Exploring the Relationship between Male Circumcision and Sexual Risk Compensation in Kisumu, Kenya

Three randomized controlled trials (RCT) and more than 40 observational studies have shown that male circumcision (MC) reduces sexual transmission of human immunodeficiency virus (HIV) from women to men by approximately 60%. Following the publication of the results from the three RCTs the World Health Organization recommended that voluntary medical male circumcision (VMMC) be part of a comprehensive HIV prevention package. Related to the promotion of MC there has been concern that men and women would engage in sexual risk compensation, by halting or decreasing previous HIV prevention efforts, due to a man’s circumcision status. Risk compensation at significant levels could undermine the effectiveness of MC. We conducted a qualitative study among the Luo, an ethnic group that does not traditionally circumcise, in Kisumu, Kenya, to explore the relationship between MC and sexual risk compensation. Focus group discussions (N=5) and in-depth individual interviews (N=70) were carried out with circumcised men, uncircumcised men, and women. A secondary objective was to examine perceptions of MC in relation to Luo MC norms. A majority of circumcised male respondents reported either no behavior change or increased protective sexual behaviors, including increasing condom use and reducing the number of sexual partners. A minority of men reported engaging in higher-risk behaviors, either not using condoms or increasing the number of sex partners. Women indicated that they care about men’s circumcision status and that it is a relevant factor in partner selection and condom use. Female respondents perceived circumcised men as cleaner, carrying fewer diseases and having greater sexual prowess. Results indicate that communities such as the Luo, which do not traditionally practice MC, will support VMMC programs, particularly when faced with a significant HIV epidemic. Knowledge of the health benefits of MC increased support and acceptance. Male circumcision accompanied by HIV testing and counseling fosters positive behavior change and maintains sexual behavior and should be provided to mitigate risk compensation. A better understanding of MC’s HIV prevention benefits, counseling and testing, women’s perceptions, and Luo MC norms influenced sexual behavior, demand creation, acceptance, and uptake of MC.