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）是目前最有效的生物医学艾滋病毒预防策略之一，可在艾滋病毒高流行国家实施（Auvert等，2005；Gray等，2007；Bailey等，2007）。模型显示，要对艾滋病毒/艾滋病流行产生最大影响，必须在年轻成年男性人群中大量摄取MC，但这可能被风险补偿（RC）抵消（Bollinger等人，2009；Gray等人，2007；UNAIDS, 2009）；也就是说，割包皮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被密切跟踪（每3或6个月），并在每次随访中提供预防咨询、性病治疗和免费安全套。因此，RCT队列不太可能提供一个很好的指示，在MC的普通推广中，重复强化预防咨询是不可行的，RC将在多大程度上发生。显然，有必要确定在艾滋病毒高流行国家实施的国家MC项目中，接受包皮环切手术的男性是否会出现风险补偿，并制定预防策略。由于津巴布韦目前正在实施MC计划，作为其国家艾滋病预防战略的一部分，这是进行纵向研究的理想时机和环境，以确定：a)通过该计划进行割礼的男性中是否发生了RC， b)自割礼以来RC的流行程度和流行程度的变化，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，我们将从决定接受包皮环切术的男性和决定不接受包皮环切术的1200名男性中随机选择1200名男性作为对照组。我们将在基线（包皮环切术前）和6、12、24和36个月时对这些男性进行调查，以确定RC是否在MC愈合后不久发生，还是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，以测量RC行为的潜在环境（社会文化）和个人（态度、规范、个人代理、性满足）决定因素。将进行分析，以确定做过包皮环切术的男性与未做过包皮环切术的男性在危险行为方面是否存在差异变化，以及随时间变化的RC模式；并确定最能解释RC的特定模型结构和信念。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在RC和决定因素方面是否存在种族差异（Shona, Matabele）。这项研究将首次提供有关在推行包皮环切术的国家规划中风险补偿流行程度的信息，并对这种行为的决定因素进行建模，以便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.