Evidence that promotion of male circumcision did not lead to sexual risk compensation in prioritized Sub-Saharan countries

Abstract

BackgroundWHO and UNAIDS prioritized 14 eastern and southern African countries with high HIV and low male circumcision prevalence for a voluntary medical male circumcision (VMMC) scale-up in 2007. Because circumcision provides only partial protection against HIV infection to men, the issue of possible risk compensation in response to VMMC campaigns is of particular concern. In this study, we looked at population-level survey data from the countries prioritized by WHO for a VMMC scale-up. We compared the difference in sexual risk behaviours (SRB) between circumcised and uncircumcised men before and after the WHO’s official VMMC promotion.Materials and methodsTen countries (Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, Tanzania, Uganda, Zambia and Zimbabwe) participating in the WHO’s VMMC scale-up had available data from the Demographic and Health Surveys (DHS). We used cumulative-link mixed models to investigate interactions between survey period and circumcision status in predicting SRB, in order to evaluate whether the difference between the behavior of the two groups changed before and after the scale-up, while controlling for socio-demographic and knowledge-related covariates. The main responses were condom use at last sex and number of non-cohabiting sexual partners, both in the last 12 months.ResultsThere was little change in condom use by circumcised men relative to uncircumcised men from before the VMMC scale up to after the scale up. The relative odds ratio is 1.06 (95% CI, 0.95–1.18; interaction P = 0.310). Similarly, there was little change in the number of non-cohabiting partners in circumcised men (relative to uncircumcised men): the relative odds ratio of increasing the number of partners is 0.95 (95% CI, 0.86–1.05; interaction P = 0.319). Age, religion, education, job, marital status, media use and HIV knowledge also showed statistically significant association with the studied risk behaviours. We also found significant differences among countries, while controlling for covariates.ConclusionsOverall, we find no evidence of sexual risk compensation in response to VMMC campaigns in countries prioritized by WHO. Changes in relative partner behaviour and the relative odds of condom use were small (and of uncertain sign). In fact, our estimates, though not significant, both suggest slightly less risky behavior. We conclude that sexual risk compensation in response to VMMC campaigns has not been a serious problem to date, but urge continued attention to local context, and to promulgating accurate messages about circumcision within and beyond the VMMC context.

Prevalence and covariates of human immunodeficiency virus (HIV) risk behaviours among circumcised and uncircumcised men in Botswana: A national cross sectional study

“…Circumcised men were less likely to have not used condoms consistently compared to men who were uncircumcised. This is not consistent with findings from other studies (Kibira et al, 2016;Shi et al, 2017) which have revealed that circumcision often gives circumcised men more freedom to have unprotected sex and in some instances to have many sexual partners. Decline in condom use is the most consistently expressed concern regarding male circumcision promotion and uptake, although our findings show the contrary.…”

“…There is evidence on the efficacy of safe male circumcision in reducing risk of HIV infection among heterosexual men which has resulted in increased demand for male circumcision services in many African countries (Letamo, 2011;Shi et al, 2017).…”

Service delivery interventions to increase uptake of voluntary medical male circumcision for HIV prevention: A systematic review

“…While these measures are a potential measure of service quality, this is also challenging, as individual clients may opt-out of these services, and 100% uptake on either of these measures might indicate coercive or nonoptional uptake. Further, despite the lack of studies quantifying uptake of counseling during VMMC, relationships between VMMC, counseling, and risk compensation have been assessed substantially in the literature; evidence indicates that VMMC leads to little or no risk compensation in sub-Saharan Africa [54][55][56][57][58][59][60].…”

Voluntary Medical Male Circumcision and Sexual Practices among Sexually Active Circumcised Men in Mzuzu, Malawi: A Cross-Sectional Study

“…These findings may be attributed to the place of study; being urban location, most of those aged 18 -29 are either students or dependents who are being cared for and the income they generate is mostly spent on social life (alcohol, night clubs) that may expose them to paid sex. A study across the VMMC prioritized countries in the Sub Saharan region showed that age, religion, education, job and marital status were significant with risky sexual practices [36].…”

“…(Table 7) On transactional sex, age, marital status, location and occupation were significantly associated with engaging in transaction sex. The odds of being involved in transactional sex among those aged [30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49] was 81% less compared to those aged 18-29 (OR 0.19, 95% CI 0.09, 0.37 p <0.0001). The odds of being involved in transaction sex among the married ones was 88% less compared to those that were single (OR 0.12, 95% CI 0.07, 0.22 p <0.0001).…”