Medical male circumcision and risk compensation – Authors' reply
Authors: David Musoke Serwadda, Godfrey Kigozi
Journal: The Lancet Global Health (2021)

An extensive meta-analysis by Gao and colleagues1Gao 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; 9: e932-e941Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar showed that, overall, there is no association between medical male circumcision (MMC) and increased risk of sexual behaviour. In response to our Comment on this Article,2Serwadda DM Kigozi G Does medical male circumcision result in sexual risk compensation in Africa?.Lancet Glob Health. 2021; 9: e883-e884Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar Fish and colleagues3Fish M Shahvisi A Gwaambuka T Tangwa GB Earp BD Medical male circumcision and risk compensation.Lancet Glob Health. 2021; 9e1368Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar have taken exception to our conclusion that such findings “refute the alleged associations between MMC and risk compensation”. The evidence suggests that, in aggregate, there is no evidence of net risk compensation after MMC; however, this does not exclude the possibility of individual risk compensation behaviours. The Article by Gao and colleagues1Gao 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; 9: e932-e941Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar rightfully recognised both positive and negative findings on risk compensation from different studies and cautioned readers to carefully interpret the findings. The meta-analysis specifically emphasises “the need to strengthen risk reduction education, especially for specific groups, including those with lower education, married men, and men with alcoholism.” Ongoing studies and programmes are identifying groups that need special attention to mitigate risk compensation. These groups can then be targeted with appropriate education and mobilisation messages.We agree with Fish and colleagues3Fish M Shahvisi A Gwaambuka T Tangwa GB Earp BD Medical male circumcision and risk compensation.Lancet Glob Health. 2021; 9e1368Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar on the need for investigations and programme evaluation to identify contextual factors that might lead to risk compensation in different communities. However, the observed overall magnitude of risk compensation from the pooled analysis does not justify stopping or curtailing MMC programmes, given that the pooled analyses showed no evidence of significant risk compensation for condom use and multiple sex partners in all subcategories analysed. The MMC programmes have been shown to reduce HIV incidence in men in randomised controlled trials and observational studies, suggesting that any risk compensation does not offset the benefit of HIV prevention. We believe that voluntary MMC programmes need to engage with the local communities, including cultural, religious, political, and other opinion leaders, to mitigate risk compensation. In this regard, we agree with Fish and colleagues3Fish M Shahvisi A Gwaambuka T Tangwa GB Earp BD Medical male circumcision and risk compensation.Lancet Glob Health. 2021; 9e1368Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar that there is a need for attention to local cultural variance and other contextual issues. 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 AccessMedical male circumcision and risk compensation14 years into the medical male circumcision (MMC) campaign for HIV prevention in sub-Saharan Africa, questions about scaling up remain. Researchers have reported evidence of increased sexual risk behaviours among a subset of men in some communities, possibly due to a false sense of security against HIV transmission from MMC. Other studies, involving different samples, assumptions, or measurements, have not found evidence of such risk compensation. Serwadda and Kigozi1 acknowledge this heterogeneity and highlight a meta-analysis that found no overall association between MMC and risky sexual behaviour. Full-Text PDF Open Access