Medical male circumcision (MMC) lowers the risk of heterosexually acquired HIV infection in men by approximately 60%. In Swaziland, self-reported MMC prevalence among adult males (18+years) was 8% in the 2007 Demographic and Health Survey, and 17% in the 2011 Swaziland HIV Incidence Measurement Survey (SHIMS), SHIMS1. The global target for MMC coverage is 80% in high HIV prevalence countries, and the Swazi national target is 70% by 2018. We assessed self-reported MMC prevalence in the 2016/7 SHIMS (SHIMS2).
SHIMS2 was a nationally representative, two-stage cluster randomized, cross-sectional household survey. From August 2016 to March 2017, male participants 15+ years self-reported MMC status through an individual questionnaire. We calculated the MMC prevalence by sociodemographic characteristics and HIV status. The Rao-Scott chi-square test was used to test group differences. Multivariate logistic models evaluated the associations between MMC status and sociodemographic characteristics: age, education, wealth quintile, location, marital and HIV status. All analyses were adjusted for survey design, non-coverage, and non-response.
Among the 4,815 men (median age 29.2 years, Interquartile range [IQR]: 19.9, 42.8), overall MMC prevalence was 27.1% (95% Confidence Interval [95% CI]: 25.3-29.0%) peaking in the age group 15-19 years 38.7% (95% CI: 35.1-42.3%) and lowest in the age group 65+ years 7.9% (95% CI: 4.8-11.1%), p<0.0001. In the multivariate analysis, the odds of self-reporting MMC were significantly lower among men aged 25+ (aOR=0.69, 95 CI%: 0.57-0.85) versus 15-24 yrs men; HIV positive men (aOR=0.55, 95% CI: (0.44-0.69); married men (aOR=0.72, 95%CI: 0.58-0.89) versus never married men; men with no education (aOR=0.52, 95%CI: 0.34-0.81) versus those with primary schooling. Compared to men in the middle wealth quintile, men in the highest quintile were more likely to self-report MMC (aOR=1.47, 95% CI: 1.09-1.97). Among males 18-49 years, MMC prevalence increased from 17% (95% CI: 16.2-18.4) in SHIMS1 to 28% (95% CI: 26.0-30.4) in SHIMS2.
Although a modest increase in MMC prevalence has been observed since 2011, the national and international targets will likely not be met. Innovative MMC approaches are needed to increase MMC prevalence, particularly among uneducated, low wealth and older men.