Demand for medical male circumcision for HIV prevention: the influence of economic and psychological factors and their policy implications

Abstract

Background: Male Circumcision (MMC) of adolescent boys and men is an effective and potentially cost-effective intervention for the prevention of HIV. Most high HIV burden, low MMC prevalence countries in sub-Saharan Africa have fallen short of WHO/UNAIDS targets for the uptake of MMC for 2016, despite significant demand generation efforts. The aim of this dissertation project was to apply economic and psychology decision theories to study the incentives that drive the uptake of MMC for HIV prevention. Methods: The study was conducted in Mukono and Buikwe districts among predominantly fishing communities at landing sites on the northern shores of Lake Victoria, in Uganda. We conducted 11 focus group discussions and six key informant interviews to explore the economic and psychological factors affecting the uptake of MMC for HIV prevention. Based on the factors identified, we designed and executed a stated-preference discrete choice experimental (DCE) survey, coupled with measurement of psychological factors among 406 self-reported heterosexual, uncircumcised, HIV-negative men between 18-45 years-old. We used mixed logit, latent class logit and parameter-covariate mixed logit models to estimate preferences for MMC attributes, and to examine the extent to which preferences are influenced by psychological factors. Results: The demand for MMC was conceptualized as a process of valuation formation—based on psychological factors (HIV threat perceptions, subjective beliefs about MMC outcomes, and normative expectations), and action—based on economic factors (preferences for MMC service attributes). Socioeconomic characteristics and personality traits could explain differences in how people respond to factors at each stage of this process. In the DCE, marginal utilities (µ; se) were highest for accessing services at permanent health facilities (2.138; 0.214), and incentives: voucher vs none (0.512; 0.153) and cash vs none (0.968; 0.174). Marginal disutility (µ; se) was highest for device MMC (-1.674; 0.265). There was significant heterogeneity in preferences for accessing services at permanent health facilities (partly explained by subjective probability of pain during the MMC procedure), number of week-days during which services were available at facilities, device circumcision (partly explained by difference in the subjective probability of infection and pain from the MMC procedure, expected time away from work and sex after the MMC procedure), cash incentives and price/value of incentive compensation. Conclusion: Preferences were strongest permanent health facilities, surgical circumcision and incentives. Heterogeneity in preferences for these MMC service attributes exists and was only partly explained by the sociodemographic characteristics and subjective beliefs about MMC outcomes. MMC service delivery should be optimized based on individual preferences for these attributes. Further research should identify more demographic, and other non-observable influences on preferences, e.g., social influences and non-observable personality traits, that could be used to channel demand creation interventions accordingly.