A random household survey of male circumcision and HIV in

Kisumu, KenyaCircumcision Impact Study (CIRCIS)

Matthew WestercampUniversity of Illinois at Chicago

BackgroundKisumu, Kenya

• Kenya’s third largest city with a population of over 350,000

• Luo ethnic group, traditionally non-circumcising, majority

• 60% of residents live in peri-urban and informal settlements often lacking in municipal water, sewage, and/or electrical services

BackgroundCircumcision in Kisumu

Pre-2000

2010

2002

2006

(Feb 2002) Recruitment for Kisumu circumcision RCT begins

(Dec 2006) Trial concludes showing 60% reduction of risk in concordance with two concurrent trials in Uganda & South Africa – results released

(Jul - Oct 2006) ARTIS, cross-sectional population based survey [Cohen, et al. 2009)]

2008(Nov 2008-Apr 2009) Circumcision Impact Study (CIRCIS) data collection(Sep 2008) Rollout of Circumcision service in Nyanza

(Feb 2011) Planned start of CIRCIS2 data collection

(1997-1998) Multicentre study in sub-Saharan Africa – Kisumu [Buve, et al. 2001]

Methods• Households were selected by multi-stage

sampling. – All men and women aged 15-49 years,

sleeping in the house the night before the first visit by the field team were eligible for study participation.

– 40 study clusters by random PPS sampling– ~ 28 households by systematic random

sampling• 2,563 eligible individuals• 1,868 (72.9%) located and asked to participate• 105 (5.6%) refused to participate • Final sample size = 1,763

Circumcision Prevalence• Circumcision status based on self-report

– 460 men (68%) uncircumcised– 215 (32%) circumcised

• 351 (52%) men agreed to visual confirmation – 234 men (67%) were determined uncircumcised– 117 (33%) circumcised– PPV of self-report = 0.99 / NPV of self-report = 0.97

• Preference to be circumcised in uncircumcised males = 272 (59%) men

• Preference for circumcised partners in Luo women = 658 (73%) women

Prevalence – Kisumu, Kenya

1997/1998 2006 20090%5%

10%15%20%25%30%35%

25% 25%

32%

10% 11%

19%

Prevalence of Circumcision

Kisumu - MenKisumu - Luo Men

2006 20090%

10%20%30%40%50%60%70%80%

55% 59%63%73%

Prevalence of Preference for Circumcision

Uncircumcised MenLuo Women

p=0.005

p=0.0001

p=0.24p<0.0001

More Likely Less Likely About the same0%

20%

40%

60%

80%

100%

6%

84%

10%4%

57%

39%

In your opinion, how likely are circumcised men to get infected with HIV compared to uncircum-

cised men?

Pref. Circ Pref. Uncirc

Uncircumcised Men MC and HIV infection risk

Now that MC is available, you are less worried about HIV infection (Percent Agreement)

Series10%

10%

20%

15% 15%

Circumcised Uncircumcised

p = 1.00

Series10%

10%

20%19%

9%

Pref. Circ Pref. Uncirc

p = 0.0043

Now that MC is available, condom use during sex is less necessary (Percent Agreement)

Series1-10%

0%

10%

20%

30%

15%20%

Circumcised Uncircumcised

p = 0.16

Series1-10%

0%

10%

20%

30%

25%

7%

Pref. Circ Pref. Uncir

p = 0.0015

Circumcised men have more, less, about the same sexual pleasure than uncircumcised

men.

More Less About the same0%

20%

40%

60%

80%

100%

49%

13%

38%

29%

16%

55%

Pref. Circ Pref. Uncirc

p <.001

Perception of HIV Risk

• Participants self identified as low vs. high risk– No difference by circumcision status (p=0.78)– No difference by preference of circumcision

(p=0.81)

Limitations

• Cross-sectional design– Cannot show causation nor temporality

• Self-reported circumcision status– Misclassification bias unlikely

• Difficulty in recruiting males– Possible selection bias

• Prevalence comparisons based on different study methodologies– Different study cluster/areas within Kisumu

• Results may not be generalizable to other populations in Kenya or sub-Saharan Africa

Conclusions• The prevalence of circumcision appears to have

remained stable between 2000 and 2006 and increased between 2006 and 2009 in Kisumu, Kenya

• Circumcised and uncircumcised men have similar perceived risk of HIV infection. This is consistent with no sexual risk compensation by circumcised men

• However, uncircumcised men who prefer to become circumcised do perceive circumcised men as being at lower risk of HIV and as engaging in riskier behavior

• Preference for circumcision is related to ideas consistent with circumcision enhancing the sexual experience

Acknowledgments • William Nyongo and Mr. Obudno

– Kenya National Bureau of Statistics

• Natecho Wekesa– District Commissioner – Kisumu East

• Chiefs and Assistant Chiefs of Kisumu• CIRCIS Staff and Participants

• Dr. Robert Bailey• Dr. Kawango Agot• Prof Ndinya-Achola

• Dr. Craig Cohen

References• Buve, A., et al., The multicentre study on factors

determining the differential spread of HIV in four African cities: summary and conclusions. AIDS, 2001. 15 Suppl 4: p. S127-31.

• Cohen, C.R., et al., Association of Attitudes and Beliefs towards Antiretroviral Therapy with HIV-Seroprevalence in the General Population of Kisumu, Kenya. PLoS ONE., 2009. 4(3): p. e4573.

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www.malecircumcision.org