Voluntary medical male circumcision and educational gradient in relation to HIV infection among sexually active adult men in Eswatini: evidence from the national surveys in 2006-2007 and 2016

BACKGROUND

To address knowledge gaps, this study examined social determinants, such as education attainment and HIV prevention, among sexually active men (SAM), with a focus on voluntary medical male circumcision (VMMC).

METHODS

Two nationally representative surveys, the Eswatini Demographic and Health Survey 2006 and the Eswatini HIV Incidence Measurement Survey 2016, were used to estimate whether or not VMMC at the individual and community levels contributes to HIV disparities to any meaningful extent. Multilevel logistic regression models further explored the educational gradient in HIV infection for 2006-2007 and 2016 with regard to VMMC among SAM, while adjusting for household poverty, sexual practices and individual characteristics.

RESULTS

Among SAM with tertiary education, HIV prevalence declined from 25.0% in 2006-2007 to 10.5% in 2016. A 51% decrease in HIV prevalence was found to be associated with an increase in VMMC (adjusted odds ratio 0.49; 95% CI 0.40 to 0.60). Compared with SAM with tertiary education, those who had a lower level of education were more likely to have HIV infection and this education gradient effect had become particularly profound in 2016.

CONCLUSIONS

VMMC began to be promoted in 2008 in Eswatini and results suggest its effect, along with the education attainment effect, significantly resulted in a meaningful reduction in HIV prevalence among SAM by 2016.

Male circumcision uptake and misperceived norms about male circumcision: Cross-sectional, population-based study in rural Uganda

Background

Over the past decade, 15 high-priority countries in eastern and southern Africa have promoted voluntary medical male circumcision for human immunodeficiency virus (HIV) and sexually transmitted infection (STI) prevention. The prevalence of male circumcision in Uganda nearly doubled from 26% in 2011 to 43% in 2016, but remains below the 2020 target level. Little is known about how common male circumcision is perceived to be, how accurate such perceptions are, and whether they are associated with men's own circumcision uptake.

Methods

We conducted a cross-sectional study of all adult residents of eight villages in Rwampara District, southwestern Uganda in 2020-2022. We elicited their perceptions of the adult male circumcision prevalence within their village: >50% (most men), 10% to <50% (some), <10%, (few to none), or do not know. We compared their perceived norms to the aggregated prevalence of circumcision reported in these villages. We used a modified multivariable Poisson regression model to estimate the association between perceived norms and personal circumcision uptake among men.

Results

We surveyed 1566 participants (91% response rate): 698 men and 868 women. Among the men, 167 (27%) reported being circumcised, including 167/444 (38%) men <50 years of age. Approximately one-fourth of the population (189 (27%) men and 177 (20%) women) believed that few to no men in their own village had been circumcised. In a multivariable regression model, men who underestimated the prevalence of male circumcision were less likely to be circumcised themselves (adjusted relative risk (aRR) = 0.51; 95% confidence interval (CI) = 0.37-0.83).

Conclusions

In this population-based study in rural Uganda, one-fourth of men underestimated the prevalence of male circumcision. Men who underestimated the extent of circumcision uptake were themselves less likely to be circumcised. If the observed association is causal and underestimates within the population contribute to low uptake, then interventions correcting these misperceived norms could increase uptake of voluntary medical male circumcision.

Non-therapeutic male circumcision in infancy or childhood and risk of human immunodeficiency virus and other sexually transmitted infections: national cohort study in Denmark

Whether male circumcision in infancy or childhood provides protection against the acquisition of human immunodeficiency virus (HIV) or other sexually transmitted infections (STIs) in adulthood remains to be established. In the first national cohort study to address this issue, we identified 810,719 non-Muslim males born in Denmark between 1977 and 2003 and followed them over the age span 0–36 years between 1977 and 2013. We obtained information about cohort members’ non-therapeutic circumcisions, HIV diagnoses and other STI outcomes from national health registers and used Cox proportional hazards regression analyses to calculate hazard ratios (HRs) with 95% confidence intervals (CIs) associated with foreskin status (i.e., circumcised v. genitally intact). During a mean of 22 years of follow-up, amounting to a total observation period of 17.7 million person-years, 3375 cohort members (0.42%) underwent non-therapeutic circumcision, and 8531 (1.05%) received hospital care for HIV or other STIs. Compared with genitally intact males, rates among circumcised males were not statistically significantly reduced for any specific STI. Indeed, circumcised males had a 53% higher rate of STIs overall (HR = 1.53, 95% CI: 1.24–1.89), and rates were statistically significantly increased for anogenital warts (74 cases in circumcised males v. 7151 cases in intact males, HR = 1.51; 95% CI: 1.20–1.90) and syphilis (four cases in circumcised males v. 197 cases in intact males, HR = 3.32; 95% CI: 1.23–8.95). In this national cohort study spanning more than three decades of observation, non-therapeutic circumcision in infancy or childhood did not appear to provide protection against HIV or other STIs in males up to the age of 36 years. Rather, non-therapeutic circumcision was associated with higher STI rates overall, particularly for anogenital warts and syphilis.