22 Jul Male Circumcision Did Not Increase Risky Sexual Behavior
MedicalResearch.com Interview with:
Dr. Nelli Westercamp PhD, MPH, MBA
University of Illinois at Chicago
School of Public Health
Kenya, Epidemiology and Public Health
Medical Research: What are the main findings of the study?
Dr. Westercamp: The three clinical control trials in Kenya, Uganda and South Africa found that male circumcision reduces the risk of female to male transmission by up to 60%, prompting the endorsement of medical male circumcision as an HIV prevention intervention by the WHO and UNAIDS. However, as medical male circumcision services for HIV prevention are being rolled out in the priority countries, questions remain whether the male circumcision promotion will actually translate into decreases in HIV infections. One factor that could reduce the effectiveness of male circumcision for HIV prevention at the population level is the behavioral risk compensation. In other words, if men who become circumcised believe that they are fully protected against HIV and engage in higher sexual risk taking behaviors as a result of this belief, this could reduce or even negate the protective effect of male circumcision against HIV.
To answer this question, we conducted a large prospective study concurrently with the scale up of male circumcision services in Western Kenya. We recruited 1,588 men seeking circumcision services as well as 1,598 men who decided to remain uncircumcised and assessed their sexual behaviors over 2 years, every 6 months. We then compared the behaviors of circumcised men before and after circumcision and also the behaviors of circumcised and uncircumcised men over time.
In the beginning of the study, we found that men choosing to become circumcised believed they were at higher risk of HIV than their uncircumcised counterparts. This perception of HIV risk declined significantly among the circumcised men after circumcision (from 30% at baseline to 14% at 24 months of follow up), while remaining relatively stable among the uncircumcised men (24% to 21%, respectively). Looking at sexual risk behaviors, we saw that the overall level of sexual activity increased equally in both groups, mostly driven by the youngest age group (18-24 year old). However, despite the decrease in risk perception among circumcised men and the increase in sexual activity among all men, all other risky behaviors decreased in both groups and protective behaviors – such as condom use – increased, particularly among circumcised men.
Medical Research: Were any of the findings unexpected?
Dr. Westercamp: Previous evidence about the risk compensation following male circumcision came from the three RCTs of male circumcision for HIV prevention, in-depth and extended follow up studies embedded in these RCTs, and a prospective study in Kenya that took place before the protective effect of male circumcision against HIV was shown by the RCTs.
The lack of risk compensation found in these studies has been questioned due to the following limitations:
1) rigorous risk reduction counseling provided as part of trial design that is unrealistic in operational settings; and
2) lack of certainty about the protective effect of MC against HIV when these studies were done.
It was important to assess behavioral risk compensation in real world settings, where men coming for circumcision services receive a one-time risk reduction counseling and then resume their normal life. It was important to do a study of risk compensation in the conditions of the medical male circumcision program scale up and our results not only strongly support previous empirical findings, but place them in the real life, population-level context.
Medical Research: What should clinicians and patients take away from your report?
Dr. Westercamp: Our recommendations are mostly relevant for program implementation and policy development. A number of countries have been holding back on scaling up the medical male circumcision programs due to several concerns. One of such concerns is the potential negative effect that risk compensation could have on the effectiveness of the male circumcision as an HIV prevention method in the conditions of wide-spread promotion and program implementation. In light of our results and those of previous studies in varying populations, concerns about risk compensation in the context of medical male circumcision programs for HIV prevention should not impede the widespread scale-up of the circumcision services
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Westercamp: Further research is needed to evaluate risk compensation following male circumcision in other populations. Additionally, previous modeling of the impact of widespread medical male circumcision programs has included sensitivity analyses of the hypothetical effect of only increases in risk behaviors after circumcision. It would now be prudent for models to include scenarios of safer sexual behaviors occurring in the context of such programs, as modeling often drives national policy debate and funding projections
Citation:
Nelli Westercamp, Kawango Agot, Walter Jaoko, Robert C. Bailey. Risk Compensation Following Male Circumcision: Results from a Two-Year Prospective Cohort Study of Recently Circumcised and Uncircumcised Men in Nyanza Province, Kenya. AIDS and Behavior, 2014; DOI: 10.1007/s10461-014-0846-4
Last Updated on July 22, 2014 by Marie Benz MD FAAD