Tracking Risk Compensation Over Time in a National MC Roll-Out in Zimbabwe

描述(由申请人提供)：男性包皮环切术(MC)目前是可在艾滋病毒高流行国家实施的最有效的生物医学艾滋病毒预防策略之一(Auvert等人，2005年；Gray等人，2007年；Bailey等人，2007年)。模型显示，要对艾滋病毒/艾滋病流行产生最大影响，年轻成年男性人群必须高度感染MC，但这可能会被风险补偿(RC)抵消(Bollinger等人，2009；Gray，等人，2007；联合国艾滋病规划署，2009)；即，接受割礼的男性可能会通过增加他们的风险行为来补偿MC提供的保护(Templeton，2010)。对肯尼亚、乌干达和南非的三个MC随机对照试验(RCT)队列的随访表明，随着时间的推移，RC很少。然而，这些随机对照试验中的男性接受了密集(每隔3或6个月)的预防咨询、性病治疗和每次随访时提供的免费避孕套。因此，随机对照试验队列不太可能很好地表明在MC的普通推广中RC的发生程度，在这种情况下，重复强化预防咨询是不可行的。显然有必要确定在艾滋病毒高流行国家实施的国家MC计划中，接受割礼的男性是否会发生风险补偿，并制定预防战略。由于津巴布韦目前正在实施一项MC计划，作为其国家艾滋病毒预防战略的一部分，现在是进行纵向研究的理想时机和环境，以确定：a)通过该计划接受割礼的男性是否发生RC，b)RC的患病率及其随时间的变化，以及c)RC的行为决定因素。因此，我们建议进行一项队列研究，我们将从那些决定接受割礼的人中随机挑选1200名男性，并将1200名决定不接受割礼的男性作为非同等对照组。我们将在基线(包皮环切术前)以及6个月、12个月、24个月和36个月时对这些人进行调查，以确定RC是否在MC愈合后不久发生，或者RC是否持续更长时间。综合行为模型(Montano&Kasprzyk，2008)将为设计调查提供理论框架，以衡量RC行为的潜在环境(社会文化)和个人(态度、规范、个人代理、性满意度)决定因素。将进行分析，以确定接受割礼的男性与未接受割礼的男性在风险行为方面是否存在差异，以及RC随时间的变化模式；并确定最能解释RC的特定模型结构和信念。然后，这些结果将指导基于理论的预防信息。这项研究将包括津巴布韦两个主要城市哈拉雷和布拉瓦约的男性，这将使我们能够确定RC和决定因素是否存在种族差异(肖纳和马塔贝利)。这项研究将首次提供有关包皮环切术国家计划中风险补偿流行率的信息，并对这种行为的决定因素进行建模，以设计有效的风险预防信息。

DESCRIPTION (provided by applicant): Male circumcision (MC) is currently one of the most effective biomedical HIV-prevention strategies that can be implemented in high HIV prevalence countries (Auvert, et al, 2005; Gray, et al., 2007; Bailey, et al., 2007). Modeling shows that high uptake of MC must occur in a young adult male population to have the largest impact on the HIV/AIDS epidemic, but this may be offset by risk compensation (RC) (Bollinger et al., 2009; Gray, et al., 2007; UNAIDS, 2009); that is, men who are circumcised may compensate for the protection MC offers by increasing their risk behavior (Templeton, 2010). Follow-up with the three MC randomized control trial (RCT) cohorts in Kenya, Uganda, and South Africa suggests little RC over time. However, the men in these RCTs were followed intensely (every 3 or 6 months) with prevention counseling, STD treatment, and free condoms offered at each follow-up visit. Thus, the RCT cohorts are unlikely to provide a good indication of the degree to which RC will occur in an ordinary roll out of MC where repeat intensive prevention counseling is not feasible. There is a clear need to determine whether risk compensation occurs among men getting circumcised through national MC programs that are being implemented in high HIV-prevalence countries, and to develop strategies to prevent it. Since Zimbabwe is currently implementing an MC program as part of its national HIV prevention strategy, this is the ideal time and setting to conduct a longitudinal study to determine: a) whether RC occurs among men circumcised through this program, b) the prevalence and change in prevalence in RC over time since circumcision, and c) the behavioral determinants of RC. Thus, we propose to conduct a cohort study where we will accrue 1200 randomly selected men from those who have made a decision to get circumcised and a non-equivalent comparison group of 1200 men who have decided not to get circumcised. We will conduct surveys of these men at baseline (prior to circumcision) and at 6-, 12-, 24-, and 36-months, in order to determine whether RC occurs soon after MC healing or whether RC continues longer term. The Integrated Behavioral Model (Montano & Kasprzyk, 2008) will provide the theoretical framework for designing the survey to measure potential environmental (socio-cultural) and individual (attitudinal, normative, personal agency, sexual satisfaction) determinants of RC behavior. Analyses will be carried out to determine whether there is differential change in risk behavior among men who get circumcised compared with those who do not, and the patterns of change in RC over time; and to identify specific model constructs and beliefs that best explain RC. These results will then govern theory-based prevention messages. The study will include men in Zimbabwe's two main cities, Harare and Bulawayo, which will allow us to determine whether there are ethnic (Shona, Matabele) differences in RC and determinants. This study will be the first to provide information on the prevalence of risk compensation in a national program rolling out circumcision, as well as model the determinants of this behavior in order to design effective risk-prevention messages.