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Background: Three randomized control trials (RCTs) demonstrated at least 60% protection of voluntary medical male circumcision (VMMC) for adult male HIV acquisition. VMMC has also been shown to be protective against the acquisition of ulcerative STIs, and HPV, providing important reproductive health benefits to men. However, this positive impact may be offset by risk compensation (RC). No studies have determined whether VMMC continues to be protective under the auspices of a national Male Circumcision (MC) program, where circumcised men are not given free condoms, and are not exposed to repeated safe sex messages as they were in the RCTs. We assessed HIV incidence in a longitudinal study of circumcised vs. not circumcised men in the Zimbabwe MC Programme.
Methods: We enrolled a cohort of 2379 HIV-negative men age 18-40 in two urban districts in Zimbabwe, 1196 recently circumcised and 1183 not circumcised. Men were surveyed, at baseline, 6, 12, and 24-months, with HIV testing at 24-months. Men did not differ on sexual behavior at baseline, but differed on marital status, education, and income. We compared the two cohorts on HIV incidence at 24-months, also controlling for demographic differences at baseline. 134 uncircumcised arm men who got circumcised during the study were excluded.
Results: Mean age = 25.3; mean age at first sex = 19.3; mean lifetime sexual partners = 6.0. After excluding crossovers, 1745 completed the 24-month survey (78% of cohort). 1560 (89%) agreed to HIV testing at 24-months. There were 16 sero-conversions, 12 in the uncircumcised, 4 in the circumcised group. Overall 2-yr incidence = 1.03%; 1.65% in uncircumcised men; 0.48% in circumcised men (p< .05), corresponding to a reduction of acquiring HIV of 71%. Baseline cohort group differences (marital status, income, education) were not significantly associated with sero-conversion. Analyses controlling for them still found significantly less sero-conversion among circumcised men.
Conclusions: These findings indicate that in Zimbabwe circumcision appears to be protective among men circumcised through the National VMMC Programme, even if there is increased sexual risk behavior. This extends the RCT findings to programmatic roll-out of MC in countries, and provides important support for continued implementation of national VMMC programs.

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