Male Circumcision Status Research Articles

Understanding male circumcision: insights from a peri-urban community in Maputo City, Mozambique.

Circumcision is a protective measure against sexually transmitted infections (STIs), reducing the risk of HIV infection. This study reported coverage of male circumcision and assessed the factors associated with male uncircumcision in a peri-urban area in Maputo City, Mozambique. This cross-sectional study of the Health Demographic Surveillance System in the Polana Caniço neighborhood investigated the sociodemographic and behavioral factors associated with uncircumcised males aged 15-49 y from October 2019 to June 2021. Data were collected from an HIV risk factors questionnaire and descriptive analyses conducted comparing self-reported male circumcision status by sociodemographic factors and sexual behaviors. The association was assessed via χ2 tests, and a multivariable logistic regression model was constructed. Adjusted ORs and 95% CIs were reported for factors associated with uncircumcised status. Of the 3481 males aged 15-49 y who responded to the questionnaire, 79.5% (2766) self-reported being circumcised. The percentage of uncircumcised men steadily increased with age, ranging from 12.4% (95) among males aged 15-19 y to 34.5% (148) of men aged 40-49 y. Men without education or with primary education, as well as those not practicing Islam, were 3-4 times more likely to be uncircumcised. Uncircumcised men were more likely to self-report an STI and a lack of condom use. Being uncircumcised was associated with not using condoms and having STIs, highlighting the need to further emphasize combination HIV-prevention programs and regular HIV/STI screening. Targeting males with lower education and across religions can help reach those with lower coverage of this effective prevention intervention.

The Association between Male Circumcision and Physical Intimate Partner/Spouse Violence in Kenya

Intimate partner violence against women is a global public health problem with many short-term and long-term effects on the physical and mental health of women and their children. Intimate partner/spouse violence is predominantly perpetrated by men against women victims. Sustainable Development Goal 5.2 aims to eliminate all forms of violence against all women and girls. This study sought to determine the association between of male circumcision and physical intimate partner/spouse violence in Kenya. Data from the nationwide and representative Kenya Demographic and Health Survey, conducted in 2014, were further analyzed. The Demographic and Health Survey utilizes a two stage stratified sampling technique. This study found that Male circumcision is very popular in Kenya (92.4%, n=12819). This study establishes that physical intimate partner/ spouse violence is rife in Kenya (34.5%, n=3265). A Pearson Chi Square test of independence found that there was a significant association between male circumcision status and physical intimate partner/spouse violence (x2(1) =44.51a, p<0.000). Binary Logistic regression predicted that the males who were uncircumcised had over two-fold higher odds of executing physical intimate partner/spouse violence compared to those were circumcised (OR 2.44, CI 1.86-3.19). This study concludes that male circumcision is beneficial in the long-term and adds to the holistic value of men beyond the physical removal of prepuce for health reasons. This study recommends male circumcision especially with a period of seclusion. This study recommends that programs should focus on initiatives or interventions that encourage male circumcision accompanied by structured learning programs during the period of initiates’ seclusion. Keywords: Male Circumcision, Intimate Partner/Spouse Violence, Social Cognitive Theory

HIV testing uptake and determinants among adolescents and young people in Burundi: a cross-sectional analysis of the Demographic and Health Survey 2016–2017

ObjectivesTo assess HIV testing uptake and its determinants among adolescents and young adults.DesignCross-sectional design involving analysis of 2016 Demographic and Health Survey data.SettingNationally representative survey of Burundi.ParticipantsA total of 7218...

Male circumcision uptake during the Botswana Combination Prevention Project.

Voluntary medical male circumcision (VMMC) uptake has been slow in some countries, including Botswana. To inform demand creation efforts, we examined sociodemographic characteristics and referral procedures associated with VMMC uptake in the Botswana Combination Prevention Project (BCPP) and examined the effectiveness of referral of men to MC services from HIV testing venues. BCPP was a community-randomized trial evaluating the impact of a combination HIV prevention package which included VMMC on community HIV incidence. We conducted a sub-analysis of VMMC uptake in intervention communities. During the initial VMMC campaign in 15 intervention communities, baseline male circumcision (MC) status was assessed among men eligible for HIV testing. Uncircumcised male community residents aged 16-49 years with negative/unknown HIV status were mobilized and linked to study VMMC services. Outcomes included MC baseline status and uptake through study services. Univariate and multivariate logistic regressions were performed to identify factors associated with MC uptake. Of 12,864 men eligible for testing, 50% (n = 6,448) were already circumcised. Among the uncircumcised men (n = 6,416), 10% (n = 635) underwent MC. Of the 5,071 men identified as eligible for MC through HIV testing services, 78% declined referral and less than 1% of those were circumcised. Of those accepting referral (n = 1,107), 16% were circumcised. Younger (16-24 years) (aOR: 1.51; 95%CI:1.22,1.85), unemployed men (aOR:1.34; 95%CI: 1.06,1.69), and those undergoing HIV testing at mobile venues (aOR: 1.88; 95%CI: 1.53,2.31) were more likely to get circumcised. Fear of pain was the most prevalent (27%) reason given for not being circumcised. Younger, unemployed men seeking HIV testing at mobile sites in Botswana were more likely to get VMMC. Addressing unique barriers for employed and older men may be necessary. Given the simplicity of VMMC as an intervention, the HIV testing programs offer a platform for identifying uncircumcised men and offering information and encouragement to access services.

HIV Incidence by Male Circumcision Status From the Population-Based HIV Impact Assessment Surveys-Eight Sub-Saharan African Countries, 2015-2017.

Male circumcision (MC) offers men lifelong partial protection from heterosexually acquired HIV infection. The impact of MC on HIV incidence has not been quantified in nationally representative samples. Data from the population-based HIV impact assessments were used to compare HIV incidence by MC status in countries implementing voluntary medical MC (VMMC) programs. Data were pooled from population-based HIV impact assessments conducted in Eswatini, Lesotho, Malawi, Namibia, Tanzania, Uganda, Zambia, and Zimbabwe from 2015 to 2017. Incidence was measured using a recent infection testing algorithm and analyzed by self-reported MC status distinguishing between medical and nonmedical MC. Country, marital status, urban setting, sexual risk behaviors, and mean population HIV viral load among women as an indicator of treatment scale-up were included in a random-effects logistic regression model using pooled survey weights. Analyses were age stratified (15-34 and 35-59 years). Annualized incidence rates and 95% confidence intervals (CIs) and incidence differences were calculated between medically circumcised and uncircumcised men. Men 15-34 years reporting medical MC had lower HIV incidence than uncircumcised men [0.04% (95% CI: 0.00% to 0.10%) versus 0.34% (95% CI: 0.10% to 0.57%), respectively; P value = 0.01]; whereas among men 35-59 years, there was no significant incidence difference [1.36% (95% CI: 0.32% to 2.39%) versus 0.55% (95% CI: 0.14% to 0.67%), respectively; P value = 0.14]. Medical MC was associated with lower HIV incidence in men aged 15-34 years in nationally representative surveys in Africa. These findings are consistent with the expected ongoing VMMC program impact and highlight the importance of VMMC for the HIV response in Africa.

Prevalence of male circumcision in four culturally non-circumcising counties in western Kenya after 10 years of program implementation from 2008 to 2019.

Kenya started implementing voluntary medical male circumcision (VMMC) for HIV prevention in 2008 and adopted the use of decision makers program planning tool version 2 (DMPPT2) in 2016, to model the impact of circumcisions performed annually on the population prevalence of male circumcision (MC) in the subsequent years. Results of initial DMPPT2 modeling included implausible MC prevalence estimates, of up to 100%, for age bands whose sustained high uptake of VMMC pointed to unmet needs. Therefore, we conducted a cross-sectional survey among adolescents and men aged 10-29 years to determine the population level MC prevalence, guide target setting for achieving the goal of 80% MC prevalence and for validating DMPPT2 modelled estimates. Beginning July to September 2019, a total of 3,569 adolescents and men aged 10-29 years from households in Siaya, Kisumu, Homa Bay and Migori Counties were interviewed and examined to establish the proportion already circumcised medically or non-medically. We measured agreement between self-reported and physically verified circumcision status and computed circumcision prevalence by age band and County. All statistical were test done at 5% level of significance. The observed MC prevalence for 15-29-year-old men was above 75% in all four counties; Homa Bay 75.6% (95% CI [69.0-81.2]), Kisumu 77.9% (95% CI [73.1-82.1]), Siaya 80.3% (95% CI [73.7-85.5]), and Migori 85.3% (95% CI [75.3-91.7]) but were 0.9-12.4% lower than DMPPT2-modelled estimates. For young adolescents 10-14 years, the observed prevalence ranged from 55.3% (95% CI [40.2-69.5]) in Migori to 74.9% (95% CI [68.8-80.2]) in Siaya and were 25.1-32.9% lower than DMMPT 2 estimates. Nearly all respondents (95.5%) consented to physical verification of their circumcision status with an agreement rate of 99.2% between self-reported and physically verified MC status (kappa agreement p-value<0.0001). This survey revealed overestimation of MC prevalence from DMPPT2-model compared to the observed population MC prevalence and provided new reference data for setting realistic program targets and re-calibrating inputs into DMPPT2. Periodic population-based MC prevalence surveys, especially for established programs, can help reconcile inconsistencies between VMMC program uptake data and modeled MC prevalence estimates which are based on the number of procedures reported in the program annually.

Estimating the HIV Effective Reproduction Number in the United States and Evaluating HIV Elimination Strategies.

The reproduction number is a fundamental epidemiologic concept used to assess the potential spread of infectious diseases and whether they can be eliminated. We estimated the 2017 United States HIV effective reproduction number, Re, the average number of secondary infections from an infected person in a partially infected population. We analyzed the potential effects on Re of interventions aimed at improving patient flow rates along different stages of the HIV care continuum. We also examined these effects by individual transmission groups. We used the HIV Optimization and Prevention Economics (HOPE) model, a compartmental model of disease progression and transmission, and the next-generation matrix method to estimate Re. We then projected the impact of changes in HIV continuum-of-care interventions on the continuum-of-care flow rates and the estimated Re in 2020. United States. The HOPE model simulated the sexually active US population and persons who inject drugs, aged 13 to 64 years, which was stratified into 195 subpopulations by transmission group, sex, race/ethnicity, age, male circumcision status, and HIV risk level. The estimated value of Re in 2017 and changes in Re in 2020 from interventions affecting the continuum-of-care flow rates. Our estimated HIV Re in 2017 was 0.92 [0.82, 0.94] (base case [min, max across calibration sets]). Among the interventions considered, the most effective way to reduce Re substantially below 1.0 in 2020 was to maintain viral suppression among those receiving HIV treatment. The greatest impact on Re resulted from changing the flow rates for men who have sex with men (MSM). Our results suggest that current prevention and treatment efforts may not be sufficient to move the country toward HIV elimination. Reducing Re to substantially below 1.0 may be achieved by an ongoing focus on early diagnosis, linkage to care, and sustained viral suppression especially for MSM.

Understanding the linkages between male circumcision and multiple sexual partnership among married Ghanaian men: Analysis of data from the 2014 Ghana demographic and health survey.

IntroductionThis current study sought to investigate the association between male circumcision status and engaging in multiple sexual partnership among men in Ghana.MethodsData from this study come from the men's file of the 2014 Ghana demographic and health survey. Both descriptive and inferential statistics were conducted among 1, 948 men and the level of statistical significance was pegged at p < 0.05.ResultsResults revealed that men who have been circumcised were more likely to engage in multiple sexual partnership (AOR = 3.36; CI:1.14–9.89), compared to those who have not been circumcised. With the covariates, men with primary level of education were more likely to have multiple sexual partners (AOR = 2.01; CI:1.10–3.69), compared to those with no education. With wealth status, men with richest (AOR = 2.27; CI:1.04–4.97), richer (AOR = 2.05; CI: 1.03–4.08), and middle wealth status (AOR = 1.83; CI:1.01–3.34) had the highest likelihood of having multiple sexual partners, compared to those with poorest wealth status. Conversely, men who professed the Islamic faith were less likely to engage in multiple sexual partnership (AOR = 0.58; CI: 0.36–0.94), compared to Christians. Similarly, men who resided in the Brong Ahafo (AOR = 0.51; CI: 0.26–0.99), Upper East (AOR = 0.41; CI:0.19–0.89), and Ashanti regions (AOR = 0.39; CI: 0.20–0.78) were less likely to engage in multiple sexual partnership.ConclusionBased on the current findings, educational campaigns by stakeholder groups (e.g., Ministry of Health in collaboration with the National Commission on Civic Education, civil society, educational institutions) should sensitize the sexually active population at the community level to consistently use condoms, especially when they have multiple sexual partners, even when a man is circumcised. Campaign messages must clearly emphasize that male circumcision should not substitute precautionary measures such as delay in the onset of sexual relationships, averting penetrative sex, reducing the number of sexual partners as well as correct and consistent use of male or female condoms regardless one's social standing.

Voluntary Medical Male Circumcision and Perceived Sexual Functioning, Satisfaction, and Risk Behavior: A Qualitative Study in Botswana.

This article examines perceptions of sexual functioning, satisfaction, and risk-taking related to voluntary medical male circumcision (VMMC) in Botswana. Twenty-seven focus group discussions were conducted in four purposively selected communities with community leaders, men, and women. Discussions were analyzed using an inductive content analytic approach. Perceptions of VMMC's impact on sexual functioning and satisfaction varied. Increased satisfaction was attributed to improved penile health and increased ejaculatory latency time, whereas decreased satisfaction was attributed to erectile dysfunction and increased vaginal irritation during sex. Most participants thought sexual disinhibition occurred after circumcision; nevertheless, some women said they used male circumcision status as a marker of HIV status, thereby influencing sexual decision-making and partner selection. Messaging should emphasize that VMMC does not afford complete HIV protection. Optimizing VMMC's impact requires increasing uptake while minimizing behavioral disinhibition, with a balance between potential messaging of improved sexual functioning and satisfaction and the potential impact on sexual disinhibition.

Sexually Transmitted Diseases at Monkey Bay Community Hospital in Mangochi, Malawi; an Analysis of Characteristics of Common Sexually Transmitted Diseases

We present the characteristics of the commonly diagnosed sexually transmitted infections (STI) at a clinic of Monkey Bay community hospital by a retrospective study. We conducted an audit of patients’ hospital records from a STIs clinic at Monkey Bay community hospital in Mangochi District (Malawi) covering a period from January 2019 to June 2019 (18 months). Data was tabulated in excel and analyses were made based on sex, age, male circumcision status, pregnancy and the pattern of STIs diagnosed within the chosen study period. A total number of 659 clients presented at STI clinic of Monkey Bay community hospital between January 2018 and June 2019. Out these clients, 409 (62%) were females and 250 (38%) were males. Most of the patients were in the age range of 25 years or above (447, 68%). Majority of the patients were HIV negative (523, 79%). Out of the 250 males, 113 (45%) were circumcised. Among female patients 56 of the 409 (14%) were pregnant. The most common presentations for all cases put together were lower abdominal pain (253, 38%), then urethral discharge (189, 29%), abnormal vaginal discharge (141, 21%), genital ulcer disease (64, 10%), in that order. Syphilis, genital warts, inguinal bubo and scrotal swelling were less common. The most common presentation in males was urethral discharge (178, 71%), while in females it was lower abdominal pain (214, 52%). Our audit showed that in Mangochi (Malawi) sexually transmitted diseases of various types are more common among young adults, females and uncircumcised men. There was no much difference in the percentage of STI’s between HIV positive and HIV negative people. These results point to an alarmingly high level of risky sexual behaviors among sexually active age groups in this part of Malawi, a country which still has one of the highest HIV prevalence in sub-Saharan Africa. This calls for continued and better research and control for transmission of STIs in the district.

What impact could DMPA use have had in South Africa and how might its continued use affect the future of the HIV epidemic?

IntroductionSome studies suggest that use of the injectable contraceptive depot medroxyprogesterone acetate (DMPA) may increase susceptibility to HIV infection. We aim to determine the influence that such an association could have had on the HIV epidemic in South Africa.MethodsWe simulate the heterosexual adult HIV epidemic in South Africa using a compartmental model stratified by age, behavioural risk group, sex, male circumcision status and contraceptive use. We model two possible scenarios: (1) The “With Effect” scenario assumes that DMPA increases susceptibility to HIV infection by 1.20‐fold (95% confidence interval 1.06 to 1.36) based on a combination of the results of a recent randomised controlled trial (ECHO trial) and a number of observational studies. (2) The “No Effect” scenario assumes that DMPA has no effect on HIV acquisition risk. We calculate the difference in HIV‐related outcomes between the With Effect and No Effect scenarios to determine the potential impact that DMPA use could have had on the HIV epidemic.ResultsA causal association between DMPA and HIV acquisition could have caused 430,000 (90% of model runs 160,000 to 960,000) excess HIV infections and 230,000 (90,000 to 470,000) AIDS deaths in South Africa from 1980 to 2017. These figures represent 4.3% (1.6% to 9.6%) and 6.9% (2.6% to 15.2%) of the total modelled estimates of HIV infections and AIDS deaths respectively in South Africa in that period. Of the additional infections, 36% (25% to 48%) would have occurred among men. If DMPA use continues at current levels, a potential causal association could cause an additional 130,000 (50,000 to 270,000) infections between 2018 and 2037. The excess infections would have required an additional 640,000 (190,000 to 1,660,000) years of ART from 1980 to 2017, and a further 2,870,000 (890,000 to 7,270,000) years of ART from 2018 to 2037.ConclusionsIf there is a causal association between DMPA use and HIV risk, it could have substantially increased the scale of the HIV epidemic in South Africa, affecting not only the users of DMPA, but also their partners and the wider population. The magnitude of this potential effect demands careful data collection and a careful consideration of policy choices for contraception in settings with large HIV epidemics.

A cross-sectional study of the factors associated with male circumcision status among college youth in Ndola, Zambia, 2016.

New cases of HIV are increasing among young adults in Zambia; yet voluntary medical male circumcision (VMMC) coverage as an HIV prevention measure remains low. Despite having the highest HIV burden in the province, Ndola district had a VMMC coverage of 23% in 2015 compared to the national target of 80% among high-risk groups. To determine predictive factors associated with circumcision status among male students in Ndola district. We conducted a cross-sectional study in May 2016 among students aged 18-35 years enrolled in five conveniently sampled colleges. We administered a structured questionnaire to assess the knowledge, attitudes and perceptions about VMMC. We used multivariable logistic regression to determine factors associated with male circumcision (MC) status. Of 136 students interviewed, 63% were circumcised, and of those, 96% were medically circumcised. Half of all students were aged 21-24 years. Those who perceived the circumcision procedure to be 'safe' (adjusted odds ratio [aOR] = 5.13; 95% CI: 2.09-14.82), and knew that it reduced female to male HIV transmission risk (aOR = 3.65; 95% CI: 3.12-11.67), were more likely to be circumcised. The perception that MC promotes 'promiscuous behaviour' (aOR = 0.20; 95% CI: 0.07-0.61), and that sexual sensitivity is the 'same' regardless of circumcision status, were associated with not being circumcised (aOR = 0.13; 95% CI: 0.02-0.80). Students had adequate knowledge about the safety of medical circumcision, and the subsequent risk reduction of HIV infection. Interventions aimed at addressing negative sexual perceptions about circumcision may increase VMMC coverage among college students.

Knowledge about male circumcision and perception of risk for HIV among youth in Harare, Zimbabwe.

BackgroundMale circumcision will require high uptake among previously non-circumcising countries to realise the impact of circumcising in preventing HIV. Little is known about whether youths are knowledgeable about male circumcision and its relationship with HIV prevention and their perception of risk of HIV infection.ObjectiveThis article aimed to ascertain youth’s knowledge about male circumcision and perception of risk of HIV infection.MethodsA quantitative study on 784 youth (men aged 15–35 years) was conducted in Harare, Zimbabwe, after obtaining their consent. Multivariate analysis examined the associations between background characteristics and knowledge about male circumcision and the perception of risk of HIV infection.ResultsThe results revealed that age was a significant predictor of knowledge about male circumcision among youth in Harare, as was educational attainment and ever having tested for HIV. In addition, youth who had heard of voluntary medical male circumcision were more likely to have high knowledge of male circumcision compared to those who had never heard of it. The results also showed that male circumcision status was associated with higher knowledge about male circumcision compared to those who were not circumcised. The study also found that educational attainment, belonging to the Shona ethnic group, never having tested for HIV and disapproval of voluntary counselling and testing prior to male circumcision were associated with the perception of risk of HIV infection.ConclusionThe study provides two recommendations: the need to strengthen perceived susceptibility to HIV among the youth and the need for advocacy on the health benefits of male circumcision.

Sex and Male Circumcision: Women's Preferences Across Different Cultures and Countries: A Systematic Review.

IntroductionWomen’s choices for a sexual partner are influenced by numerous personal, cultural, social, political and religious factors, and may also include aspects of penile anatomy such as male circumcision (MC) status.AimTo perform a systematic review examining (i) whether MC status influences women’s preference for sexual activity and the reasons for this, and (ii) whether women prefer MC for their sons.MethodsPRISMA-compliant searches were conducted of PubMed, Google Scholar, Embase, and the Cochrane Database of Systematic Reviews. Articles that met the inclusion criteria were rated for quality using the SIGN system.ResultsDatabase searches identified 29 publications with original data for inclusion, including 22 for aim (i) and 4 of these and 7 others pertaining to aim (ii). In the overwhelming majority of studies, women expressed a preference for the circumcised penis. The main reasons given for this preference were better appearance, better hygiene, reduced risk of infection, and enhanced sexual activity, including vaginal intercourse, manual stimulation, and fellatio. In studies that assessed mothers’ preference for MC of sons, health, disease prevention, and hygiene were cited as major reasons for this preference. Cultural differences in preference were evident among some of the studies examined. Nevertheless, a preference for a circumcised penis was seen in most populations regardless of the frequency of MC in the study setting.ConclusionWomen’s preferences generally favor the circumcised penis for sexual activity, hygiene, and lower risk of infection. The findings add to the already well-established health benefits favoring MC and provide important sociosexual information on an issue of widespread interest.Morris BJ, Hankins CA, Lumbers ER, et al. Sex and Male Circumcision: Women’s Preferences Across Different Cultures and Countries: A Systematic Review. Sex Med 2019;7:145–161.

Are circumcised men safer sex partners? Findings from the HAALSI cohort in rural South Africa.

IntroductionThe real-world association between male circumcision and HIV status has important implications for policy and intervention practice. For instance, women may assume that circumcised men are safer sex partners than non-circumcised men and adjust sexual partnering and behavior according to these beliefs. Voluntary medical male circumcision (VMMC) is highly efficacious in preventing HIV acquisition in men and this biological efficacy should lead to a negative association between circumcision and HIV. However, behavioral factors such as differential selection into circumcision based on current HIV status or factors associated with future HIV status could reverse the association. Here, we examine how HIV prevalence differs by circumcision status in older adult men in a rural South African community, a non-experimental setting in a time of expanding VMMC access.MethodsWe analyzed data collected from a population-based sample of 2345 men aged 40 years and older in a rural community served by the Agincourt Health and socio-Demographic Surveillance System site in Mpumalanga province, South Africa. We describe circumcision prevalence and estimate the association between circumcision and laboratory-confirmed HIV status with log-binomial regression models.ResultsOne quarter of older men reported circumcision, with slightly more initiation-based circumcisions (56%) than hospital-based circumcisions (44%). Overall, the evidence did not suggest differences in HIV prevalence between circumcised and uncircumcised men; however, those who reported hospital-based circumcision were more likely to test HIV-positive [PR (95% CI): 1.28 (1.03, 1.59)] while those who reported initiation-based circumcision were less likely to test HIV-positive [PR (95% CI): 0.68 (0.51, 0.90)]. Effects were attenuated, but not reversed after adjustment for key covariates.ConclusionsMedically circumcised older men in a rural South African community had higher HIV prevalence than uncircumcised men, suggesting that the effect of selection into circumcision may be stronger than the biological efficacy of circumcision in preventing HIV acquisition. The impression given from circumcision policy and dissemination of prior trial findings that those who are circumcised are safer sex partners may be incorrect in this age group and needs to be countered by interventions, such as educational campaigns.

Effects of Reaching National Goals on HIV Incidence, by Race and Ethnicity, in the United States.

Human immunodeficiency virus (HIV) incidence and prevalence in the United States are characterized by significant disparities by race/ethnicity. National HIV care goals, such as boosting to 90% the proportion of persons whose HIV is diagnosed and increasing to 80% the proportion of persons living with diagnosed HIV who are virally suppressed, will likely reduce HIV incidence, but their effects on HIV-related disparities are uncertain. We sought to understand by race/ethnicity how current HIV care varies, the level of effort required to achieve national HIV care goals, and the effects of reaching those goals on HIV incidence and disparities. Using a dynamic model of HIV transmission, we identified 2016 progress along the HIV care continuum among blacks, Hispanics, and whites/others compared with national 2020 goals. We examined disparities over time. United States. Beginning in 2006, our dynamic compartmental model simulated the sexually active US population 13 to 64 years of age, which was stratified into 195 subpopulations by transmission group, sex, race/ethnicity, age, male circumcision status, and HIV risk level. We compared HIV cumulative incidence from 2016 to 2020 when goals were reached compared with base case assumptions about progression along the HIV care continuum. The 2016 proportion of persons with diagnosed HIV who were on treatment and virally suppressed was 50% among blacks, 56% among Hispanics, and 61% among whites/others, compared with a national goal of 80%. When diagnosis, linkage, and viral suppression goals were reached in 2020, cumulative HIV incidence fell by 32% (uncertainty range: 18%-37%) for blacks, 25% (22%-31%) for Hispanics, and 25% (21%-28%) for whites/others. Disparity measures changed little. Achieving national HIV care goals will require different levels of effort by race/ethnicity but likely will result in substantial declines in cumulative HIV incidence. HIV-related disparities in incidence and prevalence may be difficult to resolve.

Agreement between self-reported and physically verified male circumcision status in Nyanza region, Kenya: Evidence from the TASCO study

BackgroundSelf-reported male circumcision (MC) status is widely used to estimate community prevalence of circumcision, although its accuracy varies in different settings depending on the extent of misreporting. Despite this challenge, self-reported MC status remains essential because it is the most feasible method of collecting MC status data in community surveys. Therefore, its accuracy is an important determinant of the reliability of MC prevalence estimates based on such surveys. We measured the concurrence between self-reported and physically verified MC status among men aged 25–39 years during a baseline household survey for a study to test strategies for enhancing MC uptake by older men in Nyanza region of Kenya. The objective was to determine the accuracy of self-reported MC status in communities where MC for HIV prevention is being rolled out.MethodsAgreement between self-reported and physically verified MC status was measured among 4,232 men. A structured questionnaire was used to collect data on MC status followed by physical examination to verify the actual MC status whose outcome was recorded as fully circumcised (no foreskin), partially circumcised (foreskin is past corona sulcus but covers less than half of the glans) or uncircumcised (foreskin covers half or more of the glans). The sensitivity and specificity of self-reported MC status were calculated using physically verified MC status as the gold standard.ResultsOut of 4,232 men, 2,197 (51.9%) reported being circumcised, of whom 99.0% were confirmed to be fully circumcised on physical examination. Among 2,035 men who reported being uncircumcised, 93.7% (1,907/2,035) were confirmed uncircumcised on physical examination. Agreement between self-reported and physically verified MC status was almost perfect, kappa (k) = 98.6% (95% CI, 98.1%-99.1%. The sensitivity of self-reporting being circumcised was 99.6% (95% CI, 99.2–99.8) while specificity of self-reporting uncircumcised was 99.0% (95% CI, 98.4–99.4) and did not differ significantly by age group based on chi-square test. Rate of consenting to physical verification of MC status differed by client characteristics; unemployed men were more likely to consent to physical verification (odds ratio [OR] = 1.48, (95% CI, 1.30–1.69) compared to employed men and those with post-secondary education were less likely to consent to physical verification than those with primary education or less (odds ratio [OR] = 0.61, (95% CI, 0.51–0.74).ConclusionsIn this Kenyan context, both sensitivity and specificity of self-reported MC status was high; therefore, MC prevalence estimates based on self-reported MC status should be deemed accurate and applicable for planning. However MC programs should assess accuracy of self-reported MC status periodically for any secular changes that may undermine its usefulness for estimating community MC prevalence in their unique settings.

Difficult decisions: Evaluating individual and couple-level fertility intentions and HIV acquisition among HIV serodiscordant couples in Zambia.

IntroductionAttempts to conceive and pregnancy may increase HIV transmission to sex partners and infants. Our study evaluated the association between fertility intentions and HIV acquisition among Zambian HIV-serodiscordant couples.MethodsWe collected demographic, behavioral, clinical exposures, and data on fertility intentions in a cohort of HIV-serodiscordant couples in Lusaka, Zambia from 2005 to 2012. We evaluated factors associated with fertility intentions stratified by gender using multivariable logistic regression. Multivariable Cox proportional hazard models were used to evaluate the associations between fertility intentions and HIV acquisition controlling for a priori confounders and covariates that substantially (>10%) changed the effect estimates in univariate analyses.ResultsAmong 1,029 serodiscordant couples, 311 agreed that they wanted children in the future (30%), 368 agreed they did not want children (36%), and 344 couples disagreed about having children (34%), with men more likely than women to want children. Women wanting child(ren) was associated with increased odds of baseline pregnancy (adjusted odds ratio [aOR] = 4.80 (95% confidence interval [CI] = 2.93, 7.85)), fewer previous pregnancies (aOR = 0.85 per additional pregnancy (95% CI = 0.78, 0.93)), and partner fertility intention (aOR = 2.89 (95% CI = 2.14, 3.91)) adjusting for woman’s age, literacy, years cohabiting and HIV status. Men wanting child(ren) was associated with younger age (aOR = 0.96 per year (95% CI = 0.93, 0.99)), fewer years cohabiting (aOR = 0.95 (95% CI = 0.92, 0.98)), number of previous partners’ pregnancies (aOR = 0.90 (95% CI = 0.82, 0.98)), and partner fertility intention (aOR = 3.00 (95% CI = 2.21, 4.07)) adjusting for partner’s age, literacy, HIV status and partner’s baseline pregnancy. In adjusted survival analyses, HIV-negative women were more likely to seroconvert if they themselves wanted children (aHR = 2.36 (95% CI = 1.41, 3.96)) vs. did not want children, or if their partner wanted children (aHR = 2.34 (95% CI = 1.33, 4.11)) vs. did not want children, or if the couple agreed that they wanted children (aHR = 2.08 (95% CI = 1.01, 4.30)), adjusting for women’s age, women’s literacy, previous pregnancies and time in study. HIV-negative men were more likely to seroconvert if their female partner wanted a child in the next 12-months (aHR = 1.94 (95% CI = 1.02, 3.68)) vs. did not want children, and when both partners wanted children (aHR = 2.02 (CI = 1.09, 3.73)) vs. they did not want children, adjusting for men’s age and literacy, couple income, number of live children, male circumcision status and time in study.ConclusionWomen had increased risk of HIV acquisition if they and/or their partner wanted a child, while men had increased risk of HIV acquisition when their partner or if both partners agreed that they wanted children. Safer-conception interventions are needed to protect HIV uninfected women and men from HIV acquisition in HIV-serodiscordant couples who want children.

Foreskin and the molecular politics of risk.

In this paper, I examine disputes over recent claims that male circumcision reduces HIV risk to suggest a complicated relationship between risk individualization and categorization. Whereas randomized controlled trials (RCTs) conducted in sub-Saharan Africa appear to have provided key evidence for the World Health Organization's endorsement of male circumcision as an HIV prevention strategy, RCTs alone did not provide evidence for the underlying causal mechanism. For that, medical authorities have turned to histo-immunological studies of the foreskin's biomolecular vulnerability to HIV, thus molecularizing risk. Some actors used these studies both as a way of shoring up results of RCTs conducted in sub-Saharan Africa and as an important rationale in arguments for making neonatal circumcision more widely available. Others, however, resisted this move to generalize the RCT results to other parts of the world, citing both contextual differences in HIV transmission patterns and conflicting scientific details regarding the biomolecular basis of the foreskin's susceptibility. Nevertheless, by locating an abstract notion of relative risk in the body itself, I argue that histological studies of foreskin have played a key role in stabilizing male circumcision status as a new risk category, largely independent of a given individual's risk profile.

Changes in Male Circumcision Prevalence and Risk Compensation in the Kisumu, Kenya Population, 2008-2013.

Three randomized controlled trials showed that voluntary medical male circumcision (VMMC) reduces the risk of female-to-male HIV transmission by approximately 60%. However, data from communities where VMMC programs have been implemented are needed to assess changes in circumcision prevalence and whether men and women compensate for perceived reductions in risk by increasing their HIV risk behaviors. Scale-up of free VMMC began in Kisumu, Kenya in 2008. Between 2009 and 2013, a sequence of 3 unlinked cross-sectional surveys were conducted. All individuals 15-49 years of age residing in randomly selected households were interviewed and offered HIV testing. Male circumcision status was confirmed by examination. Design-adjusted bivariate comparisons and multivariable analyses were used for statistical inference. The prevalence of male circumcision increased from 32% (95% CI: 26% to 38%) in 2009 to 60% (95% CI: 56% to 63%) in 2013. The adjusted prevalence ratio of HIV and genital ulcer disease in circumcised compared with uncircumcised men was 0.48 (95% CI: 0.36 to 0.66) and 0.51 (95% CI: 0.37 to 0.69), respectively. There was no association between circumcision status and sexual behaviors, HIV knowledge, or indicators of risk perception. The conditions necessary for the VMMC program to have a significant public health impact are present in Kisumu, Kenya. Between 2009 and 2013, circumcision prevalence increased from 30% to 60%; HIV prevalence in circumcised men was half that of uncircumcised men, and there was no or minimal sexual risk compensation.