Assessment of Changes in Risk Behaviors During 3 Years of Posttrial Follow-up of Male Circumcision Trial Participants Uncircumcised at Trial Closure in Rakai, Uganda

Three randomized controlled trials (RCTs) in sub-Saharan Africa have shown that male circumcision reduces female-to-male human immunodeficiency virus (HIV) incident infection by 50%–60% (1–3). In 2007, the World Health Organization (WHO)/Joint United Nations Programme on HIV/AIDS (UNAIDS) recommended that male circumcision be promoted as an “additional, important strategy for the prevention of heterosexually-acquired HIV infection in men,” and 13 sub-Saharan Africa countries, including Uganda, were identified as priority countries for male circumcision scale-up (4, p. 11; 5, p. 3). Although the RCTs proved the causal effect (i.e., efficacy) of male circumcision for reducing the risk of HIV infection in men, the long-term population-level impact of male circumcision on the HIV epidemic will depend on male circumcision coverage and the influence of male circumcision on sexual risk behaviors. Risk compensation, defined as a change toward riskier sexual behaviors after adopting an HIV prevention strategy, has been a theoretical concern with male circumcision (6–23), particularly during rapid male circumcision scale-up where provision of risk reduction education, counseling, and follow-up may be limited. Simulation studies suggest that risk compensation can reduce the impact of male circumcision on HIV incidence (24, 25), and a modest level of risk compensation in men could increase female HIV infections (26). Data on behavioral changes after male circumcision acceptance have been sparse, and no empirical data are available during the current period when the efficacy of male circumcision is well known and male circumcision rollout is taking place in programmatic settings. The Rakai Health Sciences Program conducted one of the male circumcision RCTs in Rakai, Uganda, during 2003–2006, and has continued to follow the trial participants after trial closure. Using data on the trial participants who were uncircumcised at the end of the trial, we assessed whether the adoption of male circumcision in the posttrial programmatic setting encouraged men to engage in riskier behaviors (i.e., risk compensation associated with male circumcision).