Sexual Behavior, Health, And Medical Male Circumcision In Nyanza Province, Kenya

Three randomized controlled trials (RCT) in Africa have demonstrated the efficacy of male circumcision (MC) in reducing the risk of female-to-male HIV transmission by approximately 60%. Following these results, the United Nations Joint Programme on HIV/AIDS and the World Health Organization recommended MC as an important additional strategy for HIV prevention. Kenya was one of the first priority countries to initiate the national MC scale-up. However, questions remain about whether the promotion of MC as an HIV prevention intervention will translate into a decline in HIV incidence in the general population. Risk compensation—defined as an increase in risky behavior in response to the perceived risk reduction following an intervention—is an important possible mechanism that could negatively impact the effectiveness of MC programs. To assess the concerns about risk compensation, we conducted a prospective observational study to monitor the sexual risk behaviors of circumcised men before and after circumcision and compare them to the behaviors of uncircumcised controls over 24 months of follow-up. As a secondary objective, we also aimed to evaluate the impact of circumcision on sexual health and function. Finally, we sought to conduct an in-depth investigation of one of the understudied HIV risk behaviors—sexual partner concurrency—among circumcised and uncircumcised men, based on an earlier study of risk compensation embedded in the MC RCT in Kisumu, Kenya. We found no evidence of risk compensation. To the contrary, both circumcised and uncircumcised men significantly reduced their HIV risk behaviors over two years. In our evaluation of penile coital injuries as one measure of sexual health, we found that coital cuts, scratches, abrasions, soreness, and bleeding were quite common among young Kenyan men. We observed a significant decline in penile coital injuries following MC, with reductions evident as early as six months after the procedure, and identified several factors associated with penile coital injuries. Sexual concurrency was also common in this population, but not associated with circumcision. Our results enabled policy makers throughout the region to make evidence-based decisions about medical MC implementation and alleviated several concerns and barriers associated with widespread circumcision scale-up.