of conditional economic compensation and lottery-based rewards on uptake of medical male circumcision in Kenya: a randomized trial. 8th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention. Vancouver, July 19-22, 2015. Abstract TUAC0102.

M Yotebieng, H Thirumurthy, KE Moracco, et al. Effectiveness of conditional cash transfers to increase retention in care and adherence to PMTCT services: a randomized controlled trial. 8th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention. Vancouver, July 19-22, 2015. Abstract TUAD0202.