Effectiveness of Voluntary Medical Male Circumcision for Human Immunodeficiency Virus Prevention in Rakai, Uganda
Authors: Loevinsohn Gideon , Kigozi Godfrey , Kagaayi Joseph , Wawer Maria J , Nalugoda Fred , Chang Larry W , Quinn Thomas C , Serwadda David , Reynolds Steven J , Nelson Lisa , Mills Lisa , Alamo Stella , Nakigozi Gertrude , Kabuye Geoffrey , Ssekubugu Robert , Tobian Aaron A R , Gray Ronald H , Grabowski M Kathryn ,   Rakai Health Sciences Program, Nabukalu Dorean , Ndyanabo Anthony , Ssekasanvu Joseph , Nakawooya Hadijja , Nakukumba Jessica , Kigozi Grace N , Nantume Betty S , Resty Nampijja , Kambasu Jedidah , Nalugemwa Margaret , Nakabuye Regina , Ssebanobe Lawrence , Nankinga Justine , Kayiira Adrian , Nanfuka Gorreth , Ahimbisibwe Ruth , Tomusange Stephen , Galiwango Ronald M , Kalibbali Sarah , Nakalanzi Margaret , Otobi Joseph Ouma , Ankunda Denis , Ssembatya Joseph Lister , Ssemanda John Baptist , Kairania Robert , Kato Emmanuel , Kisakye Alice , Batte James , Ludigo James , Nampijja Abisagi , Watya Steven , Nehemia Kighoma , Anyokot Sr Margaret , Mwinike Joshua , Kibumba George , Ssebowa Paschal , Mondo George , Wasswa Francis , Nantongo Agnes , Kakembo Rebecca , Galiwango Josephine , Ssemango Geoffrey , Redd Andrew D , Santelli John , Kennedy Caitlin E , Wagman Jennifer , Lutalo Tom , Makumbi Fred , Sewankambo Nelson K , Laeyendecker Oliver 
Published: October 2020

Abstract

Background
The efficacy of voluntary male medical circumcision (VMMC) for human immunodeficiency virus (HIV) prevention in men was demonstrated in 3 randomized trials. This led to the adoption of VMMC as an integral component of the United States President’s Emergency Plan for AIDS Relief (PEPFAR) combination HIV prevention program in sub-Saharan Africa. However, evidence on the individual-level effectiveness of VMMC programs in real-world, programmatic settings is limited.

Methods
A cohort of initially uncircumcised, non-Muslim, HIV-uninfected men in the Rakai Community Cohort Study in Uganda was followed between 2009 and 2016 during VMMC scale-up. Self-reported VMMC status was collected and HIV tests performed at surveys conducted every 18 months. Multivariable Poisson regression was used to estimate the incidence rate ratio (IRR) of HIV acquisition in newly circumcised vs uncircumcised men.

Results
A total of 3916 non-Muslim men were followed for 17 088 person-years (PY). There were 1338 newly reported VMMCs (9.8/100 PY). Over the study period, the median age of men adopting VMMC declined from 28 years (interquartile range [IQR], 21–35 years) to 22 years (IQR, 18–29 years) (P for trend &lt; .001). HIV incidence was 0.40/100 PY (20/4992.8 PY) among newly circumcised men and 0.98/100 PY (118/12 095.1 PY) among uncircumcised men with an adjusted IRR of 0.47 (95% confidence interval, .28–.78). The effectiveness of VMMC was sustained with increasing time from surgery and was similar across age groups and calendar time.

Conclusions
VMMC programs are highly effective in preventing HIV acquisition in men. The observed effectiveness is consistent with efficacy in clinical trials and supports current recommendations that VMMC is a key component of programs to reduce HIV incidence.