A random household survey of male circumcision and HIV in Kisumu, Kenya Circumcision Impact Study (CIRCIS) Matthew Westercamp University of Illinois at Chicago

Background Kisumu, 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

Background Circumcision in Kisumu Pre (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 CIRCIS 2 data collection ( ) Multicentre study in sub-Saharan Africa – Kisumu [Buve, et al. 2001]

Methods Households were selected by multi-stage sampling. – All men and women aged 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 p=0.005 p= p=0.24 p<0.0001

Uncircumcised Men MC and HIV infection risk

Now that MC is available, you are less worried about HIV infection (Percent Agreement) p = 1.00 p =

Now that MC is available, condom use during sex is less necessary (Percent Agreement) p = 0.16 p =

Circumcised men have more, less, about the same sexual pleasure than uncircumcised men. 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, Suppl 4: p. S 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., (3): p. e4573. Latest in MC Information For HIV Prevention