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Background: HIV rates vary widely across Sub-Saharan Africa. High rates of multiple concurrent sexual partners (MCP) and low rates of male circumcision (MC) have each separately been identified as underlying drivers of HIV in Sub-Saharan Africa. However, their joint contribution to HIV risk has not been examined empirically.
Methods: Using Demographic and Health Survey data on couples with linked serostatus, the joint impact of MC and MCP on HIV risk for men and women was examined through multilevel models that accounted for the prevalence of both indicators at the regional-level. “High-risk individuals” were categorized as those whose partner had other sexual partners and where the male was uncircumcised and “high-risk regions” as those where >5% of the population had multiple partners and < 80% of the population was circumcised. A varying-intercept model was run to identify the intercepts for MC prevalence and MCP prevalence and their interaction on individual risk for HIV infection, adjusting for individual demographic and behavioral covariates. The models were run on nearly 30,000 observations across 96 regions within 11 Sub-Saharan countries.
Results: Assessing the joint impact of MC and MCP at the individual-level, higher-risk individuals had up to a 15% higher likelihood of contracting HIV (p< 0.05). Assessing the joint impact at the regional level, living in a high-risk region was associated with up to a 3.2 times higher likelihood of being HIV-positive for men and up to nearly two times higher likelihood for women (p< 0.001). The lowest-risk regions had a mean HIV prevalence of 1.4% and highest-risk regions had a prevalence of 21.6%. With nearly a three-times higher relative risk, the regional-level interaction risk factor was more predictive of the HIV status for both sexes than the individual-level interaction factor (p< 0.001).
Conclusions: MC and MCP should not be addressed as separate interventions. While much emphasis has been placed on scaling up male circumcision, in the absence of concerted efforts to reduce sexual concurrency, increased circumcision may have a less-than-anticipated impact. Adopting an integrated approach to addressing male circumcision and sexual concurrency is critical to achieving the Sustainable Development Goal target 3.3: Ending the AIDS epidemic by 2030.

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