Counselling Key to Success of Male Cut. 2/11/10
Male circumcision reduces a man's risk of contracting HIV through vaginal sex by up to 60 percent
Kisumu - When Kenya launched its national voluntary male circumcision campaign in 2008, critics worried that it could lead to greater sexual risk-taking - but men in the western Nyanza Province seem to be disproving this theory.
"When I heard people say male circumcision helps in reducing HIV infection, I went there with the sole purpose that it would lessen the burden of having to use a condom," said 23-year-old Victor Oluoch. "But after that, I have known a lot through the counselling I received; I use a condom every time with anybody... I am not married so I am not going to trust anybody."
A key component of Kenya's programme, which aims to circumcise more than one million men by 2013, is HIV testing and compulsory counselling on HIV prevention, including messages about the importance of continued condom use, as circumcision does not offer full protection from the virus. This counselling appears to have been effective in preventing a phenomenon known as "risk compensation", whereby an intervention that lowers an individual's HIV risk may cause them to take greater risks through other behaviours.
A small 2010 study by the University of Illinois in Kisumu, capital of Nyanza Province, found that most respondents - whether circumcised traditionally or in health facilities - reported either no behaviour change or improved protective behaviour, such as increased condom use and fewer sexual partners.
The research revealed an understanding among the 30 respondents surveyed that male circumcision only provided partial protection against HIV.
The authors speculated that the low levels of risk compensation were due to the effects of counselling, HIV testing and condom availability.
A separate 2007 study, also conducted in Nyanza, found that circumcised men did not engage in more risky sexual behaviours than uncircumcised men in the first year after the operation.
Sending the right message
Most men in Kenya are circumcised as teenagers during rites of passage into adulthood that do not generally feature HIV education. Paul Wasike was circumcised during the traditional ceremony of western Kenya's Bukusu community, when he was told that after circumcision, he was man enough to have sex with as many girls as he chose.
"For people like me who were cut at the traditional ceremony, it is sex and adulthood that was emphasized, but I have heard it being talked about on the radio and everywhere that circumcision cannot prevent you from [getting] HIV unless you use a condom or are faithful," said Wasike.
"There is a need to look at how different types and quantity of HIV prevention counselling among men getting circumcised may lead to different types of risk perceptions and behaviours post-circumcision," Thomas Reiss, lead author of the University of Illinois study, told IRIN/PlusNews. "Those circumcised in traditional ceremonies where there is no prevention counselling might vary in risk perception to those circumcised in institutional settings."
Five of the study's respondents reported that they did engage in risky sexual behaviour after circumcision; one man continued to have unprotected sex with his primary girlfriend but reported using condoms with his two other girlfriends.
Donald Were, 31, a married father of three, did not participate in the study but said curiosity was a major factor in having unprotected sex after circumcision.
"You have been having the skin and now when it is not there, you are just curious... you want to test how it [sex] feels without it," he said. "After knowing, then you turn to a condom. I tried it, but with my wife - I can't try it with somebody I don't trust."
Ultimately, Reiss said, preventing risk compensation was a question of information.
"Some people may be misinformed about the protective effects of male circumcision... others may not understand the actual risks of their behaviour and need to be counselled about the risks of their current sexual behaviour and how they can still contract HIV even if circumcised," he said. "Basically it comes down to getting the correct information about HIV risk and circumcision protection to men and women," he said.