Risk Compensation Is Not Associated with Male Circumcision in Kisumu, Kenya: A Multi-Faceted Assessment of Men Enrolled in a Randomized Controlled Trial

School of Public Health, University of Illinois at Chicago, Chicago, Illinois, United States of America.
PLoS ONE (Impact Factor: 3.23). 06/2008; 3(6):e2443. DOI: 10.1371/journal.pone.0002443
Source: PubMed


Three randomized controlled trials (RCTs) have confirmed that male circumcision (MC) significantly reduces acquisition of HIV-1 infection among men. The objective of this study was to perform a comprehensive, prospective evaluation of risk compensation, comparing circumcised versus uncircumcised controls in a sample of RCT participants.
Between March 2004 and September 2005, we systematically recruited men enrolled in a RCT of MC in Kenya. Detailed sexual histories were taken using a modified Timeline Followback approach at baseline, 6, and 12 months. Participants provided permission to obtain circumcision status and laboratory results from the RCT. We evaluated circumcised and uncircumcised men's sexual behavior using an 18-item risk propensity score and acquisition of incident infections of gonorrhea, chlamydia, and trichomoniasis. Of 1780 eligible RCT participants, 1319 enrolled (response rate = 74%). At the baseline RCT visit, men who enrolled in the sub-study reported the same sexual behaviors as men who did not. We found a significant reduction in sexual risk behavior among both circumcised and uncircumcised men from baseline to 6 (p<0.01) and 12 (p = 0.05) months post-enrollment. Longitudinal analyses indicated no statistically significant differences between sexual risk propensity scores or in incident infections of gonorrhea, chlamydia, and trichomoniasis between circumcised and uncircumcised men. These results are based on the most comprehensive analysis of risk compensation yet done.
In the context of a RCT, circumcision did not result in increased HIV risk behavior. Continued monitoring and evaluation of risk compensation associated with circumcision is needed as evidence supporting its' efficacy is disseminated and MC is widely promoted for HIV prevention.

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    • "Lack of understanding about partial efficacy could impact on risky sexual behavior, putting people at increased risk for HIV infection. Previous research shows varied levels of concern about behavioral disinhibition (Albert et al., 2011; De Bruyn et al., 2010; Herman-Roloff et al., 2011; Milford et al., 2012), but less evidence of its occurrence (Ayiga and Letamo, 2011; Mattson et al., 2008; Maughan-Brown and Venkataramani, 2012). Despite the limited evidence of overall increased risk behavior in clinical trial situations, and limited studies of this behavior outside of these conditions, behavioral disinhibition in even a small number of individuals might put these individuals and their partners at increased risk of HIV infection. "
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    ABSTRACT: Medical male circumcision has been shown to reduce HIV transmission to an uninfected male partner. In South Africa, medical male circumcision programs were rolled-out in 2010. Prior to roll-out, we explored healthcare providers' knowledge, attitudes and practices about medical male circumcision and their understandings of partial efficacy for HIV prevention. We conducted qualitative research, using in-depth interviews. Participants were from three rural and three urban primary healthcare clinics, randomly selected in eThekwini District, KwaZulu-Natal. 25 healthcare providers (including nurse managers, nurses and counselors) were purposively selected from the clinics. In-depth interviews were recorded, transcribed and translated. Independent researchers reviewed the transcripts and developed a codebook based on emergent themes, using thematic analysis. NVivo 8 was used to facilitate data management, coding and analysis. Although most providers had heard that medical male circumcision can reduce risk of HIV acquisition in men, most did not have accurate scientific understandings of this. Some providers had misperceptions about the limited/partial protection medical male circumcision offers. Many had concerns that their communities would misunderstand it, causing increased risky sexual behavior. These data provide a baseline of providers' understandings of medical male circumcision prior to roll-out, and can be used to compare current data and ensure accurate messaging to clients. Healthcare provider messaging should build client understandings of the meaning of partially efficacious technologies. Copyright © 2015 Elsevier Ltd. All rights reserved.
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    • "[20] A trial of male circumcision found a higher number of sexual partners and contacts in the circumcised group compared with the control group, [21] although risk behavior in both groups was lower during the study than at baseline. There was no difference in risk behaviors between study arms in another two trials of male circumcision, [22], [23] with one of those studies finding no evidence of risk compensation during three years of post-trial follow-up. [24] There was no increase in risk behaviors in an HIV vaccine efficacy trial, [25] and overall decreases in risk behavior in two longitudinal studies of post-exposure prophylaxis (PEP). "
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    ABSTRACT: Preexposure prophylaxis (PrEP) with emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) reduced HIV acquisition in the iPrEx trial among men who have sex with men and transgender women. Self-reported sexual risk behavior decreased overall, but may be affected by reporting bias. We evaluated potential risk compensation using biomarkers of sexual risk behavior. Sexual practices were assessed at baseline and quarterly thereafter; perceived treatment assignment and PrEP efficacy beliefs were assessed at 12 weeks. Among participants with ≥1 follow-up behavioral assessment, sexual behavior, syphilis, and HIV infection were compared by perceived treatment assignment, actual treatment assignment, and perceived PrEP efficacy. Overall, acute HIV infection and syphilis decreased during follow-up. Compared with participants believing they were receiving placebo, participants believing they were receiving FTC/TDF reported more receptive anal intercourse partners prior to initiating drug (12.8 vs. 7.7, P = 0.04). Belief in receiving FTC/TDF was not associated with an increase in receptive anal intercourse with no condom (ncRAI) from baseline through follow-up (risk ratio [RR] 0.9, 95% confidence interval [CI]: 0.6-1.4; P = 0.75), nor with a decrease after stopping study drug (RR 0.8, 95% CI: 0.5-1.3; P = 0.46). In the placebo arm, there were trends toward lower HIV incidence among participants believing they were receiving FTC/TDF (incidence rate ratio [IRR] 0.8, 95% CI: 0.4-1.8; P = 0.26) and also believing it was highly effective (IRR 0.5, 95% CI: 0.1-1.7; P = 0.12). There was no evidence of sexual risk compensation in iPrEx. Participants believing they were receiving FTC/TDF had more partners prior to initiating drug, suggesting that risk behavior was not a consequence of PrEP use.
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    • "For example, if circumcised men have more sexual partners or reduce condom usage, or if women are more willing to have unprotected sex with circumcised men because they believe they are at less risk of disease, the protective effects of male circumcision could be offset [18]. Little risk compensation has been observed among men during the three RCTs in South Africa, Uganda and Kenya [1–3,19,20]. However, intensive behavioral counseling, along with free and unlimited provision of condoms, may have contributed to a decrease in risk behaviors among all trial participants which may not be applicable to programmatic settings. "
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    ABSTRACT: While male circumcision reduces the risk of female-to-male HIV transmission and certain sexually transmitted infections (STIs), there is little evidence that circumcision provides women with direct protection against HIV. This study used qualitative methods to assess women's perceptions of male circumcision in Iringa, Tanzania. Women in this study had strong preferences for circumcised men because of the low risk perception of HIV with circumcised men, social norms favoring circumcised men, and perceived increased sexual desirability of circumcised men. The health benefits of male circumcision were generally overstated; many respondents falsely believed that women are also directly protected against HIV and that the risk of all STIs is greatly reduced or eliminated in circumcised men. Efforts to engage women about the risks and limitations of male circumcision, in addition to the benefits, should be expanded so that women can accurately assess their risk of HIV or STIs during sexual intercourse with circumcised men.
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