Adult male circumcision as an intervention against HIV: an operational study of uptake in a South African community (ANRS 12126)

Abstract

Background: To evaluate the knowledge, attitudes and beliefs about adult male circumcision (AMC), assess the association of AMC with HIV incidence and prevalence, and estimate AMC uptake in a Southern African community.

Methods: A cross-sectional biomedical survey (ANRS-12126) conducted in 2007-2008 among a random sample of 1198 men aged 15 to 49 from Orange Farm (South Africa). Face-to-face interviews were conducted by structured questionnaire. Recent HIV infections were evaluated using the BED incidence assay. Circumcision status was self-reported and clinically assessed. Adjusted HIV incidence rate ratios (aIRR) and prevalence ratios (aPR) were calculated using Poisson regression.

Results: The response rate was 73.9%. Most respondents agreed that circumcised men could become HIV infected and needed to use condoms, although 19.3% (95%CI: 17.1% to 21.6%) asserted that AMC protected fully against HIV. Among self-reported circumcised men, 44.9% (95%CI: 39.6% to 50.3%) had intact foreskins. Men without foreskins had lower HIV incidence and prevalence than men with foreskins (aIRR = 0.35; 95%CI: 0.14 to 0.88; aPR = 0.45, 95%CI: 0.26 to 0.79). No significant difference was found between self-reported circumcised men with foreskins and other uncircumcised men. Intention to undergo AMC was associated with ethnic group and partner and family support of AMC. Uptake of AMC was 58.8% (95%CI: 55.4% to 62.0%).

Conclusions: AMC uptake in this community is high but communication and counseling should emphasize what clinical AMC is and its effect on HIV acquisition. These findings suggest that AMC roll-out is promising but requires careful implementation strategies to be successful against the African HIV epidemic.

Figure 1

Adjusted HIV incidence rate (aIRR) by self-reported male circumcision status and clinical circumcision status among men aged 22 to 34. Self-reported uncircumcised and self-reported circumcised men are labeled "Uncir" and "Circ" on the figure, respectively. aIRR, 95% confidence intervals (CI) and p-values (p) were calculated using Poisson regression. Covariates were age, ethnic group, marital status, number of lifetime sexual partners, number of sexual partners in the past 12 months, consistent condom use with non spousal partners and HSV-2 status.

Figure 2

Adjusted HIV prevalence rate (aPR) by self-reported male circumcision status and clinical circumcision status among men aged 22 to 34. Self-reported uncircumcised and self-reported circumcised men are labeled "Uncir" and "Circ" on the figure, respectively. The two darker bars to the left represent men with foreskins, by reported circumcision status. The two lighter bars to the right represent all men in the sample, by clinical circumcision status. aPR, 95% confidence intervals (CI) and p-values (P) were obtained using Poisson regression. Covariates are the same as in Figure 1.