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

Abstract

Background: WHO 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 methods: Ten 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.

Results: There 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.

Conclusions: Overall, 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.

Fig 1. The effect of circumcision status on condom use at last sex before and after the WHO’s VMMC scale-up campaign.

The relative odds ratio is higher by a factor of 1.06 than the corresponding odds ratio (95% CI, 0.95–1.18; interaction P = 0.310). Groups are offset horizontally for readability.

Fig 2. The effect of circumcision status on number of non-cohabiting partners before and after the WHO’s VMMC scale-up campaign.

The relative odds ratio of a circumcised man taking an extra sexual partner in the later period is 0.95 (95% CI, 0.86–1.05; interaction P = 0.319).

Fig 3. The effect of covariates on condom use at last sex.

Solid lines and dash lines show the effect and 95% prediction interval for continuous covariates. Solid points and vertical solid lines show the effect and 95% prediction interval for discrete covariates. Variable-level P values are included for each covariate.

Fig 4. The effect of covariates on reported non-cohabiting partners in the previous year.

See Fig 3 for details.