Circumcision for HIV Prevention: Failure to Fully Account for Behavioral Risk Compensation

PLoS Medicine, Volume 4, Issue 3: Page e138, March 2007.

Urinary Retention, Erectile Dysfunction and Penile Anaesthesia After Circumcision: A Mixed Dissociative (conversion) Disorder

Seth Kalichman, Lisa Eaton, Steven Pinkerton

Three randomized controlled trials (RCTs) of male circumcision (MC) have been halted when interim analyses showed signi. cant reductions in HIV infection among men who received this intervention1–3. Modeling suggests that increased MC coverage in southern Africa could prevent as many as 2 million HIV infections over ten years4. Moreover, the cost-effectiveness analysis by Kahn et al. recently published in PLoS Medicine indicates that MC could be cost-saving5. However, the protection of MC may be partially offset by increased HIV risk behavior, or risk compensation, especially reduction in condom use or increases in numbers of sex partners. Risk compensation occurs when individuals adjust their behavior in response to perceived changes in their vulnerability to a disease6. Risk compensation may be especially important for MC because avoiding the sexual dissatisfactions of condom use and the desire to have more sex partners are likely to be significant motivations for men to seek circumcision7. In South Africa, 73% of men between the ages of 15 and 24 report using condoms during the last time they had sex8. It is dif. cult to imagine a convincing public health message that effectively in. uences men to undergo circumcision and continue to consistently use condoms.

Circumcised men in the ANRS 1265 trial reported 18% more sexual contacts at follow-up than did uncircumcised men, but no other sexual behavior differences were obtained1. However, for ethical reasons all men in MC RCTs receive ongoing risk-reduction counseling and free condoms, which reduces the utility of these trials for estimating the potential behavioral impact of MC when implemented in a natural setting. One model of the potential impact of MC did not take into account risk compensation4, but noted that increases in risk-taking behaviour among circumcised men could reduce the bene. t of MC. Based on the 18% difference in sexual contacts for circumcised and uncircumcised men in the ANRS 1265 trial and the assumption that risk compensation might be higher in a nonresearch program scale-up, Kahn et al.5 adjusted the 60% effectiveness estimate obtained in this RCT downward to 50% to re. ect a 25% increase in sexual risk behaviors among circumcised men. Although Kahn et al.s model explicitly incorporated the increased risk of HIV acquisition associated with risk compensation, it did not consider the impact of risk compensation on the HIV transmission risk of HIV-infected circumcised men, or on circumcised mens risk for non-HIV sexually transmitted infections (STIs).

There is no evidence that circumcision increases or decreases the risk of HIV transmission by HIV-infected men. However, risk compensation by HIV-infected circumcised men will substantially increase the risk of transmission to their sex partners. This suggests that, in the short term at least, circumcision would reduce the incidence of HIV among men, but increase the incidence among women, translating to increased prevalence among women, which in turn translates to greater risk to men. Epidemiological models of MC should take this dynamic into account.

Countless studies have shown that ulcerative and nonulcerative STIs account for at least some of the rapid increases in HIV transmission in southern Africa9. Non-HIV STIs are associated with a 2- to 5-fold increase in HIV transmission risk in countries with low and high rates of MC9. In areas with prevalent STIs, the relative increase in mens STI-associated HIV risk can be as high as 60% to 340%10. Circumcision likely reduces the risk of acquiring a non-HIV STI and may be partially responsible for the decreased HIV risk observed in circumcision RCTs1. Nevertheless, the failure of models to account for increased STI risk due to risk compensation likely inflates estimates of averted HIV infections. Estimates of HIV risks resulting from increased exposure to STIs that coincide with reductions in condom use have been included in previous models of the cost-effectiveness of HIV prevention interventions11 and should be included in MC models.

Seth Kalichman (E-Mail seth.kalichman@uconn.edu)

Lisa Eaton, External link University of Connecticut, Storrs, Connecticut, United States of America

Steven Pinkerton, External link Center for AIDS Intervention Research, Milwaukee, Wisconsin, United States of America

References

  1. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, et al. (2005) Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 Trial. PLoS Med 2: e298. doi:10.1371/journal.pmed.0020298 [External link Full Text]
  2. Bailey RC, Moses S, Parker C, Agot K, Maclean I, et al. (2007) Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomized controlled trial. Lancet 369: 643–656. [External link PubMed]
  3. Gray RH, Kigozi G, Serwadda D, Makumbi F, Watya S, et al. (2007) Male circumcision for HIV prevention in Rakai, Uganda: A randomized trial. Lancet 369: 657–666. [External link PubMed]
  4. Williams BG, Lloyd-Smith JO, Gouws E, Hankins C, Getz WM, et al. (2006) The potential impact of male circumcision on HIV in Sub-Saharan Africa. PLoS Med 3: e262. doi:10.1371/journal.pmed.0030262
  5. Kahn JG, Marseille E, Auvert B (2006) Cost-effectiveness of male circumcision for HIV prevention in a South African setting. PLoS Med 3: e517. doi:10.1371/journal. pmed.0030517 [External link Full Text]
  6. Pinkerton SD (2001) Sexual risk compensation and HIV/STD transmission: Empirical evidence and theoretical considerations. Risk Analysis 21: 727–736. [External link Abstract]
  7. Westercamp N, Bailey RC (2006) Acceptability of male circumcision for prevention of HIV/AIDS in sub-Saharan Africa: A review. AIDS Behav. Epub 20 October 2006. doi: 10.1007/s10461-006-9169-4 [External link PubMed]
  8. Shisana O, Rehle T, Simbayi L, Parker W, Bhana A, et al. (2005) South African national HIV prevalence, incidence, behaviour and communication survey 2005. Cape Town: Human Sciences Research Council Press
  9. Fleming DT, Wasserheit JN (1999) >From epidemiological synergy to public health policy and practice: The contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Trans Infect 75: 3–17. [External link Abstract]
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  11. Chesson HW, Pinkerton SD (2000) Sexually transmitted diseases and the increased risk for HIV transmission: Implications for cost-effectiveness analyses of sexually transmitted disease prevention interventions. J Acquir Immune Defic Syndr 24: 48–55. [External link Abstract]

Citation: Kalichman S, Eaton L, Pinkerton S (2007) Circumcision for HIV prevention: Failure to fully account for behavioral risk compensation. PLoS Med 4(3): e138. doi:10.1371/journal.pmed.0040138

Copyright: © 2007 Kalichman et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: Preparation of this article was supported by the National Institute of Mental Health grant R01 MH71164.

Competing Interests: The authors have declared that no competing interests exist.

Citation:

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