Risk Compensation Following Male Circumcision: Results from a Two-Year Prospective Cohort Study of Recently Circumcised and Uncircumcised Men in Nyanza Province, Kenya
- 814 Downloads
We present the results of the first study of longitudinal change in HIV-associated risk behaviors in men before and after circumcision in the context of a population-level voluntary medical male circumcision (VMMC) program. The behaviors of 1,588 newly circumcised men and 1,598 age-matched uncircumcised controls were assessed at baseline, 6, 12, 18 and 24 months of follow-up. Despite the precipitous decline in perception of high HIV risk among circumcised men (30–14 vs. 24–21 % in controls) and increased sexual activity among the youngest participants (18–24 years; p-time < 0.0001, p-group = 0.96), all specific risk behaviors decreased over time similarly in both groups. The proportion of men reporting condom use at last sex increased for both groups, with a greater increase among circumcised men (30 vs. 6 %). We found no evidence of risk compensation in men following circumcision. Concerns about risk compensation should not impede the widespread scale-up of VMMC initiatives.
KeywordsRisk compensation Behavioral disinhibition Male circumcision HIV/AIDS Sexual behavior Africa
Support for this study was provided by a Grant to FHI360 from the Bill and Melinda Gates Foundation to support the Male Circumcision Consortium, a partnership between FHI360, EngenderHealth, and University of Illinois at Chicago working closely with the Nyanza Reproductive Health Society (Grant #47394). Robert C. Bailey received support from the Chicago Developmental Center for AIDS Research, an NIH funded program (P30 AI 082151). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
We thank all of the participants, without whom this work would not have been possible. We are grateful to Timothy Okeyo, Cosam Ang’awa, Yusto Okembia, Kevine Amolloh, Kelvin Akoth, Kennedy Otieno, Danstan Ochieng’, Victor Odula, George Kidi, David Ang’awa, Evans Otieno, Erik Ogutu, George Ong’eng’a, and Richard Okello for their dedication in recruitment, data collection, tracing, and overall commitment to the study; to Nicholas Obwama and Joseph Abuya for their tireless data entry and cleaning efforts; to Matthew Westercamp for his invaluable input and for reading and editing multiple versions of this manuscript; to Christine L. Mattson for inspiration; and to the entire NRHS staff for their assistance in making this study a success.
- 4.World Health Organization, Joint United Nations Programme on HIV/AIDS. New data on male circumcision and HIVprevention: policy and programme implications (2007).http://libdoc.who.int/publications/2007/9789241595988_eng.pdfAccessed 21 Sep 2012.
- 15.World Health Organization (WHO). Progress in scaling up voluntary medical male circumcision for HIV prevention in east and southern Africa: January–December. Geneva: World Health Organization; 2011. p. 2012.Google Scholar
- 26.Agot KE, Kiarie JN, Nguyen HQ, et al. Male circumcision in Siaya and Bondo Districts, Kenya: prospective cohort study to assess behavioral disinhibition following circumcision. J AIDS. 2007;44(1):66–70.Google Scholar
- 30.Siegfried N, Muller M, Deeks JJ, Volmink J. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database Syst Rev (Online). 2009;2:CD003362.Google Scholar
- 31.World Health Organization (WHO). Progress in scale-up of male circumcision for HIV prevention in Eastern and Southern Africa : focus on service delivery. Geneva, Switzerland: World Health Organization, 2011.Google Scholar
- 32.NACC and NASCOP. Kenya AIDS epidemic update 2011. Nairobi, Kenya: 2012.Google Scholar
- 33.Progress in voluntary medical male circumcision service provision. Kenya, 2008–2011. MMWR Morb Mortal Wkly Rep. 2012;61(47):957–61.Google Scholar
- 34.Westercamp M, Agot K, Bailey RC. Population-level changes over two years of a voluntary medical male circumcision program in Kisumu, Kenya: circumcision prevalence, beliefs, and HIV risk behaviors. Ethiopia: ICASA; Addis Ababa; 2011.Google Scholar
- 37.Hedeker D, Barlas S. RMASS2: Repeated measures with attrition: sample sizes for 2 groups. Chicago: University of Illinois at Chicago, Division of Epidemiology & Biostatistics; 1999.Google Scholar
- 38.SAS Institute Inc. SAS software. Version 9.1.3 ed. Cary, NC; 2008.Google Scholar
- 40.Mad rush to be circumcised. Standard, Kenya; 2008.Google Scholar
- 42.Reed JB, Njeuhmeli E, Thomas AG, et al. Voluntary medical male circumcision: an HIV prevention priority for PEPFAR. J AIDS. 2012;15(60):S88–95.Google Scholar
- 43.AIDS Vaccine Advocacy Coalition. A new way to protect against HIV? Understanding the results of male circumcision studies for HIV prevention. NewYork: AVAC; 2007.Google Scholar
- 48.Alsallaq RA, Abu-Raddad L. Male circumcision is a leading factor behind the differential HIV prevalence in Sub-Saharan Africa (Abstract no. MOPE0254). AIDS 2008—XVII International AIDS Conference; 2008.Google Scholar
- 53.Republic of Kenya Ministry of Public Health & Sanitation. National strategy for voluntary medical male circumcision. National AIDS & STD Control Programme (NASCOP), Nairobi; 2009.Google Scholar
- 54.National AIDS and STI Control Programme. Kenya AIDS Indicator Survey (KAIS) 2007: preliminary report. Nairobi: Ministry of Health; 2008.Google Scholar
- 55.Fonner VA, Denison J, Kennedy CE, O’Reilly K, Sweat M. Voluntary counseling and testing (VCT) for changing HIV-related risk behavior in developing countries. Cochrane Database Syst Rev (Online). 2012;9:CD001224.Google Scholar
- 56.Festinger L. A theory of cognitive dissonance. Stanford, California: Stanford University Press; 1962.Google Scholar
- 61.Vu LT, Nadol P, Le LC. HIV-Related Risk Behaviors Among the General Population: A Survey Using Audio Computer-Assisted Self-Interview in 3 Cities in Vietnam. Asia-Pac j pub health/Asia-Pac Academic Consort Pub Health. 2012.Google Scholar