Three large randomised clinical trials that took place in Kenya, Uganda, and South Africa were published in 2007, and showed that medically performed circumcision is safe and can reduce men’s risk of HIV infection by 60%. The World Health Organization (WHO) and UNAIDS therefore recommend safe male circumcision (SMC) as an essential part of HIV prevention programming. In 2010, the Ugandan Ministry of Health adopted the national safe male circumcision policy, which recommends voluntary safe male circumcision for all men, and makes it available through the public health system.
After I completed my core medical training in the UK, I spent some time in Uganda and volunteered at a UK based charity. The charity (Amigos International) helps to equip and train some of Uganda’s most vulnerable young people. While I volunteered at a vocational training centre near Kampala, Uganda, a few of their trainees were circumcised at a nearby hospital as they had learnt from the newspaper and radio advertisements that the procedure was being provided for free. I travelled with these students to find out more, provided care for them after the procedure, and asked about why they decided to get circumcised. To my surprise they were motivated by interesting and unusual misconceptions, many of which remained after their circumcision.
A study in the bulletin of the WHO, published in 2009, showed that according to data from one media archive, Uganda had the most media reports about male circumcision preventing HIV infection in men in sub-Saharan Africa compared to 23 other countries between 2007 and 2008. The study also highlighted several messages from the media reports that were either incorrect or misleading. Some of the articles published about SMC had a negative viewpoint, and of those, the issue on risk compensation was the most prominent. For example, some reports criticised SMC because a significant number of people who choose to get circumcised do so to “avoid the sexual dissatisfaction of condom use” and “the desire to have more partners”—risk compensation.
The three randomised trials found compelling evidence of the efficacy of SMC in reducing HIV transmission, but very little evidence of risk compensation. However, it is difficult to comment on the change in sexual behaviour of those individuals in the trials as people might behave differently outside this setting. Assessing a change in sexual behaviour is also difficult, and therefore risk compensation cannot be excluded completely. The level of risk compensation might reflect differently in reality, as evident by the anecdotal experience I observed in Uganda.
The potential problem is that men who lack knowledge and have misconceptions about SMC, are motivated to have this done for the wrong reasons. It is an alarming thought that seeking SMC might encourage them to engage in high risk sexual behaviour such as having more unsafe sex and multiple partnerships after circumcision. For men who are married in this group, this might promote the likelihood of multiple sexual partners, which in turn would have a negative knock-on effect within families and within society. Uganda has the youngest population in the world. Without a healthy environment of good family models for children to grow up in, fathers pursuing SMC for high risk sexual behaviour would only be making it hard for offspring to understand the value of being monogamous when they grow up and thereby perpetuating the cycle of the problem with the transmission of HIV and other STDs.
Male circumcision should be part of a comprehensive HIV prevention package, together with behavioural factors such as using condoms, remaining faithful, lowering the rate of partner change, and concurrent partnerships all of which are equally important in reducing HIV transmission. Although it is challenging to modify people’s behaviour, these issues should be dealt with equally and not focus on the procedure alone when it is advertised to the public.
WHO and UNAIDS have set a goal for countries with generalised HIV epidemics and low prevalence of male circumcision to have volunteer male medical circumcision (VMMC) to reach the target of at least 80% among 18-49 year old males by 2016. As VMMC scale up is accelerating across Africa, shortcuts might be made leading to other components in the package of services being neglected. These include HIV testing and counselling, safer sex education, STD management, and condom promotion. One should be mindful that the quality of these programmes is not being compromised by the rapid expansion of service.
To conclude, we should not be complacent with the current evidence for risk compensation. Service providers must continue to promote other preventative measures of HIV transmission, and explore effective communication strategies to deliver accurate information from the media. It would be interesting to find out how much information delivered to the public on this subject from the media is confirmed or screened by medical professionals. I think more effort should be put into identifying and clarifying misconceptions on the part of the individuals wanting to be circumcised. Healthcare professionals must ensure that adequate information surrounding the issues of male circumcision is available when SMC is provided. They should also help to ensure the accuracy of information in the public domain by engaging with the mass media. I recognise the role and power of mass media coverage in health promotion on this issue. Therefore effective public health communication strategies are crucial to convey accurate messages to the public, in order to avoid further misconceptions.
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and I declare that there is no conflict of interest.
Wilson Cheng recently completed his core medical training at Derriford Hospital, Plymouth. He has taken part in volunteer medical work with various organisations in Nigeria, Uganda, and Japan. He is currently studying for a diploma at the London School of Hygiene and Tropical Medicine.