Text messages do not reduce early resumption of sexual activity in recently circumcised men

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 changing behaviours.

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 surgery.

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.”