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Background: Voluntary medical male circumcision (VMMC) reduces HIV transmission and has been encouraged in a number of high HIV prevalence countries, but uptake among males remains low. In KwaZulu-Natal, South Africa HIV prevalence is around 30% and circumcision among males is uncommon. Understanding predictors of circumcision uptake in this region is important for the promotion of public health campaigns for men at risk of HIV acquisition.
Methods: A population-based cohort in KwaZulu-Natal, South Africa was followed longitudinally from 2003 to 2013. Self-reported circumcision status was collected for all individuals in 2003 and annually from 2009-2013. An individual was assumed to be newly circumcised if their status switched from uncircumcised to circumcised across survey years. A multivariable logistic regression model including demographic and geographic variables was used to assess predictors of circumcision uptake.
Results: 16,892 unique men reported their circumcision status (median age 22 years, IQR: 18-37 years). From 2003 to 2013 circumcision prevalence rose from 5.8% to 17.4% for all males, with the greatest gains in the 15-24 year age group (4.0% to 20.0%). Men in all ten-year age groups 25-34 and above had reduced odds of circumcision uptake compared to the reference age group of 15-24 years. Men in higher asset index quintiles had greater odds of circumcision uptake, and this increased proportionally by each increase in asset index quintile compared to the most deprived. The odds of circumcision uptake decreased with each kilometer from the nearest health facility by 0.89 (95% CI: 0.86 - 0.92).


Figure 1. Circumcision prevalence among males in KwaZulu-Natal, South Africa in 2003 and from 2009-2013, by 10-year age groups.
[Figure 1. Circumcision prevalence among males in KwaZulu-Natal, South Africa in 2003 and from 2009-2013, by 10-year age groups. ]


Conclusions: In the past 10 years, circumcision prevalence has increased dramatically in this high HIV prevalence population. While circumcision has increased, this analysis shows that circumcision uptake has been concentrated in certain populations, primarily young men and men of higher SES. Innovate interventions are needed to reach those men still yet to get circumcised.

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