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Does Incident Circumcision Lead to Risk Compensation? Evidence From a Population Cohort in KwaZulu-Natal, South Africa

Ortblad, Katrina F. MPH, ScD*; Harling, Guy MPH, ScD†,‡; Chimbindi, Natsayi PhD§; Tanser, Frank PhD§,║; Salomon, Joshua A. PhD║,¶; Bärnighausen, Till MD, ScD‡,║,#

JAIDS Journal of Acquired Immune Deficiency Syndromes: March 1, 2019 - Volume 80 - Issue 3 - p 269–275
doi: 10.1097/QAI.0000000000001912
Prevention Research

Background: Voluntary medical male circumcision reduces men's risk of HIV acquisition and may thus increase HIV risk-related sexual behaviors through risk compensation. We analyze longitudinal data from one of Africa's largest population cohorts using fixed-effects panel estimation to measure the effect of incident circumcision on sexual behaviors.

Setting: KwaZulu-Natal, South Africa.

Methods: An open population cohort of men was followed from 2009 to 2015. Men self-reported their circumcision status and sexual behavior annually. We used linear regression models with individual-level fixed effects to measure the effect of incident circumcision on recent sex (past 12 months) and sexual behaviors that increase HIV risk (not using a condom at last sex, never using condoms with the most recent sexual partner, concurrent sexual partners at present, and multiple sexual partners in the past 12 months). We controlled for potential time-varying confounders: calendar year, age, education, and sexual debut.

Results: The 5127 men in the cohort had a median age of 18 years (interquartile range 16–24) at cohort entry. Over the study period, almost 1 in 5 of these men (19.4%) became newly circumcised. Incident circumcision affected neither recent sex [percentage point (PP) change 0.0, 95% confidence interval: −1.2 to 1.3] nor sexual behaviors that increase HIV risk (PP −1.6, 95% confidence interval: −4.5 to 1.4).

Conclusions: The data from this study strongly reject the hypothesis that circumcision affects sexual risk-taking. Risk compensation should not serve as an argument against increased and accelerated scale-up of circumcision in this and similar communities in South Africa.

*Department of Global Health, University of Washington, Seattle, WA;

Institute for Global Health, University College London, London, United Kingdom;

Africa Health Research Institute, KwaZulu-Natal, South Africa;

§School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa;

Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA;

Department of Medicine, Stanford University, Stanford, CA; and

#Faculty of Medicine, Institute of Public Health, Heidelberg University, Heidelberg, Germany.

Correspondence to: Katrina F. Ortblad, MPH, ScD, Department of Global Health, University of Washington, 325 9th Avenue, 12th Floor, Ninth and Jefferson Building, Seattle, WA 98104 (e-mail:

K.F.O. is supported by the NIH (T32AI007535-16A1, PI: George Seage; R01-MH110296, PI: Heffron; R01-MH113572, PIs: Baeten/Ngure). T.B. was supported by the Alexander von Humboldt Foundation through the Alexander von Humboldt Professorship endowed by the German Federal Ministry of Education and Research. He was also supported by the Wellcome Trust, the European Commission, the Clinton Health Access Initiative, NIAI R01-AI124389 (PIs: T.B. and F.T.), and D43-TW009775 (PIs: Fawzi and T.B.). Both T.B. and G.H. are supported by NICHD R01-HD084233 (PIs: T.B. and F.T.). No funding bodies had any role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The remaining authors have no funding or conflicts of interest to disclose.

K.F.O., G.H., J.A.S., F.T., Pillay D., Mutevedzi T., and T.B. Male circumcision and risk compensation in a high HIV prevalence population in KwaZulu-Natal, South Africa. Conference on Retroviruses and Opportunistic Infections 2017; February 13–16, 2017; Seattle, WA.

K.F.O., J.A.S., G.H., and T.B. conceptualized the manuscript.

K.F.O. conducted the analyses and wrote the first draft of the manuscript. All authors edited the manuscript and analyses and approved the final version of the paper.

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Received May 10, 2018

Accepted October 26, 2018

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