Self-selection of male circumcision clients and behaviors following circumcision in a service program in Uganda

Objectives: Sub-Saharan African countries have substantially scaled-up safe male circumcision (SMC) services. However, it is unclear whether services are reaching men most at risk of HIV and whether there is behavioral disinhibition after SMC. We compared characteristics of SMC acceptors and nonacceptors in Rakai, Uganda. Design: Cohort design. Methods: Through the Rakai Community Cohort Study, baseline characteristics of 587 non-Muslim men who subsequently accepted SMC were compared with those of 4907 uncircumcised non-Muslim men. Behaviors after SMC were compared with those of men who remained uncircumcised. Poisson multivariable regression was used to estimate adjusted prevalence rate ratios of behaviors in circumcised versus uncircumcised men. Results: At baseline (pre-SMC), men subsequently circumcised were younger (mean=26.1 years), as compared with the uncircumcised (mean=28.5 years, P<0.001), more likely to live in urban areas (21.1 versus 12.4%, P<0.001), less likely to have been currently or previously married (36.5 versus 45.8%, P<0.001) and more likely to report multiple sexual partners (48.3 versus 41.6%, P=0.05) and genital discharge (7.4 versus 4.4%, P=0.03). At follow-up (post-SMC), behaviors and genital discharge did not differ between the groups. Genital ulcers were less reported among circumcised (6.8%) compared with uncircumcised men (10.5%; adjusted prevalence rate ratios=0.60, 95% confidence interval=0.42-0.87, P=0.007). Conclusion: In Rakai district, Uganda, the circumcision service program is attracting sexually active men at higher risk of HIV and we find no evidence of behavioral disinhibition following circumcision. The SMC program in this setting has the potential to reduce the HIV epidemic among men.