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.
Similar content being viewed by others
References
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Hogben M, Liddon N. Disinhibition and risk compensation: scope, definitions, and perspective. Sex Transm Dis. 2008;35(12):1009–10.
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.
Kalichman S, Eaton L, Pinkerton S. Circumcision for HIV prevention: failure to fully account for behavioral risk compensation. PLoS Med. 2007;4(3):138.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
NACC and NASCOP. Kenya AIDS epidemic update 2011. Nairobi, Kenya: 2012.
Progress in voluntary medical male circumcision service provision. Kenya, 2008–2011. MMWR Morb Mortal Wkly Rep. 2012;61(47):957–61.
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.
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.
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.
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.
SAS Institute Inc. SAS software. Version 9.1.3 ed. Cary, NC; 2008.
Kalichman SC, Eaton L, Pinkerton SD. Male circumcision in HIV prevention. Lancet. 2007;369(9573):1597.
Mad rush to be circumcised. Standard, Kenya; 2008.
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.
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.
AIDS Vaccine Advocacy Coalition. A new way to protect against HIV? Understanding the results of male circumcision studies for HIV prevention. NewYork: AVAC; 2007.
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.
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.
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.
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.
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.
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.
Hankins C. Male circumcision: implications for women as sexual partners and parents. Reprod Health Matters. 2007;15(29):62–7.
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.
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.
Republic of Kenya Ministry of Public Health & Sanitation. National strategy for voluntary medical male circumcision. National AIDS & STD Control Programme (NASCOP), Nairobi; 2009.
National AIDS and STI Control Programme. Kenya AIDS Indicator Survey (KAIS) 2007: preliminary report. Nairobi: Ministry of Health; 2008.
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.
Festinger L. A theory of cognitive dissonance. Stanford, California: Stanford University Press; 1962.
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.
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.
Mensch BS, Hewett PC, Erulkar AS. The reporting of sensitive behavior by adolescents: a methodological experiment in Kenya. Demography. 2003;40(2):247–68.
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.
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.
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.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Westercamp, N., Agot, K., Jaoko, W. et al. Risk Compensation Following Male Circumcision: Results from a Two-Year Prospective Cohort Study of Recently Circumcised and Uncircumcised Men in Nyanza Province, Kenya. AIDS Behav 18, 1764–1775 (2014). https://doi.org/10.1007/s10461-014-0846-4
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10461-014-0846-4