DEMOGRAPHIC

AND

HEALTH

SURVEYS

DHS WORKING PAPERS

2013 No. 100

Simon P.S. Kibira 

Elizabeth Nansubuga 

Nazarius M. Tumwesigye

August 2013

This document was produced for review by the United States Agency for

International Development.

Male Circumcision, Sexual Behavior, and 

HIV Status in Uganda

Male Circumcision, Sexual Behavior, and HIV Status in Uganda 

Simon P.S. Kibira 1

Elizabeth Nansubuga 2

Nazarius M. Tumwesigye 3

ICF International 

Calverton, Maryland, USA 

August 2013 

1

 Department of Community Health and Behavioural Sciences, School of Public Health, Makerere University 

2

 Department of Population Studies, School of Statistics and Planning, Makerere University 

3

 Department of Epidemiology and Biostatistics, School of Public Health, Makerere University 

Corresponding author: Simon P.S. Kibira, Department of Community Health and Behavioural Sciences, School of 

Public Health, Makerere University, Uganda; Email: pskibira@musph.ac.ug 
ACKNOWLEDGEMENTS 

The authors are very grateful to USAID and ICF International for their financial and 

technical support in writing and producing this working paper. This work would not have been 

possible without the valuable contribution, input, comments, reviews and suggestions made by 

Wenjuan Wang, Sarah Staveteig, Helen Nviiri, and Kerry MacQuarrie. In a special way, we are 

grateful to Wenjuan Wang for the constant advice she provided us and to Joy Fishel for 

reviewing our paper and providing invaluable comments. In addition, we would like to extend 

our sincere appreciation to all the 2013 DHS Fellows and facilitators for their support throughout 

the Fellows Program. 
ABSTRACT 

After a series of studies that revealed the protective effect of male circumcision against 

HIV infection, WHO/UNAIDS in 2007 recommended the adoption of safe male circumcision as 

one of the effective strategies in reducing heterosexually acquired HIV. To this effect, in 2010 

the Ministry of Health in Uganda developed a circumcision policy, and circumcision was added 

to the strategy of abstinence, being faithful, and condom use (ABC) to protect against AIDS. 

Especially after the implementation of the safe male circumcision (SMC) policy, however, there 

has been a concern that some circumcised men may lead a more risky sexual lifestyle than noncircumcised men. This paper, therefore, examines the associations among circumcision status, 

age at circumcision, risky sexual behaviors, and HIV serostatus among men. 

The paper uses data from the 2011 Uganda AIDS Indicator Survey, focusing on a 

subsample of 7,969 weighted cases of men age 15-59 who have ever had sex and who have 

received their HIV test results. The paper examines associations between risky sexual behaviors 

and circumcision status among all men, and associations between risky sexual behaviors and age 

at circumcision among circumcised men. At the multivariate level, the paper establishes the 

independent relationships between circumcision status and age at circumcision, risky sexual 

behaviors, and HIV serostatus. 

Results show that 28% of men in Uganda have been circumcised, and the majority were 

circumcised before age 10. At the bivariate level, circumcision status is not independent of risky 

sexual behaviors. Results from the logistic regression models show that circumcised men are 

more likely to engage in risky sexual behaviors, while age at circumcision is not significantly 

associated with these behaviors. Circumcised men are also less likely to be HIV-positive. 

The findings suggest a need to repackage the circumcision messages to account for the 

increased risky sexual behaviors among men who have been circumcised. Intensified, individual 

tailored counseling before and after SMC procedures may help to reduce these risky behaviors. 

Furthermore, qualitative research should explore the reasons for circumcision and the drivers for 

risky sexual behavior. 

1 

INTRODUCTION 

Background 

Male circumcision is the surgical removal of the intact foreskin of the human penis. 

Intact foreskin is one of the risk factors for HIV transmission from infected women to men 

(Wabwire-Mangen et al. 2009). Circumcision is undertaken worldwide for religious, cultural, 

and social as well as medical reasons (Government of Uganda MOH 2010). Randomized clinical 

trials, conducted in sub-Saharan Africa; Uganda (Gray et al. 2007); Kenya (Bailey et al. 2007) 

and South Africa (Auvert et al. 2005), showed that male circumcision protects against HIV as 

well as reduces the incidence of other sexually transmitted infections (STIs), including genital 

ulcers, human papilloma virus (HPV), and chlamydia in female partners of men. These studies 

showed that circumcision reduced the risk of heterosexual HIV transmission from an infected 

woman to a circumcised man by more than 60%. Due to such evidence, in 2007 WHO/UNAIDS 

recommended the adoption of male circumcision as part of the comprehensive strategy to reduce 

heterosexually-acquired HIV infection in countries with high HIV prevalence and low levels of 

male circumcision (WHO and UNAIDS 2007). 

In 2010 Uganda launched the safe male circumcision (SMC) policy as part of the 

comprehensive strategy on HIV prevention, in addition to the existing strategy of abstinence, 

being faithful to one partner, and condom use (ABC). Prior to the launch of this policy, male 

circumcision was mainly practiced for socio-cultural reasons as a rite of passage from childhood 

to manhood among the Bagisu and Bakonjo ethnic groups; and also as a religious ritual among 

the Moslems. The goal of the SMC policy is to contribute to the reduction of HIV and other STIs 

through safe male circumcision services (Government of Uganda MOH 2010). In addition, one 

of the key objectives of this policy is to establish a research agenda focusing on male 

circumcision services for HIV prevention. This policy also recommends the integration of safe 

male medical circumcision services in the HIV prevention and sexual and reproductive health 

care services. The target population for this policy is all males, including neonates whose parents 

and guardians consent to the procedure, while the recommended age for circumcision is before 

puberty with a higher preference for age at circumcision below age 1, followed by age 2–9 and 

age 10–17, respectively (Government of Uganda MOH 2010). 
2 

As a result of the policy, several strategies including limited offer of free circumcision at 

public health facilities, community mobilization, and sensitization of the population have been 

put in place to scale up male medical circumcision in Uganda. Furthermore, in light of the 

research agenda of the policy, several studies (Galukande et al. 2012; Kitara et al. 2013) have 

been undertaken to provide evidence-based information useful for future implementation of 

circumcision programs or services in the country. 

Although Uganda recorded a slight increase in the percentage of circumcised adult males 

age 15–59, from 25% in 2004 to 27% in 2011, the HIV prevalence rate increased from 6.4% to 

7.3%, with male HIV prevalence increasing from 5.4% to 6.1% in the same period (MOH and 

ICF International 2012). The possible reasons for the increased HIV prevalence are twofold: 

first, as a result of the introduction of antiretroviral treatment leading to higher life expectancy 

among those infected, and second, as a result of complacency in HIV prevention efforts, 

especially among married people exhibiting risky sexual behavior, including concurrent multiple 

partnerships, non-consistent condom use with non-marital and non-cohabiting partners, and 

transactional sex (MOH and ICF International 2012). 

This sexual behavior disinhibition, which undermines the great strides Uganda has 

achieved in reducing its HIV prevalence, may be explained by the behavior risk compensation 

theory. Behavior risk compensation is an observed effect where people tend to adjust 

their behavior in response to the perceived level of risk, usually behaving less cautiously where 

they feel more protected and more cautiously where they feel a higher level of risk. In the 

context where circumcision is viewed as a natural condom (Bonner 2001) against HIV 

transmission, there is a possibility of behavior risk compensation (Hedlund 2000; Adams and 

Hillman 2001; Riess et al. 2010) among circumcised men, leading them to engage in risky sexual 

behavior, including higher-risk sex with high-risk partners, non-condom use, and multiple sexual 

partners (Cassell et al. 2006; Eaton and Kalichman 2009). To date, there are still unanswered 

questions as to what difference circumcision will make in terms of risky sexual behavior and 

HIV infection. 

There is also a growing need to establish the recommended age for circumcision in any 

given setting for individuals to enjoy the full public health benefits of male circumcision in the 

fight against HIV transmission. There are wide variations in the recommended age at 
3 

circumcision in different countries and study settings. While neonatal circumcision is highly 

preferred for various reasons, parents also differ in preference for the appropriate age at 

circumcision for their children (Bailey et al. 2002) . Therefore, this study examines whether age 

at male circumcision matters in terms of risky sexual behavior and HIV status in Uganda. 

Uganda is facing challenges and setbacks in its implementation of the traditional HIV 

control and prevention strategies (the ABC strategy). With the recent addition of circumcision as 

part of Uganda’s HIV prevention strategies, there is need for research-based evidence on the 

relationships among circumcision status, age at circumcision, sexual behavior and HIV status in 

the country. This paper specifically compares sexual behavior between circumcised and 

uncircumcised men; establishes the associations between circumcision and sexual behavior, 

circumcision status and HIV serostatus, age at circumcision and sexual behavior, and age at 

circumcision and HIV status. Results from this study will contribute to the safe male 

circumcision policy research agenda, in addition to strengthening promotion and use of safe male 

circumcision in the country. Furthermore, the results will also provide insights into when males 

should become circumcised if circumcision is to have a protective public health benefit in the 

fight against HIV/AIDS. This information will also be useful in designing strategies that can 

respond to the circumcision challenges and thus contribute to the attainment of MDG 6 (to 

combat HIV/AIDS, malaria, and other diseases) in Uganda. 

Conceptual Framework 

The conceptual framework for this study is shown in Figure 1. There is a link between 

circumcision status, age at circumcision, risky sexual behavior and HIV status. In developing 

countries, being circumcised is primarily influenced by religious and ethnic/cultural reasons in 

addition to other socio-demographic and economic factors, including but not limited to 

education, residence, region, wealth status, occupation, age, and marital status (Shaffer et al. 

2007; WHO and UNAIDS 2007; Connolly et al. 2009). However, with increased sensitization 

about the hygienic and HIV-related benefits of safe male medical circumcision, the educated, 

employed, and urban populations are more likely than others to get circumcised. Although there 

is a positive relationship between education of parents and circumcision, particularly with 

reference to neonatal circumcision, a study in Central Uganda (Asiimwe 2010) showed 
4 

decreased personal willingness toward safe male circumcision among young men with increased 

educational attainment, which may partly reflect the limited knowledge on the public health 

benefits of circumcision. 

Individual background characteristics not only affect men’s circumcision status but also 

the age at which they are likely to be circumcised. Socio-demographic and economic factors play 

an important role in determining the age at circumcision. In Uganda most Moslems are 

circumcised during infancy or before age 10. In contrast, among the Bagisu culture, circumcision 

practiced as a transition from childhood to adulthood takes place from the onset of puberty, as 

early as age 12. 

Men’s circumcision status can influence their sexual behavior. Circumcised men may 

behave sexually differently from non-circumcised men. Circumcised men tend to engage in risky 

sexual behaviors, including but not limited to engaging in risky sex, concurrent partners, noncondom use during high-risk sex, transactional sex, age at first sex below age 18 and high 

number of lifetime partners. With the general belief that circumcision is an HIV vaccine, 

circumcised men tend to have unprotected sexual intercourse (Differding 2007). Such changes in 

sexual behavior are postulated in behavioral risk compensation theory, as observed in other 

studies (Differding 2007; Kalichman et al. 2007). 

Men’s sexual behavior may also be influenced by their age at circumcision. Men who are 

circumcised later in life, after puberty or adolescence, are likely to be circumcised for health 

reasons, specifically for HIV protection. This is in light of the increased sensitization of the safe 

male circumcision programs by government and civil society, which offer free circumcision 

services, especially in government health facilities. Having been circumcised for health reasons 

and particularly for HIV prevention may influence these men’s sexual behavior. Thus sexual 

behavior (risky or otherwise) is linked with HIV serostatus as an outcome. This study of data 

from Uganda focuses on the associations among circumcision status, age at circumcision, risky 

sexual behaviors, and HIV status among men who have ever had sex. 
5 

Figure 1. Conceptual framework showing relationship between male circumcision, age at 

circumcision, risky sexual behavior and HIV status 

Research Questions 

The study attempts to answer the following research questions: 

i. Are there differences in sexual behavior among circumcised and uncircumcised 

men? 

ii. Is age at circumcision associated with risky sexual behavior among circumcised 

men in Uganda? 

iii. Is circumcision status associated with HIV status? 

iv. Is age at circumcision associated with HIV status? 

Circumcision Status 

Age at Circumcision 

Background Characteristics 

Religion 

Ethnicity 

Education 

Age 

Residence 

Region 

Wealth Status 

Marital Status 

Risky Sexual Behavior 

Higher-risk sex in last 12 months 

Condom use at last higher-risk sex 

Sexual debut before age 18 

High number of lifetime partners 

Transactional sex 

HIV Status 
6 

Hypotheses 

 In line with the research questions, the following hypotheses are tested: 

i. The level of risky sexual behavior differs between circumcised and uncircumcised 

men. 

ii. There is a relationship between age at circumcision and risky sexual behavior. 

iii. Circumcised men are more likely to be HIV-negative compared with 

uncircumcised men. 

iv. Men circumcised before age 10 are more likely to be HIV negative compared 

with men circumcised at age 10 or older.
7 

DATA AND METHODS 

Data 

This study draws on data from the 2011 Uganda AIDS Indicator Survey (AIS). This 

survey dataset was chosen because it contains information on the background characteristics, 

circumcision status, age at circumcision, sexual behavior, and HIV serostatus of the target 

population. The target population for this study was men age 15–59 who were interviewed, had 

ever had sex, and had received HIV test results. The AIS uses a stratified two-stage cluster 

sampling methodology, which involves selecting clusters from each stratum at the first stage and, 

at the second stage, selecting households for interview. The strata were urban-rural and subregions of the country, while the clusters were enumeration areas updated from the 2010 Uganda 

National Household Survey. 

The Individual Record (IR) and HIV Record (AR) data sets were downloaded, with 

permission, from the Measure DHS website. The two datasets were then merged to form a 

sample of 9,524 men who were interviewed and had valid HIV serostatus data. Out of 9,524 

men, 7,969 men who ever had sex were considered for analysis and thus formed the sample size 

for this study. 

Key Variables and Measurements 

The study variables were categorized into dependent and independent variables. There 

were two dependent variables (HIV status, sexual behavior). HIV status was categorized as HIVpositive (code 1) or HIV-negative (code 0). The risky sexual behaviors considered for this study 

included having higher-risk sex in the last 12 months, transactional sex in the last 12 months, 

non-condom use at last higher-risk sexual encounter, age at first sex, and number of lifetime 

partners. 

In this study higher-risk sex refers to sex with a non-marital or non-cohabiting partner in 

the 12 months immediately preceding the survey. Transactional sex means payment for sex or 

exchange of any gift items for sex in last 12 months prior to the survey. Non-condom use at last 

higher-risk sex refers to not using a condom the last time a respondent engaged in higher-risk 
8 

sex. These three variables (high-risk sex, transactional sex, non-condom use at last higher-risk 

sex) were coded as “0” for “no” and “1” for “yes”. Given that the age of consent for sex, 

marriage, and adult decision making in Uganda is age 18, age at first sex was categorized as first 

sex at age 18 or older (code 0) or first sex before age 18 (code 1). This variable only applies to 

men who were age 18 or older at the time of the survey because those who were younger than 

age 18 were still at risk of having first sex before age 18. The variable on number of lifetime 

partners was organized into two categories: 1–3 lifetime partners and 4+ partners. 

The key independent variables considered in the analysis were circumcision status and 

age at circumcision. Circumcision was categorized as circumcised (1, yes) and uncircumcised (0, 

no). Age at circumcision was recorded in one of four age groups; below 10, 10–14, 15–19, or age 

20 or older. These categories were drawn partly because of the age at which circumcision is 

performed, especially for religious and cultural reasons and in relation to the onset of puberty. 

Circumcised men who did not know the age at which they were circumcised were grouped with 

those who were circumcised before age 10. This was done with the assumption that most likely 

they were circumcised in infancy. The first age group (below age 10) was to account for 

circumcisions in infancy or before puberty, while circumcision at age 10–14 and age 15–19 was 

to account for onset of puberty, sexual activity, and adolescence. The last category (age 20+) was 

primarily to account for those who were circumcised later in life, most probably for health 

reasons. 

Men’s demographic and socioeconomic characteristics were controlled for in multivariate 

analyses. These included residence, marital status, religion, education, wealth status, region, age, 

and ethnicity. Residence was categorized as rural-urban; marital status as never-married, 

currently married/cohabiting, and formerly married; religion as Moslem, Catholic, Anglican, 

Pentecostal, Seventh Day Adventist, other Christians, and other. Education was categorized as no 

education, primary, secondary, and higher education; wealth status as poorest, poorer, middle, 

richer, and richest. Region was categorized according to the major geographical locations of the 

country: Kampala, Central, Eastern, Northern, and Western regions. Age was categorized by 

five-year age groups, from ages 15 to 59. Ethnicity was categorized according to similarities in 

cultures among the different tribes. Also those that practice cultural circumcision, such as the 

Bagisu/ Sabiny and Bakonzo/Bakonjo, were grouped together. 
9 

Data Management and Statistical Analysis

Data management involved recoding of variables and computing new variables. HIV 

sample weights were applied to the data to adjust for complex surveys and non-response. At the 

bivariate level, chi-square tests were computed to examine the associations between outcomes 

and key independent variables. The bivariate analysis for age at first sex and number of sexual 

partners in lifetime was conducted with the full sample. The analysis for higher-risk sex and 

transactional sex was restricted to men who had sex in the past 12 months, while condom use at 

the last higher-risk sex included only men who had higher-risk sex. 

 At the multivariate level, logistic regressions were used to establish the adjusted effect of 

circumcision and age at circumcision on risky sexual behaviors and HIV status, respectively. To 

test the hypotheses, four groups of models were fitted to predict the effect of circumcision status 

on sexual behavior and on HIV status and the effect of age at circumcision on sexual behavior 

and HIV status. In the models with sexual behaviors as the outcomes, key background or sociodemographic and economic factors were controlled for. In the models predicting effects of 

circumcision and age at circumcision on HIV status, in addition to socio-demographic and 

economic factors, risky sexual behaviors were also controlled for. Odds ratios along with 95% 

confidence intervals for circumcision and age at circumcision from the models were reported. 
10 

RESULTS

Description of the Respondents 

Table 1 shows a summary of the background characteristics of all men studied and of 

circumcised men. Overall, out of the 7,969 respondents, the majority resided in rural areas 

(81%), had primary education (57%), were currently married/ cohabiting (72%), and primarily 

belonged to the Baganda (17%) ethnic group, followed by the Langi/Acholi ethnic group (11%). 

Over 75% of respondents were Catholic or Anglican, while 13% were Moslems. Almost equal 

proportions of respondents lived in the four main geographic locations of Uganda (Eastern, 

Western, Northern, and Central). 

Table 1. Background characteristics of all men and circumcised men 

Background characteristics

All men Circumcised men

Weighted Unweighted 

N 

 Weighted Unweighted 

% N N % N 

Age 

15-19 9.3 742 746 10.3 230 236 

20-24 15.0 1,198 1,170 17.1 380 390 

25-29 16.6 1,326 1,293 17.9 399 392 

30-34 14.2 1,134 1,126 13.9 309 330 

35-39 14.0 1,118 1,091 13.0 290 300 

40-44 11.1 883 868 9.8 218 227 

45-49 9.0 720 723 6.8 153 163 

50-54 6.5 519 516 7.1 158 162 

55-59 4.1 329 340 4.1 91 97 

Place of residence 

Urban 19.1 1,520 1,504 27.1 604 593 

Rural 80.9 6,449 6,369 72.9 1,624 1,704 

Region 

Central 22.4 1,784 1,528 22.0 491 423 

Kampala 7.1 568 779 9.6 215 308 

Eastern 21.3 1,701 1,738 39.6 882 906 

Northern 25.1 1,999 2,289 9.0 201 294 

Western 24.0 1,916 1,539 19.7 439 366 

Highest education level 

No education 7.2 570 543 6.4 143 156 

Primary 56.8 4,526 4,490 52.3 1,166 1,219 

Secondary 27.0 2,155 2,128 31.3 697 699 

Higher 9.0 718 712 10.0 222 223 

(Continued...)
11 

Table 1. – Continued

Background characteristics

All men Circumcised men

Weighted Unweighted 

N 

 Weighted Unweighted 

% N N % N 

Marital status 

Never married 20.7 1,649 1,638 23.5 523 523 

Currently married 71.7 5,710 5,614 68.9 1,534 1,587 

Formerly Married 7.6 609 621 7.7 171 187 

Ethnicity 

Baganda 16.6 1,321 1,297 18.0 400 419 

Banyakore 10.0 794 643 4.9 109 98 

Iteso/Karimojong 9.2 730 739 2.9 64 58 

Lugbara/Madi/Alur/Japadhola 9.8 783 1,046 8.4 186 259 

Basoga 9.0 716 719 14.1 314 319 

Langi/Acholi 11.2 896 878 0.9 19 23 

Bakiga 5.4 427 353 1.9 42 37 

Bagisu/Sabiny/Bakonzo/Bakonjo 8.5 680 694 29.0 646 656 

Banyoro/Batooro 8.5 680 588 7.4 164 141 

Bafumbira 2.1 165 130 1.1 24 20 

Bagwere/Samia 3.5 280 276 4.4 99 96 

Others 6.2 497 510 7.3 163 171 

Religion 

Catholic 42.2 3,365 3,354 21.5 478 484 

Anglican 34.4 2,741 2,621 24.4 543 547 

SDAs 1.5 116 103 1.6 36 32 

Pentecostal 5.6 449 418 3.8 85 83 

Moslems 13.0 1,038 1,105 46.1 1,026 1,087 

Other Christians 2.4 191 201 2.1 46 51 

Others 0.9 69 71 0.6 14 13 

Circumcision status 

No 72.0 5,741 5,576 

Yes 28.0 2,228 2,297 

Total 100.0 7,969 7,873 100.0 2,228 2,297 

Table 1 also shows that more than one-quarter of respondents (28%) were circumcised. 

The percentage of circumcised men increases by age from age 15 to 34, and then decreases. 

Almost-three quarters (73%) of the circumcised men resided in rural areas, while 40% were from 

Eastern region, 22% were from Central region, and 20% were from Western region. Over half 

(52%) had primary education, and over two-thirds (69%) were married or living together at the 

time of the survey. Twenty-nine percent were either Bagisu/Sabiny or Bakonjo, the ethnic groups 

in Uganda that practices cultural circumcision, while a considerable percentage were either 

Baganda (18%) or Basoga (14%). Even though Moslems were a small percentage of all men 
12 

compared with Catholics and Anglicans, they were 46% of circumcised men, having been 

circumcised for religious reasons. 

Figure 2 shows that almost half of the respondents (47%) were circumcised before 

reaching age 10, while 25% were circumcised between ages 15 and 19, 16% were circumcised at 

age 20 or older, and 12% at age 10-14. 

Figure 2. Percentage distribution of circumcised men by age at circumcision 

46.6

12.2

25.3

15.9

<10 yrs 10-14 15-19 20+

Age at Circumcision

Comparison of Sexual Behavior between Circumcised and Uncircumcised Men 

Bivariate analysis (Figure 3) shows the association between circumcision status and risky 

sexual behaviors. Overall, the percentages of circumcised men who engaged in various risky 

sexual behaviors were higher compared with the percentages of uncircumcised men. 

Circumcision status is significantly associated with four of the five risky sexual behaviors 

studied: higher-risk sex, number of lifetime sexual partners, age at first sex, and non-condom use 
13 

at last higher-risk sex. However, no association was found to exist between circumcision status 

and transactional sex in the last 12 months. 

Figure 3. Percentage of men who had risky sexual behavior by circumcision status 

52.8

65.8

38.4

58.4

3.7

43.7

56.4

30.2

52.9

2.7

First sex before 18* 4+ lifetime partners* Higher-risk sex* Non-use of condom at

last higher risk sex*

Transactional sex

Circumsized Uncircumsized

* p-value from the chi2 test is less than 0.05 

Half of the circumcised men had first sex before age 18 compared with 42% of 

uncircumcised men. Two-thirds of the circumcised men had four or more lifetime sexual partners 

compared with 56% of uncircumcised men. Thirty-eight percent of circumcised men engaged in 

higher-risk sex in the last 12 months before the survey compared with 30% of uncircumcised 

men. More than half of the respondents, whether circumcised or not, did not use condoms the 

last time they had higher-risk sex. 
14 

Age at Circumcision and Sexual Behavior 

Table 2 shows the results from bivariate analysis for age at circumcision and risky sexual 

behavior. Among the risky sex behaviors studied, only age at first sex and having higher-risk sex 

are associated with age at circumcision. With the exception of men circumcised at age 20+ years, 

more than half of all circumcised men had sex before age 18. Men circumcised between ages 10 

and 14 had the highest percentage (48%) engaging in higher-risk sex, followed by men 

circumcised before age 10 (42%). 

Men circumcised at age 20 or older had the highest percentage (72%) with four or more 

lifetime sexual partners, while 4% engaged in transactional sex. Men circumcised between ages 

15 and 19 had the highest proportion not using condoms during their last higher-risk sex (65%). 

Table 2. Among circumcised men, the percentage who reported various risky sexual behaviors, by 

age at circumcision 

Sexual behavior 

Age at circumcision (years)

Total 

< age 10 

% 

10-14 

% 

15-19 

% 

20+ 

% 

First sex below age 18* 52.1 52.4 52.7 41.7 50.6 

Four or more lifetime sexual partners 62.8 68.0 66.6 71.8 65.8 

Had transactional sex in last 12 months 3.9 2.5 3.7 4.3 3.7 

Had higher-risk sex in the last 12 months* 42.0 47.7 34.1 28.2 38.4 

Did not use a condom at last higher-risk sex 56.3 60.5 65.4 50.9 58.4 

 * p-value from the chi2 test is less than 0.05 

HIV Results by Circumcision Status and Age at Circumcision 

Figure 4 shows a bivariate analysis for HIV serostatus by circumcision status and by age 

at circumcision, for men who were circumcised. HIV prevalence was lower among the 

circumcised men (5%) compared with uncircumcised men, and the association is significant. 

Among circumcised men, those who were circumcised at age 20 or older had a higher HIV 

prevalence (7%) compared with other age groups. However this association is not significant. 
15 

Figure 4. HIV prevalence by circumcision status and age at circumcision 

7.8

4.8

4.4

5.3

4.1

7.1

Uncircumcised Circumcised <10 yrs 10-14 15-19 20+

Circumcision Status* Age at Circumcision

*p-value from the chi2 test is less than 0.05 

Adjusted Associations among Circumcision Status, Age at Circumcision, and Sexual 

Behaviors 

Table 3 shows adjusted associations between risky sexual behaviors and circumcision 

status. The table contains five models, one for each of the selected sexual behaviors, comparing 

circumcision status and controlling for key background characteristics including age, ethnicity, 

residence, wealth status, marital status, region and education. Overall, circumcision status is 

significantly associated with number of lifetime sexual partners, age at first sex, higher-risk sex, 

and condom use at last higher-risk sex. However, transactional sex is not associated with 

circumcision status. 

Model 1 shows that circumcision status is significantly associated with number of 

lifetime sexual partners (p< 0.01). The odds of having four or more lifetime partners are 1.47 

times higher among the circumcised men compared with uncircumcised men. Model 2 also 
16 

shows the odds of circumcised men having first sexual intercourse before age 18 to be 1.25 times 

higher than among uncircumcised men (p<0.01). Having higher-risk sex (model 3) and using a 

condom at last higher-risk sex (model 4) also are significantly associated with circumcision 

status (p<0 .05). The odds of circumcised men having higher-risk sex in the last 12 months are 

1.25 times higher compared with uncircumcised men, while the odds of having used a condom 

during the last higher-risk sex are 20% lower among circumcised men. 

Table 3. Adjusted odds ratios for risky sexual behaviors comparing circumcised and 

uncircumcised men 

(1) (2) (3) (4) (5) 

 Number of 

lifetime 

partners 

ORs (95% CI) 

Age at first sex 

below age 18 

ORs (95% CI) 

Had higherrisk sex in the 

last 12 months 

ORs (95% CI) 

Condom use at 

last higher-risk 

sex 

ORs (95% CI) 

Transactional 

sex in last 12 

months 

ORs (95% CI) 

Circumcision status 

Uncircumcised 1.00 1.00 1.00 1.00 1.00 

Circumcised 1.47** 

(1.28-1.68) 

1.25** 

(1.09-1.44) 

1.25* 

(1.03-1.50) 

0.80* 

(0.63-1.00) 

1.22 

(0.83-1.80) 

Background characteristics 

Age **   **  * 

Ethnicity **   **  * 

Residence **   

Wealth status **  ** ** 

Marital status ** * ** * 

Region * * * ** 

Education ** * ** 

 

Number of men 7,969 7,661¥

 7,114 2,313 7,109 

* p<0.05, ** p<0.01, Background characteristics were controlled for in all five models. ¥based on only men who were 

age 18+ years. 

Table 4 shows adjusted associations between risky sexual behaviors and age at 

circumcision, with separate models for each of the five selected risky sexual behaviors and age at 

circumcision, controlling for background characteristics, as in Table 3. In Table 4, however, age 

was not controlled for because it was highly correlated with age at circumcision. In Table 4 only 

model 3 (having higher-risk sex in the last 12 months) shows a strong significant relationship 

with age at circumcision. Men who were circumcised between ages 10 and 14 were 56% more 

likely to have had higher-risk sex in the last 12 months preceding the survey compared with men 
17 

circumcised before age 10. However circumcision after age 15 is not associated with higher-risk 

sex. None of the other four risky sexual behaviors is significantly associated with age at 

circumcision. 

Table 4. Adjusted odds ratios for risky sexual behaviors comparing age at circumcision 

(1) (2) (3) (4) (5) 

 Number of 

lifetime 

partners 

ORs (95% CI) 

First sex 

below age 18 

ORs (95% CI) 

Had higherrisk sex in the 

last 12 months 

ORs (95% CI) 

Condom use 

at last higherrisk sex 

ORs (95% CI) 

Transactional 

sex in the last 

12 months 

ORs (95% CI) 

Age at circumcision 

Below 10 years 1.00 1.00 1.00 1.00 1.00 

10-14 1.30 

(0.99-1.72) 

1.05 

(0.75-1.48) 

1.56* 

(1.02-2.39) 

1.05 

(0.59-1.87) 

0.57 

(0.21-1.55) 

15-19 1.10 

(0.80-1.52) 

1.05 

(0.78-1.39) 

0.96 

(0.66-1.40) 

1.16 

(0.67,2.02) 

1.10 

(0.51-2.35) 

20+ 1.10 

(0.76-1.61) 

0.82 

(0.61-1.10) 

1.03 

(0.70-1.52) 

1.50 

(0.84-2.68) 

1.13 

(0.51-2.52) 

Background characteristics 

Ethnicity ** * * 

Residence 

Wealth status ** * 

Marital status ** ** 

Region * * 

Education * 

 

Number of 

circumcised men 2,228 2,125¥

 2,053 766 1,997 

* p<0.05, ** p<0.01, Background characteristics were controlled for in all five models, ¥based on only men who were 

aged 18+ years 

Adjusted Associations between Circumcision Status, Age at Circumcision, and HIV Status 

Table 5 shows the adjusted association between HIV status and circumcision status 

(model 1), controlling for background characteristics including age, ethnicity, residence, wealth 

status, marital status, region, and education. Model 2 shows the adjusted association between 

HIV status and circumcision status, controlling for both background characteristics and risky 

sexual behaviors. In model 1 the odds of being HIV positive among circumcised men are 32% 

lower compared with uncircumcised men, after controlling for background characteristics, while 

in model 2 the odds of being HIV-positive among circumcised men are 35% lower compared 
18 

with uncircumcised men, after controlling for both background characteristics and risky sexual 

behaviors. The protective effect of circumcision seems to even be stronger after controlling for 

risky sexual behaviors, although the confidence intervals in the two models overlap. Among the 

risky sexual behaviors that were controlled for in the model, number of lifetime partners and 

transactional sex are significantly associated with HIV status. 

Table 5. Adjusted odds ratios for HIV positive comparing circumcised and uncircumcised men 

 (1) (2) 

HIV status, adjusted for 

background characteristics 

ORs (95% CI) 

HIV status, adjusted for 

background characteristics and 

risky sexual behaviors¥

ORs (95% CI) 

Circumcision status 

Uncircumcised 1.00 1.00 

Circumcised 0.68* 

(0.48-0.95) 

0.65* 

(0.46-0.92) 

Background characteristics 

Age ** ** 

Ethnicity * ** 

Residence * 

Wealth status 

Marital status ** * 

Ethnicity * 

Region ** 

Education * 

Number of lifetime partners 

Less than four 1.00 

Four or more 1.68** 

(1.33-2.12) 

Age at first sex 

Below age 18 1.00 

Age 18 and above 0.95 

(0.77-1.16) 

Transactional sex in last 12 months± 

Did not pay for sex 1.00 

Paid for sex 2.17** 

(1.26-3.74) 

 

Number of men 7,969 7,969 

* p<0.05, ** p<0.01 

¥ Higher-risk sex and condom use at higher-risk sex were omitted because of collinearity. ±

To utilize the full sample (all men who ever had sex) in the analysis, men who did not have sex in the last 12 months 

were grouped in a separate category for the variable, transactional sex in the last 12 months. 
19 

Table 6 shows, among the circumcised men, the adjusted association between HIV status 

and age at circumcision (model 1), controlling for background characteristics. Model 2 shows the 

adjusted association between HIV status and age at circumcision, controlling for both 

background characteristics and risky sexual behaviors. In both models, HIV status is not 

significantly associated with age at circumcision. 

Table 6. Adjusted odds ratios for HIV positive comparing age at circumcision 

 (1) (2) 

HIV status, adjusted for 

background characteristics 

ORs (95% CI) 

HIV status, adjusted for 

background characteristics 

higher-risk sexual behavior 

ORs (95% CI) 

Age at circumcision 

Below age 10 1.00 1.00 

10-14 1.21 

(0.55-2.67) 

1.16 

(0.52-2.60) 

15-19 1.11 

(0.43-2.84) 

1.04 

(0.40-2.73) 

20+ 1.35 

(0.70-2.61) 

1.32 

(0.68-2.57) 

Background characteristics 

Ethnicity 

Residence * 

Wealth status 

Marital status ** ** 

Ethnicity 

Region ** 

Education 

Number of lifetime partners 

Less than four 1.00 

Four or more 1.41 (0.78-2.53) 

Age at first sex 

Below age 18 years 1.00 

Age 18 and above 0.79 (0.52-1.19) 

Transactional sex in last 12 months 

Did not pay for sex 1.00 

Paid for sex 0.83 (0.29-2.36) 

 

Number of circumcised men 2,228 2,228 

* p<0.05, ** p<0.01 
20 

DISCUSSION

The findings show that circumcised men have higher odds of having four or more 

lifetime partners, having first sex before reaching age 18, engaging in higher-risk sex, and noncondom use at last higher-risk sex compared with uncircumcised men in Uganda. This is 

consistent with findings from other studies (Bailey et al. 1999; Differding 2007), which have 

shown that circumcision often gives circumcised men more leeway to have unprotected sex and 

to have many sexual partners. This is often the case when men view circumcision as an HIV 

“vaccine” and thus believe that they are protected from acquiring HIV. 

Some studies attribute such unexpected differences in sexual behavior to behavior risk 

compensation, where men change their sexual behaviors for the worse with the knowledge that 

their risk of infection is reduced (Kalichman et al. 2007; Eaton and Kalichman 2009; Riess et al. 

2010). In the study by Riess and colleagues, some men stopped using condoms temporarily after 

undergoing male circumcision as part of the new program in Kisumu, Kenya, while others 

increased their number of sexual partners. In the three randomized clinical trials that gave rise to 

the circumcision recommendation by UNAIDS in 2007, the South African study showed 

evidence of risk compensation. In that trial, circumcised men reported more sexual partners than 

uncircumcised men at the 4-12 month and 13-21 month recall periods (Auvert et al. 2005). Given 

this evidence, promotion of the Safe Male Contraception (SMC) policy without increased 

education and counseling among men may hinder progress in further HIV reduction (Sidler et al. 

2008), as circumcised men engage in risky sexual behaviors. This may undermine the efforts in 

the fight against HIV/AIDS, or even reverse the gains made in reducing HIV incidence. 

Another possible explanation could be that men who already practice risky sexual 

behaviors may decide to undergo circumcision to reduce their chances of HIV infection. Their 

risk-taking may not change after circumcision. 

In relation to circumcision and HIV status, multivariate results show that circumcised 

men are more likely to be HIV-negative compared with uncircumcised men. These findings are 

consistent with some randomized controlled studies (Auvert et al. 2005; Bailey et al. 2007; Gray 

et al. 2007) that have shown a protective effect of circumcision against heterosexual HIV 

infection from infected women to men. These results were observed even though the odds of 

risky sexual behaviors were higher among the circumcised men. This could mean that the effect 
21 

of risk compensation in the Ugandan context may be small compared with the fundamental 

benefits of the SMC interventions in this population. 

The relationship between age at circumcision and sexual behavior, in both bivariate and 

multivariate analysis, is inconsistent, except for engaging in higher-risk sex in the last 12 

months. The likelihood of having higher-risk sex was higher among men circumcised at age 10–

14 than among men circumcised before age 10. However, these results need to be interpreted 

with caution. We found no literature to explain why circumcision at age 10–14 may increase the 

odds of having higher-risk sex compared with circumcision before age 10. In addition, age at 

circumcision is not significantly associated with HIV status among men, consistent with findings 

from other studies (Connolly et al. 2009). Hence, more studies need to be done to explore the 

relationship between age at circumcision and sexual behavior and HIV serostatus. 

Conclusions 

There is a strong association between circumcision and risky sexual behavior. Even given 

this strong association, however, circumcised men are less likely than uncircumcised men to be 

HIV-positive, which could mean that the benefits of circumcision outweigh the behavior risk 

compensation that could result. Age at circumcision is not significantly associated with men’s 

sexual behavior or HIV serostatus. 

Recommendations 

The findings suggest a need to repackage Uganda’s circumcision messages to account for the 

increase in risky sexual behaviors among circumcised men. Intense, individualized counseling 

before and after SMC procedures may help to reduce these risky behaviors. More sensitization at 

the population level, in health service provision, and at institutions on the advantages of 

circumcision needs to be done to encourage more men to get circumcised. This sensitization 

should be detailed enough to show that circumcision is part of the comprehensive HIV 

prevention package, and not a replacement for the ABC strategy. 
22 

Future Research 

There is need for qualitative studies to understand the motivation for circumcision among 

men who seek circumcision services. This could help determine if messages about protective 

effects of male circumcision have been sufficiently disseminated and correctly interpreted. 

Furthermore, there is a need for more research on the possible connection of the roll out of SMC 

and the increased risky sexual behaviors among circumcised men. A comparison of the surveys 

before and after the launching of the SMC policy would fill in some of the gaps in knowledge. 

Limitations of the Study 

The study is based on data from a cross-sectional survey design. Therefore, while the 

analysis shows associations, it is not possible to establish causality using such data. In addition, 

recall bias among respondents for some of the risky sexual behaviors may have affected the 

study results. Also, it is difficult to ascertain whether respondents got infected before 

circumcision or after circumcision. 

Another limitation is the failure to establish the mode of HIV transmission for 

respondents. Some men could have been infected from other modes, such as mother-to-child 

transmission. Finally, the Uganda AIDS Indicator Survey did not collect data on the reasons for 

circumcision that would have been helpful addressing some of the issues in the analysis. 
23 

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