Research Article: Voluntary medical male circumcision (VMMC) for prevention of heterosexual transmission of HIV and risk compensation in adult males in Soweto: Findings from a programmatic setting

Date Published: March 7, 2019

Publisher: Public Library of Science

Author(s): Hillary Mukudu, Janan Dietrich, Kennedy Otwombe, Mmatsie Manentsa, Khuthadzo Hlongwane, Maetal Haas-Kogan, Benn Sartorius, Neil Martinson, Robert K Hills.


Clinical trials have clearly shown a reduction in HIV acquisition through voluntary medical male circumcision (VMMC). However, data assessing risk compensation under programmatic conditions is limited.

This was a prospective cohort of HIV seronegative males aged 18–40 years receiving VMMC between November 2012 and July 2014. HIV serostatus was determined pre and post VMMC. Risk compensation was defined as a decrease in condom use at last sex act and/or an increase in concurrent sexual relationships, both measured twelve months post-circumcision.

A total of 233 males were enrolled and underwent voluntary medical male circumcision (VMMC) for prevention against HIV. There was no evidence of risk compensation post-circumcision as defined in this study. Significant increases in proportion of participants in the 18–24 years age group who knew the HIV status of their sexual partner (39% to 56%, p = 0.0019), self-reported condom use at last sex act (21% to 34%, p = 0.0106) and those reporting vaginal sexual intercourse in the past 12 months (67% to 79%, p-value = <0.0001) were found. In both 18–24 and 25–40 years age groups, there was a significant increase in perception of being at risk of contracting HIV (70% to 84%, p-value = <0.0001). No significant risk compensation was observed in this study on comparing pre-and post-circumcision behaviour. An increase in proportion of participants in the 18–24 years age group who had vaginal intercourse in the first 12 months post-circumcision as a possibility of risk compensation was minimal and negated by an increase in proportion of those reporting using a condom at the last sex act, increase in knowledge of partner’s HIV status and lack of increase in alcohol post-circumcision.

Partial Text

Scale up of Voluntary Medical Male Circumcision (VMMC) in South Africa followed recommendations by the World Health Organization (WHO) for the roll-out of VMMC in 2007 as an added HIV prevention strategy in countries with a generalized HIV epidemic. By 2016, nearly 15 million VMMCs had been performed in 14 priority countries of Sub-Saharan Africa [1]. VMMC has been shown to decrease HIV infection under research conditions[2] [3]. However, data on risk compensation after circumcision in a programme setting is limited. Furthermore, evidence of risk compensation in males aged 24–40 years, the group with the highest HIV incidence in South Africa, also remains unknown [3].

The study was conducted at a high volume VMMC clinic based at Chris Hani-Baragwanath Academic Hospital in Soweto, a peri-urban township in South Africa. A prospective cohort of men requesting VMMC was established, inviting every third HIV-seronegative male, aged 18–40 years who reported living in Soweto from November 2012 to July 2014 to participate. Men were circumcised routinely and followed up prospectively thereafter. A post-circumcision visit was scheduled 12 months after VMMC.

Risk compensation was defined as a decrease in condom use at last sex act and or increase in concurrent sexual partners after circumcision. Selection of these two factors is based on the fact that concurrent sexual partnerships are main drivers behind high prevalence of HIV in sub-Saharan Africa among males. Furthermore, condom use is an effective mode of HIV prevention[14][15][16]. The association between categorical measures before and after circumcision was assessed using the McNemar’s test.

Study protocol was approved by the University of the Witwatersrand Human Research Ethics Committee (certificate #M120634). Chris Hani-Baragwanath Hospital Research Committee provided additional approval for the study. Strict confidentiality procedures were maintained and written informed consent was obtained from all participants. The study protocol can be accessed at:

Our study’s findings corroborate evidence of absence of risk compensation after VMMC [17][11]. Our study also illuminated possible additional benefits of VMMC programs specifically the HIV counselling and VMMC education sessions. It was found that post-circumcision participants in the 18–24 years age group were more likely to know the HIV status of their sexual partner and more likely to use a condom at the last sex act [18]. Absence of similar findings in the 25–40 years age will warrant further research considering that older men are at substantially higher HIV risk [3].

In this cohort we found in the 12 months post-circumcision compared to pre, participants in the 18–24 years age groups, were more likely to use a condom use at last sex act, more likely to know the HV status of sexual partner and more men (both 18-24- and 25-40-years age groups) considered themselves at risk of HIV infection. This suggests that there are other potential benefits conferred by VMMC in a programme setting as a biomedical and behavioural intervention for the prevention of HIV transmission.




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