Male circumcision for HIV prevention in sub-Saharan Africa: who, what and when?

Abstract

Circumcision is a cost-saving intervention in a wide range of scenarios of HIV and initial circumcision prevalence but the United Nations Joint Programme on HIV/AIDS/WHO recommended target age group should be widened to include older HIV-uninfected men and counselling should be targeted at both newly and already circumcised men to minimize risk compensation. To maximize infections-averted, circumcision must be scaled up rapidly while maintaining quality.

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

“…At the community level, MC acceptability and feasibility studies often noted that concerns of risk compensation-expressed as the fear that circumcision will lead to sexual promiscuity, adultery, and decrease gains in condom use-could act as a barrier to community acceptance of the intervention [44][45][46][47]. The results of our study are not consistent with these concerns or with assumptions of moderate to high risk compensation used in the modeling studies projecting the long-term effect of VMMC on HIV at the population level [9,10,19,24,25,48]. Our results do strongly support previous empirical findings of a lack of risk compensation, including research done as part of the MC RCTs [1][2][3], in detailed behavioral evaluation of trial participant subgroups [28], in extended trial follow-up [27], and in a non-randomized study before trial conclusion [26].…”

“…Risk compensation could significantly reduce the impact of VMMC programs [17,18] and, if of sufficient magnitude, has the potential to completely negate the protective effect of circumcision against HIV [19]. Research designed to monitor post-circumcision risk compensation over time, in the context of active promotion of VMMC as an HIV prevention strategy, has been set as a high priority [5,19].…”

“…Research designed to monitor post-circumcision risk compensation over time, in the context of active promotion of VMMC as an HIV prevention strategy, has been set as a high priority [5,19]. This is the first study to examine longitudinal change in HIV-associated risk behaviors in men before and after circumcision in the context of a large population-level VMMC program.…”

“…This behavioral reduction in risk was noted in all sexual risk behaviors examined, including increased condom use. The only behavior that showed an increase over time was sexual activity in the past 6 months, largely driven by the youngest age group (18)(19)(20)(21)(22)(23)(24) that had similar increases in both circumcised and uncircumcised men.…”

“…Risk compensation is an important possible mechanism that could negatively impact the effectiveness of VMMC programs [17,18]. If operating, risk compensation could reduce the protective effect of circumcision against HIV and, if of sufficient magnitude, completely negate the protection [19]. Epidemiological modeling studies suggest that, at the population level, only extreme levels of increased risk behavior will offset the protection offered by circumcision to men [6,9,10,[19][20][21][22][23][24][25]; however, only moderate levels of risk compensation in men could result in increased HIV risk for women, especially in the short term [20][21][22]24].…”