Does medical male circumcision result in sexual risk compensation in Africa?
Authors: David Musoke Serwadda, Godfrey Kigozi
Journal: The Lancet Global Health (2021)

In 2007, WHO and UNAIDS officially added medical male circumcision (MMC) as a major component of the combination HIV prevention intervention, following results of three randomised trials in Africa that evaluated the efficacy of MMC for HIV prevention in men.1Auvert B Taljaard D Lagarde E Sobngwi-Tambekou J Sitta R Puren A Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial.PLoS Med. 2005; 2: e298Crossref PubMed Scopus (1748) Google Scholar, 2Bailey 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: 643-656Summary Full Text Full Text PDF PubMed Scopus (1661) Google Scholar, 3Gray RH Kigozi G Serwadda D et al.Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial.Lancet. 2007; 369: 657-666Summary Full Text Full Text PDF PubMed Scopus (1647) Google Scholar This approach has greatly contributed to HIV incidence reduction in men in both agrarian and high-risk communities in Africa.4Grabowski MK Serwadda DM Gray RH et al.HIV prevention efforts and incidence of HIV in Uganda.N Engl J Med. 2017; 377: 2154-2166Crossref PubMed Scopus (80) Google Scholar, 5Kagaayi J Batte J Nakawooya H et al.Uptake and retention on HIV pre-exposure prophylaxis among key and priority populations in South-Central Uganda.J Int AIDS Soc. 2020; 23e25588Crossref PubMed Scopus (5) Google Scholar A longitudinal study of the general population in Rakai District, Uganda, assessed the effect of combination prevention on HIV acquisition between 2011 and 2016, finding a 48% decline of HIV incidence after combination HIV prevention had been introduced. However, the decline observed in circumcised men was significantly greater (57%) than in uncircumcised men (49%).4Grabowski MK Serwadda DM Gray RH et al.HIV prevention efforts and incidence of HIV in Uganda.N Engl J Med. 2017; 377: 2154-2166Crossref PubMed Scopus (80) Google Scholar Similar patterns of decline in circumcised and uncircumcised men following combination HIV prevention were observed in HIV hyperendemic communities along Lake Victoria, in Uganda.5Kagaayi J Batte J Nakawooya H et al.Uptake and retention on HIV pre-exposure prophylaxis among key and priority populations in South-Central Uganda.J Int AIDS Soc. 2020; 23e25588Crossref PubMed Scopus (5) Google Scholar Despite the growing evidence for the effectiveness of MMC in reducing HIV acquisition, there are advocacy groups, researchers, religious groups, and policy makers who have resisted the promotion of MMC programmes in Africa. This resistance has had adverse effects on the expansion and uptake of circumcision programmes in some African countries. One of the main concerns from these groups is that circumcision could prompt HIV risk compensation, whereby circumcised men believe themselves to be protected from HIV infection and thus increase risky sexual behaviours; there are studies that appear to support this view.6Fish M Shahvisi A Gwaambuka T Tangwa GB Ncayiyana D Earp BD A new Tuskegee? Unethical human experimentation and Western neocolonialism in the mass circumcision of African men.Dev World Bioeth. 2020; (published online Sept 9.)https://doi.org/10.1016/S0140-6736(07)60313-4Crossref PubMed Scopus (5) Google Scholar A review of some of these studies by Morris and colleagues found evidence of bias in most of them,7Morris BJ Moreton S Krieger JN Critical evaluation of arguments opposing male circumcision: a systematic review.J Evid Based Med. 2019; 12: 263-290Crossref PubMed Scopus (10) Google Scholar and highlighted the need for well-designed longitudinal studies in Africa to better examine this theory. Several studies have been published since 2007 that suggest a lack of HIV behavioural disinhibition following circumcision, but many of these studies had small samples or other methodological concerns. In this issue of The Lancet Global Health, Yanxiao Gao and colleagues report findings from a meta-analysis that included 27 cohort studies, randomised controlled trials, cross-sectional studies, and case control studies.8Gao Y Yuan T Zhan Y et al.Association between medical male circumcision and HIV risk compensation among heterosexual men: a systematic review and meta-analysis.Lancet Glob Health. 2021; (published online April 30.)https://doi.org/10.1016/S2214-109X(21)00102-9Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar Their findings validate those from an earlier meta-analysis that included five cohort studies and randomised controlled trials that showed no significant association between MMC and reduction in consistent condom use.9Kabwama SN Ssewanyana D Berg-Beckhoff G The association between male circumcision and condom use behavior - a meta-analysis.Mater Sociomed. 2018; 30: 62-66Crossref PubMed Google Scholar The current meta-analysis further assessed the association between MMC and multiple sexual partners and found no significant associations between the two. The weight of the evidence suggests that MMC does not lead to sexual risk compensation. These findings are of public health importance in that they refute the alleged associations between MMC and risk compensation. The findings will guide policy makers and encourage the development of MMC service programmes without unwarranted fear of risk compensation, while continuing to support health education before and after circumcision to ensure compliance with postoperative guidelines. Despite these findings, a few issues still need to be addressed in future studies. The authors categorised condom use into two categories: consistent use, and no use or inconsistent use. This categorisation needs to be refined given the fact that men tend not to use condoms with their marital or regular partners but are more likely to consistently use condoms with non-marital or casual partners.10de Walque D Kline R Variations in condom use by type of partner in 13 sub-Saharan African countries.Stud Fam Plann. 2011; 42: 1-10Crossref PubMed Scopus (26) Google Scholar We have observed a trend of decreasing age at circumcision in many circumcision programmes in Africa. Most current MMC programmes are mainly providing MMC to adolescents aged 15–18 years, primarily due to saturation of MMC in older men willing to take up the service. This trend might affect analyses of sexual risk compensation since adolescent boys are less likely to have had their sexual debut and hence to use condoms or have multiple partners. If this group is over-represented, the effect of MMC on sexual risk compensation might be missed or diluted. Since many boys are now circumcised before they initiate sexual activity, there is a need to examine the association between MMC and sexual initiation, condom use, and multiple partners following circumcision, focusing on those who were circumcised before their sexual debut. In summary, this meta-analysis evaluating the largest number of prospective studies thus far showed no significant association between MMC and condomless sex or MMC and multiple sexual partners in all subgroup analyses. These findings are reassuring and should serve as a strong reason to redouble our efforts to promote and expand circumcision programmes, particularly in specific populations or regions that have up to now been resistant to do so due to reservations about sexual risk compensation. We declare no competing interests. Association between medical male circumcision and HIV risk compensation among heterosexual men: a systematic review and meta-analysisThe promotion of circumcision as an HIV preventive measure does not appear to increase higher-risk sexual behaviours in heterosexual men. Ongoing sexual health education should be maintained as a vital component of effective MMC programmes. Full-Text PDF Open Access