Understanding partial protection and HIV risk and behavior following voluntary medical male circumcision rollout in Kenya
In the midst of scaling up voluntary medical male circumcision (VMMC) in Kenya, there is concern that men do not adequately understand that circumcision provides only partial protection against HIV. The study goal was to determine men’s understanding of partial protection, perceptions of HIV risk before and after VMMC and use of protective measures following VMMC. In-depth interviews with 44 men aged 18–39 years recently circumcised or planning to undergo VMMC were conducted in two urban and rural districts in Nyanza Province, Kenya. Participants described partial protection as the need to continue using other HIV protective measures such as condoms, with numbers such as a ‘60 percent protection’ or ‘not 100 percent protection’, and described how circumcision reduces HIV transmission such as reduced penile bruising or bleeding. Most said their HIV risk before VMMC was high and that VMMC would reduce their risk moderately. Participants demonstrated good understanding of partial protection and there was little suggestion of risk compensation following VMMC.
Results from three large randomized controlled trials in Kenya, Uganda and South Africa documented that medical circumcision substantially reduced men’s risk of acquiring HIV infection through vaginal intercourse by approximately 50–60% [1–3]. Men in the Kenya and Uganda trials who underwent extended follow-up exhibited sustained reductions in HIV incidence of 64% at 5.5 years in Kenya and 73% at 5 years in Uganda [4–6]. Following endorsement by the World Health Organization and the Joint United Nations Programme on HIV/AIDS , the government of Kenya adopted voluntary medical male circumcision (VMMC) as a key strategy for HIV prevention. Nyanza Province in western Kenya has been prioritized for VMMC rollout because of its high prevalence of heterosexually transmitted HIV infection (14.9%) and low prevalence of male circumcision (48%) [8, 9]. Although most ethnic groups in Kenya traditionally circumcise men and 85% of Kenya men are estimated to be circumcised , the Luo, the predominant ethnic group in Nyanza Province, do not traditionally circumcise. To date, the Kenya VMMC program has circumcised more than 600 000 men (A. Ochieng’, personal communication), mostly in Nyanza Province.
VMMC reduces a man’s risk of HIV through vaginal intercourse substantially but not completely. Counseling and strategic communications are key elements of Kenya’s VMMC program and advise that VMMC provides only partial protection against HIV and therefore continued use of HIV protective measures is necessary . The Communication Strategy for Voluntary Medical Male Circumcision in Kenya, for example, states that VMMC communications should emphasize (p. 18), “… that male circumcision reduces the risk of men acquiring HIV infection by 60 percent and that this protective effect is only partial as well as the fact that the procedure is additional but not a substitute for other proven HIV prevention methods.”  It is not clear, however, whether men currently undergoing medical circumcision understand the meaning of partial protection and intend to practice other HIV protective behaviors after VMMC.
Theories of health behavior such as the Health Belief Model, AIDS Risk Reduction Model and Extended Parallel Processing Model [11–13] posit that adoption or change in behavior starts with the perception that one is at risk of a harmful health outcome. Applied to VMMC, men are motivated to undergo VMMC, in large part, because they perceive themselves to be at risk of acquiring HIV and they further believe that being circumcised will reduce their HIV risk. Beliefs about the degree of HIV protection afforded by VMMC—termed response efficacy—may moderate changes in HIV risk perception after getting circumcised and thereby influence sexual behavior. For example, if a man understands that VMMC is only partially protective against HIV, he may be inclined to practice other HIV protective behaviors. Alternatively, if he thinks that male circumcision is 100% effective at preventing HIV, he may think that he is no longer at risk of HIV infection after VMMC and engage in risky or compensatory sexual behavior. Although there is no substantive evidence, there is apprehension that medically circumcised men will engage in riskier sexual behaviors because they erroneously believe that circumcision completely reduces their risk of HIV infection—a phenomenon termed risk compensation or behavioral disinhibition [14–16].
The potential for risk compensation among users of biomedical HIV prevention technologies is a major concern [14, 17, 18], particularly as VMMC as an HIV prevention strategy is scaled up across a variety of settings in sub-Saharan Africa . Data from the three seminal medical circumcision trials in Africa have found limited evidence for risk compensation [1–3, 20–23]. However, participants in these research trials received the highest standards of preventive care in a research trial setting, and these results may not generalize to VMMC scale-up in non-research settings [20, 24, 25]. Investigations of how target audiences understand partial protection and HIV risk, along with strategies for effective communication, are critical for successful implementation of new biomedical prevention technologies such as VMMC [26–29]. Some research has found that men and women in sub-Saharan Africa have high awareness of partial HIV protection from VMMC [30, 31], although the need to use protection following circumcision is not fully understood by everyone [28, 32, 33]. In this study, men recently medically circumcised or planning to undergo medical circumcision in Nyanza Province, Kenya, were targeted for in-depth interviews. The primary goals of this study were to examine men’s understanding of communications about partial HIV protection, use of HIV protective measures following VMMC and perceptions of HIV risk before and after medical circumcision in the context of VMMC rollout in Kenya.