PLoS Medicine Publishes Opinion Pieces About Male Circumcision, HIV PreventionPLoS Medicine in its March issue includes two opinion pieces written in response to a study about the cost effectiveness of male circumcision as an HIV prevention method. James Kahn of the Institute for Health Policy Studies at the University of California-San Francisco and colleagues conducted the study among 1,000 adult men in Orange Farm, a township outside Johannesburg, South Africa. The study found that circumcising the men would prevent about 300 new HIV cases over 20 years. According to the researchers, the circumcisions translated to a total savings of about $2.4 million, which could have been spent on providing HIV/AIDS treatment for participants in the study group alone (Kaiser Daily HIV/AIDS Report, 1/5). Summaries of the opinion pieces appear below.
- Seth Kalichman, Lisa Eaton and Steven Pinkerton, PLoS Medicine: The protective effects of male circumcision might be "partially offset" by an increase in risky behaviors, or "risk compensation," especially a reduction in condom use and an increase in the number of sex partners, Kalichman and Eaton of the University of Connecticut and Pinkerton of the Medical College of Wisconsin's Center for AIDS Intervention Research write in a PLoS Medicine opinion piece. Risk compensation might be important for male circumcision because "avoiding the sexual dissatisfactions of condom use and the desire to have more sex partners are likely to be significant motivations for men to seek circumcision," the authors write, adding, "It is difficult to imagine a convincing public health message that effectively influences men to undergo circumcision and continue to consistently use condoms." In addition, risk compensation by HIV-positive, circumcised men will "increase the risk of transmission to their sex partners," according to the authors. This means that although male circumcision might reduce HIV incidence among men in the short term, it will increase HIV incidence among women, which "in turn translates to greater risk to men," the authors write, adding that epidemiological models of male circumcision "should take this dynamic into account." Male circumcision also reduces the risk of contracting a sexually transmitted infection that is not HIV," the authors write, concluding that estimates of HIV risk "resulting from increased exposure to STIs that coincide with reductions in condom use have been included in previous models of the cost-effectiveness of HIV prevention interventions and should be included in" male circumcision models (Kalichman et al., PLoS Medicine, March 2007).
- Kahn, Elliot Marseille and Bertran Auvert, PLoS Medicine: The risk compensation issues raised by Kalichman and colleagues are "cogent for refining modeled estimates of the impact of male circumcision," Kahn and Marseille of the University of California-San Francisco and Auvert of the Institut National de la Sante et de la Recherche Medicale write in a PLoS Medicine opinion piece. They add that it is even "more important" to "empirically monitor risk compensation during the scale-up of male circumcision." According to the authors, they included in their study a "risk compensation level for men susceptible to HIV," but they did not "incorporate risk compensation" among HIV-positive men -- an "adjustment which would have lessened the estimated benefits of male circumcision." In addition, the "inclusion of the effects of" STIs that are not HIV "as risk co-factors would add a useful dimension to our analysis," the authors write. They add that "current efforts to plan" male circumcision "scale-up emphasize the need for" a circumcision procedure that "incorporates effective risk reduction counseling." They write, "In the context of a medicalized adult male circumcision model and a clear public health message, risk compensation can be minimized. Thus, a great value of" male circumcision "scale-up is the opportunity to directly deliver a strong behavioral prevention message" (Kahn et al., PLoS Medicine, March 2007).