Sexually active men who accept safe male circumcision services in Uganda’s Rakai district are at higher risk of HIV before having the procedure than those who do not, according to a population-based cohort study among non-Muslim participants.¹ At baseline, men who subsequently accepted safe male circumcision services had a 15% higher likelihood than their peers who remained uncircumcised of reporting having had multiple sexual partners in the past year and a 55% higher likelihood of reporting having had genital discharge in the previous year (adjusted prevalence rate ratios, 1.2 and 1.6, respectively). In follow-up surveys, men who had accepted circumcision and those who had not reported similar sexual behaviors, which suggests that safe male circumcision services are not associated with behavioral risk compensation. In addition, compared with their peers who remained uncircumcised, men who had accepted circumcision had a 40% lower prevalence of genital ulcers.

Data for the study were obtained from the Rakai Community Cohort Study, in which individuals aged 15–49 are interviewed every 12–20 months to obtain information about their social and demographic characteristics, sexual risk behaviors and use of health services; they also provide a blood sample for HIV testing. Investigators used data from the 2006–2008, 2008–2009 and 2010–2011 surveys—each conducted during the period when circumcision services were offered free of charge to the general male population of Rakai. Analyses were restricted to HIV-negative, non-Muslim men who were uncircumcised at the time of the earliest survey; Muslim men were excluded because most are circumcised early in life. Men who had been circumcised since the prior survey and those who were still uncircumcised were identified from the 2008–2009 and 2010–2011 surveys, and their baseline characteristics were drawn from the 2006–2008 and 2008–2009 surveys, respectively. Bivariate analyses were used to compare circumcised and uncircumcised men with respect to social and demographic characteristics (age, marital status, education and urban-rural residence), STI symptoms (genital ulcers and genital discharge in the past 12 months) and behaviors in heterosexual relationships (any sexual partners in the past 12 months, number of sexual partners, condom use at last sex with nonmarital partners, use of alcohol before sex, casual sex with nonregular or noncohabiting partners and acquisition of a new sex partner in the past 12 months). Multivariable modified Poisson regression models were used to estimate adjusted prevalence rate ratios of sexual behaviors and STI symptoms.

In total, 587 men accepted and underwent male circumcision during the study period, whereas 4,329 did not. At baseline, men who subsequently became circumcised were younger, on average, than those who remained uncircumcised (mean age, 26 years vs. 29 years). Also, greater proportions of circumcised men than of uncircumcised men were never-married (46% vs. 37%) and lived in urban areas (21% vs. 12%). A large majority of both groups (75% and 79%, respectively) reported having had a sexual partner in the 12 months prior to the survey. Among sexually active men, those who became circumcised were more likely than their uncircumcised peers to report having had, in the prior 12 months, multiple sexual partners and genital discharge (adjusted prevalence rate ratios, 1.2 and 1.6, respectively). The groups did not differ with respect to education level or the other sexual risk behaviors studied.

In analyses that compared circumcised men and uncircumcised men at follow-up, no differences were found between groups with respect to any of the sexual behaviors studied. A lower proportion of circumcised men than of uncircumcised men had experienced genital ulcers in the past year (7% vs. 11%), a difference that translates to a 40% lower prevalence among circumcised men (adjusted prevalence rate ratio, 0.6); no difference was found for genital discharge. Analyses did not identify any period effect whereby the association between circumcision status and behaviors differed by study period. In addition, the main findings were unchanged after exclusion of men who were circumcised less than 12 months before their follow-up survey, to preclude the possibility that the survey captured some behaviors in these men that predated their surgery.

The study’s findings suggest that the safe male circumcision program in Uganda is reaching men who have an overall higher risk of acquiring HIV, according to the investigators, who also note that the differences documented at baseline were present before the men had received any circumcision-related health education that could have influenced behavior. The data further show no evidence of behavioral disinhibition after the procedure. The investigators conclude that "the [safe male circumcision] program in this setting has the potential to reduce the HIV epidemic among men."—S. London