AIDS and Behavior

, Volume 18, Issue 9, pp 1764–1775 | Cite as

Risk Compensation Following Male Circumcision: Results from a Two-Year Prospective Cohort Study of Recently Circumcised and Uncircumcised Men in Nyanza Province, Kenya

  • Nelli Westercamp
  • Kawango Agot
  • Walter Jaoko
  • Robert C. Bailey
Original Paper

Abstract

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.

Keywords

Risk compensation Behavioral disinhibition Male circumcision HIV/AIDS Sexual behavior Africa 

Notes

Acknowledgments

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.

References

  1. 1.
    Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet. 2007;369(9562):643–56.PubMedCrossRefGoogle Scholar
  2. 2.
    Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet. 2007;369(9562):657–66.PubMedCrossRefGoogle Scholar
  3. 3.
    Auvert B, Taljaard D, Lagarde E, et al. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med. 2005;2(11):298.CrossRefGoogle Scholar
  4. 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.
  5. 5.
    Weiss HA, Dickson KE, Agot K, Hankins CA. Male circumcision for HIV prevention: current research and programmatic issues. AIDS (Lond, Engl). 2010;24(Suppl 4):61–9.CrossRefGoogle Scholar
  6. 6.
    Kahn JG, Marseille E, Auvert B. Cost-effectiveness of male circumcision for HIV prevention in a South African setting. PLoS Med. 2006;3(12):517.CrossRefGoogle Scholar
  7. 7.
    Westercamp N, Bailey RC. Acceptability of male circumcision for prevention of HIV/AIDS in sub-Saharan Africa: a review. AIDS Behav. 2007;11(3):341–55.PubMedCentralPubMedCrossRefGoogle Scholar
  8. 8.
    Bollinger LA, Stover J, Musuka G, et al. The cost and impact of male circumcision on HIV/AIDS in Botswana. J Int AIDS Soc. 2009;12:7.PubMedCentralPubMedCrossRefGoogle Scholar
  9. 9.
    Gray RH, Li X, Kigozi G, et al. The impact of male circumcision on HIV incidence and cost per infection prevented: a stochastic simulation model from Rakai, Uganda. AIDS (Lond, Engl). 2007;21(7):845–50.CrossRefGoogle Scholar
  10. 10.
    Nagelkerke NJ, Moses S, de Vlas SJ, Bailey RC. Modelling the public health impact of male circumcision for HIV prevention in high prevalence areas in Africa. BMC Infect Dis. 2007;7:16.PubMedCentralPubMedCrossRefGoogle Scholar
  11. 11.
    UNAIDS/WHO/SACEMA Expert Group on Modelling the Impact and Cost of Male Circumcision for HIV Prevention. Male circumcision for HIV prevention in high HIV prevalence settings: what can mathematical modelling contribute to informed decision making? PLoS Med. 2009;6(9):1000109.CrossRefGoogle Scholar
  12. 12.
    Williams BG, Lloyd-Smith JO, Gouws E, et al. The potential impact of male circumcision on HIV in sub-Saharan Africa. PLoS Med. 2006;3(7):262.CrossRefGoogle Scholar
  13. 13.
    de Bruyn G, Martinson NA, Gray GE. Male circumcision for HIV prevention: developments from sub-Saharan Africa. Expert Rev Anti-infect Therapy. 2010;8(1):23–31.CrossRefGoogle Scholar
  14. 14.
    Hankins C, Forsythe S, Njeuhmeli E. Voluntary medical male circumcision: an introduction to the cost, impact, and challenges of accelerated scaling up. PLoS Med. 2011;8(11):1001127.CrossRefGoogle Scholar
  15. 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
  16. 16.
    Hogben M, Liddon N. Disinhibition and risk compensation: scope, definitions, and perspective. Sex Transm Dis. 2008;35(12):1009–10.PubMedGoogle Scholar
  17. 17.
    Cassell MM, Halperin DT, Shelton JD, Stanton D. Risk compensation: the Achilles’ heel of innovations in HIV prevention? BMJ (Clin Res Ed). 2006;332(7541):605–7.CrossRefGoogle Scholar
  18. 18.
    Kalichman S, Eaton L, Pinkerton S. Circumcision for HIV prevention: failure to fully account for behavioral risk compensation. PLoS Med. 2007;4(3):138.CrossRefGoogle Scholar
  19. 19.
    White RG, Glynn JR, Orroth KK, et al. Male circumcision for HIV prevention in sub-Saharan Africa: who, what and when? AIDS (Lond, Engl). 2008;22(14):1841–50.CrossRefGoogle Scholar
  20. 20.
    Alsallaq RA, Cash B, Weiss HA, et al. Quantitative assessment of the role of male circumcision in HIV epidemiology at the population level. Epidemics. 2009;1(3):139–52.PubMedCrossRefGoogle Scholar
  21. 21.
    Andersson KM, Owens DK, Paltiel AD. Scaling up circumcision programs in southern Africa: the potential impact of gender disparities and changes in condom use behaviors on heterosexual HIV transmission. AIDS Behav. 2011;15(5):938–48.PubMedCentralPubMedCrossRefGoogle Scholar
  22. 22.
    Dushoff J, Patocs A, Shi CF. Modeling the population-level effects of male circumcision as an HIV-preventive measure: a gendered perspective. PLoS One. 2011;6(12):28608.CrossRefGoogle Scholar
  23. 23.
    Hallett TB, Alsallaq RA, Baeten JM, et al. Will circumcision provide even more protection from HIV to women and men? New estimates of the population impact of circumcision interventions. Sex Transm Infect. 2011;87(2):88–93.PubMedCentralPubMedCrossRefGoogle Scholar
  24. 24.
    Hallett TB, Singh K, Smith JA, et al. Understanding the impact of male circumcision interventions on the spread of HIV in southern Africa. PLoS One. 2008;3(5):2212.CrossRefGoogle Scholar
  25. 25.
    Njeuhmeli E, Forsythe S, Reed J, et al. Voluntary medical male circumcision: modeling the impact and cost of expanding male circumcision for HIV prevention in eastern and southern Africa. PLoS Med. 2011;8(11):1001132.CrossRefGoogle Scholar
  26. 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
  27. 27.
    Kong X, Kigozi G, Nalugoda F, et al. Assessment of changes in risk behaviors during 3 years of posttrial follow-up of male circumcision trial participants uncircumcised at trial closure in Rakai, Uganda. Am J Epidemiol. 2012;176(10):875–85.PubMedCentralPubMedCrossRefGoogle Scholar
  28. 28.
    Mattson CL, Campbell RT, Bailey RC, et al. Risk compensation is not associated with male circumcision in Kisumu, Kenya: a multi-faceted assessment of men enrolled in a randomized controlled trial. PLoS One. 2008;3(6):2443.CrossRefGoogle Scholar
  29. 29.
    Gray R, Kigozi G, Kong X, et al. The effectiveness of male circumcision for HIV prevention and effects on risk behaviors in a posttrial follow-up study. AIDS (Lond, Engl). 2012;26(5):609–15.CrossRefGoogle Scholar
  30. 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. 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. 32.
    NACC and NASCOP. Kenya AIDS epidemic update 2011. Nairobi, Kenya: 2012.Google Scholar
  33. 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. 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
  35. 35.
    Westercamp M, Bailey RC, Bukusi EA, et al. Male circumcision in the general population of Kisumu, Kenya: beliefs about protection, risk behaviors, HIV, and STIs. PLoS One. 2010;5(12):15552.CrossRefGoogle Scholar
  36. 36.
    Hedeker D, Gibbons RD, Waternaux C. Sample size estimation for longitudinal designs with attrition: comparing time-related contrasts between two groups. J Educ Behav Stat. 1999;24(1):70–93.CrossRefGoogle Scholar
  37. 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. 38.
    SAS Institute Inc. SAS software. Version 9.1.3 ed. Cary, NC; 2008.Google Scholar
  39. 39.
    Kalichman SC, Eaton L, Pinkerton SD. Male circumcision in HIV prevention. Lancet. 2007;369(9573):1597.PubMedCrossRefGoogle Scholar
  40. 40.
    Mad rush to be circumcised. Standard, Kenya; 2008.Google Scholar
  41. 41.
    Milford C, Smit JA, Beksinska ME, Ramkissoon A. “There’s evidence that this really works and anything that works is good”: views on the introduction of medical male circumcision for HIV prevention in South Africa. AIDS Care. 2012;24(4):496–501.PubMedGoogle Scholar
  42. 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. 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
  44. 44.
    Bailey RC, Muga R, Poulussen R, Abicht H. The acceptability of male circumcision to reduce HIV infections in Nyanza Province, Kenya. AIDS Care. 2002;14(1):27–40.PubMedCrossRefGoogle Scholar
  45. 45.
    Kelly A, Kupul M, Fitzgerald L, et al. “Now we are in a different time; various bad diseases have come.” Understanding men’s acceptability of male circumcision for HIV prevention in a moderate prevalence setting. BMC Public Health. 2012;12:67.PubMedCentralPubMedCrossRefGoogle Scholar
  46. 46.
    Ngalande R, Levy J, Kapondo C, Bailey RC. Acceptability of male circumcision for prevention of HIV infection in Malawi. AIDS Behav. 2006;10(4):377–85.PubMedCrossRefGoogle Scholar
  47. 47.
    Rain-Taljaard RC, Lagarde E, Taljaard DJ, et al. Potential for an intervention based on male circumcision in a South African town with high levels of HIV infection. AIDS Care. 2003;15(3):315–27.PubMedCrossRefGoogle Scholar
  48. 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
  49. 49.
    Crosby RA, Ricks J, Young A. Condom migration resulting from circumcision, microbicides and vaccines: brief review and methodological considerations. Sex Health. 2012;9(1):96–102.PubMedCrossRefGoogle Scholar
  50. 50.
    Hankins C. Male circumcision: implications for women as sexual partners and parents. Reprod Health Matters. 2007;15(29):62–7.PubMedCrossRefGoogle Scholar
  51. 51.
    Riess TH, Achieng MM, Otieno S, Ndinya-Achola JO, Bailey RC. “When I was circumcised I was taught certain things”: risk compensation and protective sexual behavior among circumcised men in Kisumu, Kenya. PLoS One. 2010;5(8):12366.CrossRefGoogle Scholar
  52. 52.
    Agot KE, Ndinya-Achola JO, Kreiss JK, Weiss NS. Risk of HIV-1 in rural Kenya: a comparison of circumcised and uncircumcised men. Epidemiology. 2004;15(2):157–63.PubMedCrossRefGoogle Scholar
  53. 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. 54.
    National AIDS and STI Control Programme. Kenya AIDS Indicator Survey (KAIS) 2007: preliminary report. Nairobi: Ministry of Health; 2008.Google Scholar
  55. 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. 56.
    Festinger L. A theory of cognitive dissonance. Stanford, California: Stanford University Press; 1962.Google Scholar
  57. 57.
    Grund JM, Hennink MM. A qualitative study of sexual behavior change and risk compensation following adult male circumcision in urban Swaziland. AIDS Care. 2012;24(2):245–51.PubMedGoogle Scholar
  58. 58.
    Langhaug LF, Sherr L, Cowan FM. How to improve the validity of sexual behaviour reporting: systematic review of questionnaire delivery modes in developing countries. Trop Med Int Health (TM IH). 2010;15(3):362–81.CrossRefGoogle Scholar
  59. 59.
    Mensch BS, Hewett PC, Erulkar AS. The reporting of sensitive behavior by adolescents: a methodological experiment in Kenya. Demography. 2003;40(2):247–68.PubMedCrossRefGoogle Scholar
  60. 60.
    Phillips AE, Gomez GB, Boily MC, Garnett GP. A systematic review and meta-analysis of quantitative interviewing tools to investigate self-reported HIV and STI associated behaviours in low- and middle-income countries. Int J Epidemiol. 2010;39(6):1541–55.PubMedCrossRefGoogle Scholar
  61. 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

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Nelli Westercamp
    • 1
  • Kawango Agot
    • 2
  • Walter Jaoko
    • 3
  • Robert C. Bailey
    • 1
  1. 1.Division of Epidemiology and Biostatistics, School of Public HealthUniversity of Illinois at ChicagoChicagoUSA
  2. 2.Impact Research and Development OrganizationKisumuKenya
  3. 3.Department of Medical MicrobiologyUniversity of NairobiNairobiKenya

Personalised recommendations