Text messaging did not help reduce
early resumption of sex after male circumcision (MC) in a large randomised, controlled
trial conducted at twelve sites in Nyanza province, Kenya, published in the advance
online edition of the Journal of Acquired
Immune Deficiency Syndromes.
However, the study did confirm
a number of key risk factors for resumption of sexual activity prior to wound
healing, and also identified that men who resumed sex before the end of the
recommended period of abstinence were more likely to have unprotected sex when
they did so.
In this, believed to be the
first trial assessing the effect of text messaging after circumcision for HIV
prevention, approximately one in three (28.3% or 139 of 491) in the intervention
group resumed sex before the 42-day recommended abstinence period following MC,
comparable to the 25.2% (124 of 493) in the control group, relative risk (RR)
=1.13, 95% CI: 0.91-1.38, p=0.3.
Studies have found medical male
circumcision reduces female-to-male transmission of HIV by approximately 50 to 75%
and may reduce male-to-female transmission by 46%.
Following circumcision, men
are advised to abstain from sex for at least six weeks to ensure complete wound
healing. Sexual activity during this healing period may
increase the risk of HIV-negative men getting HIV, of HIV-positive men
transmitting HIV, and of post-operative surgical complications.
The authors note, in spite of
these risks, early resumption of sex has been high; examples cited include
observational studies showing approximately one in three (31%) and one in four (24%)
in Kenya and Zambia, respectively, did so.
An estimated 80% of people in
resource-poor settings now have access to mobile phones. The use of mobile
phone technology offers a cost-effective, easily accessible tool to complement
public-health interventions, so improving health outcomes and potentially
The authors note that in the
absence of empirical data, UNAIDS recommends SMS as part of strategic
communications to fast track scale-up of MC and provide high-quality services.
Text messaging, while not
universally successful, has been effective in a variety of settings and health
interventions including improved adherence to ART, early infant diagnosis,
promotion of smoking cessation and improved vaccination uptake.
The authors wanted to see
whether a series of one-way educational and reminder SMS would deter early
self-reported resumption of sexual activity after MC.
A total of 3572 men were assessed for
eligibility between September 2010 and April 2011, of whom 1200 men were randomised to receive either a series of text messages or usual care.
The participants were all over the age of 18, had a mobile phone, had just undergone circumcision
and were willing to respond to a phone interview after six weeks. The primary outcome was
self-reported resumption of sexual activity before 42 days after MC.
Following randomisation, all
participants sent a registration text message with the study site and their identification
number and received US$0.25 of airtime to cover the costs. For those in the SMS
arm, the message included the preferred time of day and preferred language (English,
Kiswahili or Dholuo) for receiving intervention messages.
Usual care comprised HIV
testing and counselling, screening and treatment for sexually transmitted
infections, condom promotion and provision, risk-reduction and safe-sex
counselling, the MC procedure and post-operative review seven days after
For the first seven days,
messages were sent once a day. After this point, messages were sent on days 8,
14, 21, 28, 35, 41 and 42 after the procedure.
While the use of SMS improved clinic
attendance following MC for HIV prevention in a previous study, it had no effect
on deterring early resumption of sexual activity in this study.
Conflicting results of SMS
are not unique to the authors’ research. They cite the example of the Cameroon
Mobile Phone SMS trial where text messaging had no effect on ART adherence, in
sharp contrast to two randomised trials in Kenya showing significant benefit.
The high overall proportion
resuming sex within 42 days (26.7%) is in keeping with other findings in
sub-Saharan Africa. Yet it is in stark contrast to two randomised trials in
Kisumu, Kenya and Rakai, Uganda where only 3.9% and 5.4%, respectively, did so. This
may be explained, the authors write, by the intense, individually tailored
risk-reduction counselling given at each study visit. Most MC programmes, they
add, include counselling only at the time of circumcision.
Ninety per cent of those who resumed sex
early did so more than 28 days after MC. This may be due to their perception of
completion of wound healing, note the authors. The message sent on day 28
advised men not to have sex until they were fully healed and may inadvertently
have supported them in resuming sex early.
Approximately one third of
men are not healed by week 42; self-assessment of wound healing is in agreement
with the clinician's assessment only 65% of the time.
Among those who resumed sex
before the end of the recommended period of abstinence, unprotected sex was
more frequent among those who received text messages. Eighty-seven of 135 participants (64.4%) in the SMS
group, compared to 47.5% (58/122) in the control group, reported unprotected sex.
Married men and those
referred to the clinic from a voluntary counselling and testing centre were
also more likely to have unprotected sex during the wound-healing period.
Future interventions, note
the authors, need to focus on risk reduction throughout the healing period and
to encourage abstinence until after day 42 regardless of wound appearance. Only
day-8 messages explicitly told the men to delay sex for six weeks.
The authors note, however, additional
analysis of the data did provide new insights and identification of key risk
factors, consistent with other studies, for early resumption of sex. These include being
married or living with a sexual partner (adjusted RR 1.57, 95% CI: 1.18-2.08,
p<0.01), reporting one or more sexual partners in the month before MC, older
age, employment and primary school or lower education level.
Study limitations include not
asking if and how many messages were received; nor were data on phone sharing collected.
The authors conclude, “as MC
programmes continue to expand… [early] resumption of sex…will continue to be an
issue to address, and a possible threat to significant reduction in HIV
incidence. Our findings point to several key risk factors…that MC programmes
should take into account as they develop interventions to address this issue.”