While the efficacy of male circumcision for HIV prevention was demonstrated in clinical trials, evidence on the long-term effectiveness of post-childhood circumcision through voluntary medical male circumcision (VMMC) programs in sub-Saharan Africa is limited. We assessed effectiveness of VMMC in preventing HIV acquisition in a President’s Emergency Plan for AIDS Relief (PEFAR) funded program in the Rakai region of Uganda using longitudinal data from the Rakai Community Cohort study (RCCS).
A cohort of initially uncircumcised HIV-uninfected men in the RCCS were followed between 2009 and 2016 in 30 communities during scale-up of VMMC programs. Self-reported data on circumcision status was collected and rapid HIV tests were done at five surveys conducted every 18 months. Incident HIV infection was estimated to occur at the midpoint of the inter-survey interval. Multivariable Poisson regression with generalized estimating equations was used to estimate adjusted incident rate ratios (IRR) and 95% confidence intervals (CI) of HIV acquisition in circumcised versus uncircumcised men adjusting for sociodemographic characteristics and sexual behaviors.
3,916 non-Muslim men were followed for 17,088 person-years over 9,469 study visits. There were 1,338 newly reported VMMCs (10.79/100py) and 138 incident HIV infections (0.81/100py) observed. At baseline, men adopting circumcision were significantly younger and more likely to have never initiated sex, consistently use condoms, and to be unmarried compared to uncircumcised men. Over the study period, the median age of men adopting circumcision declined from 28 years (interquartile range [IQR]:21-35) to 22 years (IQR:18-29; p-trend < 0.001). Overall, HIV incidence was 0.40/100 person-years (py) among circumcised men compared to 0.98/100 py among uncircumcised men (unadjusted IRR=0.4; 95% CI 0.25-0.66; adjusted IRR=0.47; 95% CI: 0.28-0.78). The effectiveness of circumcision for HIV prevention was sustained with increasing time from surgery (Figure) and was similar across age groups and calendar time.
A VMMC service program was highly effective in preventing HIV acquisition. The effectiveness of VMMC in this observational study is consistent with efficacy in clinical trials and support current recommendations that VMMC is a key component of combination HIV interventions and central to efforts to reduce HIV incidence.