Abstract
ObjectivesWe examined whether knowledge of the HIV-protective benefits of male circumcision (MC) led to risk compensating behavior in a traditionally circumcising population in South Africa. We extend the current literature by examining risk compensation among women, which has hitherto been unexplored.MethodsWe used data on Xhosa men and women from the 2009 Cape Area Panel Study. Respondents were asked if they had heard that MC reduces a man’s risk of contracting HIV, about their perceived risk of contracting HIV, and condom use. For each gender group we assessed whether risk perception and condom use differed by knowledge of the protective benefits of MC using bivariate and then multivariate models controlling for demographic characteristics, HIV knowledge/beliefs, and previous sexual behaviors. In a further check for confounding, we used data from the 2005 wave to assess whether individuals who would eventually become informed about the protective benefits of circumcision were already different in terms of HIV risk perception and condom use.Results34% of men (n = 453) and 27% of women (n = 690) had heard that circumcision reduces a man’s risk of HIV infection. Informed men perceived slightly higher risk of contracting HIV and were more likely to use condoms at last sex (p<0.10). Informed women perceived lower HIV risk (p<0.05), were less likely to use condoms both at last sex (p<0.10) and more generally (p<0.01), and more likely to forego condoms with partners of positive or unknown serostatus (p<0.01). The results were robust to covariate adjustment, excluding people living with HIV, and accounting for risk perceptions and condom use in 2005.ConclusionsWe find evidence consistent with risk compensation among women but not men. Further attention should be paid to the role of new information regarding MC, and drivers of HIV risk more broadly, in modulating sexual behavior among women.
Highlights
Randomized clinical trials (RCTs) have shown that medical male circumcision substantially reduces the risk of contracting HIV [1,2,3,4], leading many countries to adopt large-scale male circumcision (MC) campaigns as a strategy to prevent heterosexually acquired HIV infection in men [5]
The effects of risk compensation on the basis of new information about the protective benefits of MC may be even larger in traditionally circumcising populations, where a non-trivial proportion of circumcisions result in incomplete foreskin removal, thereby reducing the HIV-protective benefits of the practice [8], and where circumcisions are generally not packaged with risk reduction counseling
Of the three MC clinical trials, only the South African study showed any change in sexual behavior, with an increase in the number of sexual acts among circumcised men; there were no significant changes in unprotected sex or number of sexual partners [1]
Summary
Randomized clinical trials (RCTs) have shown that medical male circumcision substantially reduces the risk of contracting HIV [1,2,3,4], leading many countries to adopt large-scale male circumcision (MC) campaigns as a strategy to prevent heterosexually acquired HIV infection in men [5]. While the discrepancy between the observational and experimental evidence could be due to failure to account for heterogeneity in circumcision practices in the former [8], another mechanism that could generate this pattern is risk compensation [9] That is, those benefitting from MC may reduce protective behaviors such as using condoms because of lower perceived risks of acquiring HIV [10]. Of the three MC clinical trials, only the South African study showed any change in sexual behavior, with an increase in the number of sexual acts among circumcised men; there were no significant changes in unprotected sex or number of sexual partners [1] These studies did not inform participants about the relationship between MC and HIV, and individuals were not asked about their beliefs regarding this. Participants received intensive HIV risk reduction education, which is unlikely to be replicated to that degree by medical MC services
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