|
Gender differences in risk behavior and the power to negotiate safe sex: potential complications in scaling up adult male circumcision programs in Southern Africa
Presented by Kyeen Andersson (United States).
K. Andersson1, D. Owens2, D. Paltiel1
1Yale University, Department of Epidemiology & Public Health, New Haven, United States, 2VA Palo Alto Health Care System & Stanford University, Palo Alto, United States
Background: Male circumcision benefits women only indirectly because their sexual partners are less likely to be HIV-infected. Whether this benefit may be offset by increased risk-taking in men, particularly in settings where women are less able to negotiate safe sex, has not been examined.
Methods: We developed a compartmental epidemic model to simulate the population-level impact of circumcision programs on HIV transmission, parameterized to reflect the epidemic in Soweto, South Africa. We incorporated gender-specific negotiation of condom use to capture the dominant role played by the male partner in these decisions. We explored both risk reduction and disinhibition scenarios by varying post-circumcision condom use from 0-100%. We simulated short-term programs that gradually increased levels of circumcision from 35% (baseline) to 60-80% over a 5-year period and examined long-term outcomes.
Results: A 5-year program in which an additional 20% of uncircumcised men undergo circumcision each year would reduce expected infections over 20 years in men by 25% and women by 17%. If average condom use increased from 50% (baseline) to 75% in circumcised men, the benefits would be increased: the program would reduce new infections in men by 43% and women by 39%. However, if average condom use decreased to 25%, the program could be detrimental: new infections would be reduced by just 3% in men, but would increase by 12% in women. Different levels of program implementation and changes in post-circumcision condom use produced qualitatively similar results.
Conclusions: Circumcision programs could result in significant benefits to both men and women, but changes in behavior disproportionately affect women. In societies where women have less power to negotiate safe sex, decreased condom use by circumcised men could make women more susceptible to HIV infection. As circumcision programs are implemented in Southern Africa, gender-specific risk reduction counseling and female-controlled methods for HIV prevention are urgently needed.
Download the e-Poster
|