Kawango Agot, Omanga E, Kabare M, Ayieko B, Odeny R, Ohaga S. Impact Research & Development Organization, Kisumu, Kenya We too are shareholders: Why Women Must Be Meaningfully Involved In Decision-Making Around Male Circumcision

Background MMC rollout programs largely focus on men at the exclusion of their sexual partners: Mobilization/demand creation activities target men, alone; Men come to the clinic, alone; MMC education and risk reduction counseling given to men, alone; Men are tested for HIV, alone; Instructions on post-operative sexual abstinence is given to men, alone; Men come for follow up visits, alone; ….and, they hardly share these information with their partners.

Process We reviewed published and ongoing studies on MMC for: Evidence of risk compensation Evidence of risk of HIV to female partners of circumcised men Evidence of early resumption of sex What women say about MMC for HIV prevention

Selected findings: Risk Compensation The three RCTs: Men reporting sex before recommended 6 weeks of abstinence was %: No evidence of risk compensation in any of the 3 studies individually (Auvert et al, 2005; Bailey et al, 2007; Gray et al, 2007) No evidence of risk compensation in a pooled analysis (Mehta et al 2009)  Is there risk compensation during rollout? (Westercamp et al, 2012):  No evidence, 24 months after MMC

Selected findings: Effect of MMC on HIV transmission to female partners  Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: A randomised controlled trial (Wawer et al, 2009)  Trends towards increased risk of male-to-female HIV transmission, especially if sex was resumed <6 weeks.  Risk of HIV transmission to partners was higher among those who resumed sex before week 6 (27.8%) compared to those who delayed sex (9.5%) or those not circumcised (7.9%)  MMC and risk of male-to-female HIV transmission among sero- discordant couples (Baeten et al, 2010)  HIV transmission to women reduced by 40% (though statistically insignificant)

Selected findings : Early resumption of sex (1/2) Sex in stitches: Assessing the resumption of sexual activity in Zambia (Hewett, et al., 2012) 24% had sex before 6 weeks, of whom: 82% had ≥1 unprotected sex act, most of whom were married. Factors associated with the early resumption of sexual activity following MMC in Nyanza Province, Kenya (Herman- Roloff, et al, 2012) 31% overall resumed before 6 weeks, 66% of whom were married.

Selected findings : Early resumption of sex (2/2) An RCT on text messaging to improve attendance at post operative clinic visits after adult MMC (Odeny et al., 2011). 27% resumed sex before day 42, of whom 77.6% were married or in stable relationships. Wound healing and resumption of sex following adult MMC in Kisumu, Kenya (Odoyo et al., 2012) 38% had sex before 42 days, of whom 62% were married, 65% were HIV positive and 67% reported using a condom.

Selected findings: Women’s voices  What women think about MMC in Nyanza, Kenya (Okeyo et al, 2012) 88% of women felt more protected against sexual diseases after their partner’s circumcision Preference of circumcised men increasing in un-circumcising communities A qualitative assessment of men’s and women’s views of MMC in Tanzania (Plotkin, et al. 2011). Women keen to support partners to abstain if involved. Men need their partners’ support during the healing period Women’s views on MMC from 5 African countries =>74% want to be involved in their partner’s MMC process (Peltzer et al 2007). Women support MMC for HIV prevention but many lack factual knowledge of the risks and benefits to them (Feuer 2010)

Conclusions 24-38% of men resumed sex before end of recommended abstinence period, incl. HIV-positive men who knew their status: The majority were married or in stable relationships There is potential for increased risk of HIV if sex is resumed before complete wound healing Risk of HIV to partners of circumcised still unclear While there is no evidence of risk compensation, women risk perception is low on account of their partners circumcision Preference for circumcised men increasing among women Women want to support partners abstain; men want this support Operations research needed to address women’s involvement. One planned in Kenya (Agot, Mwandi et al – awaiting IRB approval)

Bertran Auvert Robert Bailey Ronald Grey Maria Wawer Supriya Mehta Jared Baeten Amy Herman-Roloff Elijah Odoyo-June Acknowledgements to the following and their teams Thank y’all Thomas Odeny Paul Hewett Nelli Westercamp Timothy Okeyo Plotkin Peltzer Feuer