Effectiveness of Voluntary Medical Male Circumcision for HIV prevention in Rakai, Uganda.

BACKGROUND The efficacy of voluntary male medical circumcision (VMMC) for HIV prevention in men was demonstrated in three randomized trials. This led to the adoption of VMMC as an integral component of the 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 were 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 versus uncircumcised men. RESULTS 3,916 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 (IQR 21-35) to 22 years (IQR 18-29; p-trend <0.001). HIV incidence was 0.40/100 py (20/4992.8 py) among newly circumcised men and 0.98/100 py (118/12095.1 py) among uncircumcised men with an adjusted IRR of 0.47 (95%CI: 0.28-0.78). 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.