Abstract
BackgroundVoluntary medical male circumcision has been promoted in high HIV prevalence settings to prevent HIV acquisition in males. However, the uptake of circumcision in many sub-Saharan African settings remains low. While many studies have measured circumcision prevalence, understanding circumcision incidence and its predictors is vital to achieving ambitious circumcision prevalence targets.SettingRural KwaZulu-Natal, South Africa.MethodsWe measured circumcision incidence over the period 2009–2014 in a longitudinal population-based cohort with high HIV prevalence and low circumcision prevalence. Multivariable survival models with Weibull distributions were used to assess socio-demographic, behavioral and biological predictors of circumcision incidence.ResultsBetween 2009 and 2014, circumcision prevalence among males 15–49 years in the cohort increased from 3% to 24%. Among 6,203 males 15–49 years, 873 new circumcisions occurred over 13,678 person-years (incidence rate: 6.4/100 person-years, 95% CI 6.0–6.8). Circumcision incidence was substantially higher amongst young males: 15–19 year olds were twice as likely to circumcise as older males. In the survival model, shorter household distance to the nearest healthcare facility, knowledge of HIV status and biological HIV-negative status were associated with an increased likelihood of circumcision incidence.ConclusionsCircumcision prevalence among males in rural KwaZulu-Natal remains well below South Africa’s national 80% coverage target across age groups. In this population, distance to the nearest healthcare facility and knowledge of HIV status were important independent predictors of circumcision incidence. Mobile circumcision clinics and innovative HIV testing services may be important tools to help achieve circumcision targets.
Highlights
Circumcision incidence was substantially higher amongst young males: 15–19 year olds were twice as likely to circumcise as older males
Global voluntary medical male circumcision (VMMC) prevalence and incidence remains low despite efforts to scale the HIV prevention intervention.[1,2]
VMMC is one of the most effective HIV prevention interventions; three randomized controlled trials found that it reduced the risk of female-to-male HIV transmission by approximately 60%.[3,4,5,6]
Summary
Global voluntary medical male circumcision (VMMC) prevalence and incidence remains low despite efforts to scale the HIV prevention intervention.[1,2] VMMC is one of the most effective HIV prevention interventions; three randomized controlled trials found that it reduced the risk of female-to-male HIV transmission by approximately 60%.[3,4,5,6] Since VMMC has been included as a key component of combination HIV prevention strategies, which haven successfully shown reductions in population-level HIV incidence.[7,8] One of the advantages of VMMC compared to other HIV prevention interventions, such as condom use or pre-exposure prophylaxis, is that its effectiveness does not rely on repeated and consistent behaviors. In 2010, the World Health Organization (WHO) recommended VMMC as an important strategy for the prevention of HIV transmission and identified 14 priority countries in eastern and southern sub-Saharan Africa for targeted scale-up of VMMC.[9,10]. South Africa, one of WHO’s 14 VMMC priority countries, [2] began expanding VMMC programs around 2010 and set ambitious national and provincial targets to achieve 80% circumcision coverage among males 15–49 years by 2015, and maintain this coverage through to 2025.[9,11] South Africa’s VMMC guidelines encourage all males not living with HIV to undergo VMMC at their nearest health facility. While many studies have measured circumcision prevalence, understanding circumcision incidence and its predictors is vital to achieving ambitious circumcision prevalence targets.
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