Knowledge, Perception, and Practice of Safe Medical Circumcision on HIV Infection Risk Reduction among Undergraduate Students of a Public University in Northern Uganda: A Cross-Sectional Study.

Background: About 70% (25.6 million) of the global HIV/AIDS burden is from Sub-Saharan Africa. Safe male circumcision (SMC) is one of the measures that were adopted by the Ugandan government aimed at reducing the risk of HIV infection contraction, as recommended by the WHO. Its main goal was to maximize HIV prevention impact with voluntary medical circumcision services to all adult men and adolescent boys. The objective of our study was to assess the knowledge, perception, and practice of safe medical circumcision on HIV infection risk reduction among undergraduate students of a public university in Northern Uganda. Methods: We conducted a cross-sectional survey among 556 randomly selected Lira University undergraduate students from March 2023 to June 2023. With the use of a self-administered questionnaire, we collected data on the knowledge and perceptions of undergraduate students towards safe medical circumcision. Data were exported to Stata® 17 statistical software. Univariate, bivariate, and multivariate regression analyses were done at a statistical level of significance P value < 0.05. Results: Our 556 study participants had an age range of 21-25 years. The majority (81.29%) of the respondents knew that safe medical circumcision reduces the risk of acquiring HIV. However, the perception is that close to 3 in 4 (74.46%) of the students were unsure if they would opt for safe medical circumcision as risk reduction measure against HIV. The practice of safe medical circumcision was 64.8% among the study participants. Conclusions: More than three in four of the undergraduate students have knowledge on safe medical circumcision as risk reduction measure for HIV infection. And close to 3 in 4 (74.46%) of the student's perception were unsure if they would opt for safe medical circumcision as risk reduction measure against HIV. The practice of safe medical circumcision was 64.8% among the study participants. Therefore, in an effort to increase SMC's adoption for HIV/AIDS prevention, the Ministry of Health of Uganda and related stakeholders in health should work hand in hand with university study bodies in order to optimize SMC uptake among university students.

Comparison of the effects of ring block and dorsal penile nerve block on parental satisfaction for circumcision operation in children: randomized controlled trial.

PURPOSE: In children, circumcision is a procedure associated with perioperative pain and parental satisfaction is an important parameter in the evaluation of anesthesia procedures. Inadequate dorsal penile nerve block (DPNB) for the ventral shaft of the penis might impact parental satisfaction negatively. To evaluate this hypothesis, we compared the effects of penile ring block (RB) and dorsal penile nerve block (DPNB) on parental satisfaction. Postoperative pain, need for additional analgesia, intraoperative hemodynamic data, recovery status, side effects, and postoperative complications were evaluated as secondary outcomes between the blocks. METHODS: Parental satisfaction and anesthetic effectiveness of RB and DPNB for circumcision in children were compared. 86 patients were randomized 1:1 to Group RB and Group DPNB, which were administered the same dose of anesthesia. Parental satisfaction was evaluated with the Pediatric Anesthesia Parental Satisfaction Questionnaire (PAPS). Postoperative pain evaluations were made with the Face, Legs, Activity, Crying, Consolability Pain Scale (FLACC). RESULTS: In terms of parent satisfaction, no differences were detected between the groups in the pre-anesthesia, pre-anesthesia and post-anesthesia, post-anesthesia, hospital team, and anesthesia team parameters (p > 0.05). The scores of Group DPNB patients were higher only in the "Q11" subparameter in the "anesthesia team" parameter, and this difference was significant (0.024). CONCLUSION: RB and DPNB were compared in circumcision, which is the most common surgical procedure for children. Parental satisfaction, anesthesia, and analgesic effects of both blocks were found to be similar. CLINICAL TRIALS: ACTRN12622001211752.

Parental Perspectives Regarding Circumcision during the Coronavirus Disease 2019 Pandemic in Indonesia.

BACKGROUND: Coronavirus disease 2019 (COVID-19) pandemic has rapidly spread worldwide and affected the healthcare system, including the deferral of surgical practice. There are various reactions regarding delayed surgeries, but parental viewpoints towards circumcision remain scarce. In light of the pandemic, this study aimed to evaluate how parents feel about circumcision and the probable determining variables. MATERIALS AND METHODS: This study is a cross-sectional study based on an online questionnaire available from March to April 2022. The factors affecting the decision were analysed using logistic regression. RESULTS: Of 1,218 (26.28%) parents who completed the survey, 879 (18.96%) met the inclusion criteria and were included in this study. Among them, 615 (70.00%) parents agreed to delay circumcision during the COVID-19 pandemic. These respondents were more likely to be non-Muslim (P = 0.01), have no relatives whose work is related to medicine or paramedicine (P = 0.02) and have monthly income equal to or below the regional minimum wage (P = 0.03). After adjusting the potential confounder, non-Muslim religion (odds ratios, 2.87; 95% confidence interval, 1.27-6.49; P = 0.012) was found to be the only independent predictor for agreeing to the deferral of circumcision amid the pandemic. CONCLUSION: Most parents agreed to postpone circumcision due to the fear of COVID-19 exposure. In order to help them feel less apprehensive about this matter, it is important to educate them about the medical benefits of circumcision and the safety of this procedure.

Evaluation of Z-plasty versus Heineke-Mikulicz scrotoplasty in the management of penoscrotal web in pediatric age group.

BACKGROUND: The penoscrotal web may be congenital or acquired following excessive ventral skin removal during circumcision. Several surgical techniques were described for the treatment of congenital webbed penis without a clear comparison between their outcomes. This prospective study aimed at comparing the surgical results of Z-scrotoplasty and Heineke-Mikulicz scrotoplasty in the treatment of congenital webbed penis in uncircumcised pediatric patients. METHODS: Our study included 40 uncircumcised patients who were divided randomly into two groups; Group A included 20 patients who were treated by Z-scrotoplasty and Group B included the other 20 patients who were treated by Heineke-Mikulicz scrotoplasty. All patients were circumcised at the end of the procedure. RESULTS: The surgical outcome was good without a significant difference between the two groups in 36 patients. Recurrent webbing developed in one patient of Group A and in three patients of Group B (FE p = 0.605) The only significant difference between the two groups was the operative duration which was shorter in Group B than in Group A (P < 0.001*). CONCLUSIONS: Treatment of congenital penoscrotal web in the pediatric age group could be done with either Z-scrotoplasty or Heineke-Mikulicz scrotoplasty with satisfactory results, however, without significant difference in the surgical outcomes. TRIAL REGISTRATION: • Registration Number: ClinicalTrials.gov ID: NCT05817760. • Registration release date: April 5, 2023.

Estimates of the prevalence of male circumcision in sub-Saharan Africa from 2010-2023-A systematic review and meta-analysis.

BACKGROUND: Male circumcision (MC) is a key part of the package of interventions to prevent HIV, the biggest health challenge in sub-Saharan Africa. OBJECTIVE: To estimate the male circumcision prevalence and to evaluate the progress towards meeting WHO targets in sub-Saharan Africa during the period 2010-2023. METHODS: We carried out a systematic review and meta-analysis of studies published during the period 2010-2023. We searched PubMed, Scopus, Cochrane CENTRAL, Google Scholar, WHO and the Demographic and Health Survey for reports on MC prevalence in sub-Saharan Africa. MC prevalence was synthesized using inverse-variance heterogeneity models, heterogeneity using I2 statistics and publication bias using funnel plots. RESULTS: A total of 53 studies were included. The overall prevalence during the study period was 45.9% (95% CI 32.3-59.8), with a higher MC prevalence in Eastern (69.9%, 95%CI 49.9-86.8) compared to Southern African (33.3%, 95%CI 21.7-46.2). The overall prevalence was higher in urban (45.3%, 95%CI 27.7-63.4) compared to rural settings (42.6%, 95% 26.5-59.5). Male circumcision prevalence increased from 40.2% (95% CI 25.0-56.3) during 2010-2015 to 56.2% (95% CI 31.5-79.5) during 2016-2023. Three countries exceeded 80% MC coverage, namely, Ethiopia, Kenya and Tanzania. CONCLUSION: Overall, the current MC prevalence is below 50%, with higher prevalence in Eastern African countries and substantially lower prevalence in Southern Africa. Most of the priority countries need to do more to scale up medical male circumcision programs.

Histological and morphological development of the prepuce from birth to prepubertal age.

PURPOSE: To study the histological changes of the preputial tissue from birth to prepubertal age in order to define unnoticed morphological changes. MATERIALS AND METHODS: Prepuce samples were obtained from 79 healthy boys who underwent routine ritual circumcision. Specimens were divided into six groups according to the boys' age: newborn, 0-1 year of age, 2-3 years of age, 4-5 years of age, 6-7 years of age, and 8-9 years of age. Histologic analysis of the specimens was performed by H&E, Masson's trichrome, Verhoeff-Von Gieson, immunohistochemical staining. RESULTS: Microscopic examinations showed that average epithelial thickness increased after the neonatal period (p=0.001). When collagen fiber density was evaluated, no significant differences between groups were found (p=0.083). When the elastic fibers in the dermis were evaluated, it was determined that the number and thickness of elastic fibers increased with age. Immunohistochemical examinations showed that the number of peripheral nerves marked with S100 was lower in the neonatal period than at other ages (p=0.048). When the vessels marked with CD105 antibody were counted, there was no significant difference between the groups (p=0.078). CONCLUSIONS: This is the first study to examine the age-related structure of connective tissue elements in the foreskin. Our results showed that the prepuce's prepubertal maturation process is continuous, and the first 2 years of life are appropriate not only in relation to the physiological effects of age but also the optimum structural changes for wound healing, such as vessel diameter, epithelium thickness, peripheral nerve count.

A prospective randomized controlled trial measuring satisfaction and parents stress after Gomco and Plastibell infant circumcision.

PURPOSE: To compare the physician and parental satisfactions between the two types of circumcision maneuvers used in our units, Gomco and Plastibell circumcision. METHODOLOGY: This study was performed from 2019 to 2021. A total of 190 children were circumcised either by Gomco or Plastibell procedure. Each child was evaluated during the procedure, immediately after the operation, and 1, 2, and 3 weeks after the procedure. Data were collected, statistically analyzed using SPSS version 25. RESULTS: A total of 190 children underwent circumcision from 2019 to 2021. Of the total 190, 98 children (51.6%) underwent circumcision by Gomco, while 92 (48.4%) underwent circumcision by Plastibell. Bleeding was significantly higher in Plastibell method, while excess skin was significantly higher in Gomco method (p value 0.048). Physician evaluation results show no significant difference between both methods in late physician evaluation. 23/92 (28%) of parents were not satisfied after Plastibell circumcision, compared to 8/98 (8.2%) of parents who were not satisfied with the results of Gomco circumcision (p value 0.002). CONCLUSION: Gomco needs a longer operative time, and Plastibell circumcision is less preferable by parents. There is no significant difference in physician satisfaction between the two procedures, but parents are less satisfied with Plastibell circumcision.

The prevalence and factors of willingness to accept circumcision among MSM in Maanshan City, China.

To investigate the prevalence of male circumcision and the willingness to undergo male circumcision and influencing factors among MSM in Maanshan City, we conducted a cross-sectional study from June 2016 to December 2019. Respondent-driven sampling (RDS) was used to recruit participants. Influential factors of willingness to accept circumcision were identified by a multivariable logistic regression model. The multivariable logistic regression model revealed that five variables were independent influential factors for willingness to participate. The factors include that used condoms during last anal intercourse (OR = 1.87, 95% CI:1.03-3.41, P = 0.04), sex with female sex partners (OR = 0.499, 95% CI:0.298-0.860, P = 0.012, level of education (junior college: OR = 0.413, 95% CI:0.200-0.854, P = 0.017; bachelor's degree or higher: OR = 0.442, 95% CI:0.208-0.938, P = 0.033), condom use during oral sex in the last six months (OR = 4.20, 95% CI:1.47-12.0, P = 0.007) and level of knowledge of PrEP (OR = 5.09, 95% CI:1.39-18.7, P = 0.014). Given the willingness of MSM to accept circumcision was low in China, establishing a proper understanding of circumcision is essential if it is to be used as a strategy to prevent HIV infection among MSM. Therefore, publicity and education on the operation should be strengthened to increase the willingness to undergo male circumcision.

Topical corticosteroids for treating phimosis in boys.

BACKGROUND: This is an updated version of a Cochrane Review first published in 2014. Phimosis is a condition in which the prepuce (foreskin) cannot be fully retracted past the head of the penis (glans). Phimosis is often treated surgically by circumcision or prepuce plasty; however, reports of non-invasive treatment using topical corticosteroids applied for four to eight weeks have suggested favorable outcomes. OBJECTIVES: To assess the effects of topical corticosteroids applied to the stenotic portion of the prepuce for the treatment of phimosis in boys compared with placebo or no treatment. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, LILACS, and ClinicalTrial.gov. We checked reference lists of included studies and relevant reviews for additional studies. There were no restrictions on the language of publication. The date of the last search was 4 October 2023. SELECTION CRITERIA: We included all randomized controlled trials (RCTs) that compared the use of any topical corticosteroid with placebo or no treatment for boys with any type or degree of phimosis. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, extracted data related to the review's primary and secondary outcomes, and assessed the studies' risk of bias. We used the random-effects model for statistical analyses and expressed dichotomous outcomes as risk ratios (RRs) with 95% confidence intervals (CIs). We contacted the authors of the primary articles to request details of the study design and specific outcome data. We used GRADE to assess the certainty of evidence on a per-outcome basis. MAIN RESULTS: In this update, we identified two new studies with 111 participants, bringing the total number of included studies to 14 (1459 randomized participants). We found that types of corticosteroids investigated, participant age, degree of phimosis, type of phimosis, and treatment duration varied considerably among studies. Compared with placebo or no treatment, topical corticosteroids may increase the complete resolution of phimosis after four to eight weeks of treatment (RR 2.73, 95% CI 1.79 to 4.16; I² = 72%; 10 trials, 834 participants; low-certainty evidence). Based on 252 complete resolutions per 1000 boys in the control group, this corresponds to 436 more complete resolutions per 1000 boys (95% CI 199 more to 796 more). We downgraded the certainty of the evidence by one level for serious study limitations and by one level for serious inconsistency. Topical corticosteroids may also increase the partial resolution of phimosis at four to eight weeks of treatment compared with placebo or no treatment (RR 1.68, 95% CI 1.17 to 2.40; I² = 44%; 7 trials, 745 participants; low-certainty evidence). Based on 297 partial resolutions per 1000 boys in the control group, this corresponds to 202 more partial resolutions per 1000 boys (95% CI 50 more to 416 more). We downgraded the certainty of the evidence by one level for serious study limitations and by one level for serious inconsistency. We are uncertain of the effect of topical corticosteroids compared to placebo on change in retractability score (standardized mean difference [SMD] -1.48, 95% CI -2.93 to -0.03; I²91%; 2 trials, 177 participants; very low-certainty evidence). We downgraded the certainty of the evidence by one level for serious study limitations, one level for serious heterogeneity, and one level for serious imprecision. Compared with placebo, topical corticosteroids may increase the long-term complete resolution of phimosis six or more months after treatment (RR 4.09, 95% CI 2.80 to 5.97; I² = 0%; 2 trials, 280 participants; low-certainty evidence). Based on 171 long-term complete resolutions per 1000 boys in the control group, this corresponds to 528 more complete resolutions per 1000 boys (95% CI 308 more to 850 more). We downgraded the certainty of the evidence by one level for serious study limitations and by one level for serious imprecision. There may be little or no difference in the risk of adverse effects between topical corticosteroids and placebo or no treatment (RR 0.28, 95% CI 0.03 to 2.62; I² = 22%; 11 trials, 1091 participants; low-certainty evidence). Only two of 11 studies that recorded adverse effects reported any adverse effects; one event occurred in the corticosteroid group and six in the control group. We downgraded the certainty of the evidence by one level for serious study limitations and by one level for serious imprecision. AUTHORS' CONCLUSIONS: Topical corticosteroids, compared to placebo or no treatment, may increase complete and partial resolution of phimosis when assessed after four to eight weeks of treatment, and may increase long-term complete resolution of phimosis assessed six or more months after treatment. Topical corticosteroids may have few or no adverse effects, and we are uncertain about their effect on retractability scores. The body of evidence is limited by poor reporting of methods in the studies, important clinical heterogeneity, and serious imprecision in the results. Future, higher-quality trials with long-term follow-up would likely improve our understanding of the effects of topical corticoids on phimosis in boys.

Honey dressing for penile skin avulsion caused by traditional circumcision: a case report.

OBJECTIVE: Penile skin avulsion is a rare complication of circumcision but commonly encountered as the result of traditional practice. We aimed to present the use of honey dressing and the benefit of its wound healing properties for management of such a complex wound. CASE: A 24-year-old male patient with penile bleeding presented to the emergency department after undergoing traditional circumcision. Complete degloving of the penis with active bleeding and foul odour, along with heavy contamination of chewed betel leaves and powdered amoxicillin was found. Honey (Madu Nusantara, PT. Madu Nusantara, Indonesia) was used as dressing after copious irrigation using saline and povidone-iodine with bleeding control. RESULTS: Honey dressing was shown to be effective for secondary wound healing of such a complicated and contaminated wound-in this case due to its antimicrobial, anti-inflammatory, immunostimulatory and autolytic debridement properties. A complete re-epithelialisation of the wound was achieved without progression to the hard-to-heal state by day 43. Suboptimal sexual function and aesthetic result due to wound contracture were observed as surgical reconstruction via split-thickness skin graft was refused due to cost. CONCLUSION: In this case report, honey dressing was shown to be effective for wound healing, even in a penile avulsion with complete skin loss and heavy contamination. In rural settings, where penile avulsion due to traditional circumcision is common, honey should be considered as one of the dressing choices.

Rethinking the Definition of Medicalized Female Genital Mutilation/Cutting.

In 2015, the international community agreed to end Female Genital Mutilation/Cutting (FGM/C) by 2030. However, the target is unlikely to be met as changes in practice, including medicalized female genital mutilation/cutting (mFGM/C), challenge abandonment strategies. This paper critically reviews the current World Health Organization (WHO) definition of mFGM/C to demonstrate that mFGM/C, as currently defined, lacks detail and clarity, and may serve as an obstacle to the collection of credible, reliable, and comparable data relevant to targeted FGM/C prevention policies and programs. The paper argues that it is necessary to initiate a discussion on the revision of the current WHO definition of mFGM/C, where different components (who-how-where-what) should be taken into account. This is argued by discussing different scenarios that compare the current WHO definition of mFGM/C with the actual practice of FGM/C on the ground. The cases discussed within these scenarios are based on existing published research and the research experience of the authors. The scenarios focus on countries where mFGM/C is prevalent among girls under 18 years, using data from Demographic Health Surveys and/or Multiple Indicator Cluster Surveys, and thus the focus is on the Global South. The paper places its arguments in relation to wider debates concerning female genital cosmetic surgery, male genital circumcision and consent. It calls for more research on these topics to ensure that definitions of FGM/C and mFGM/C reflect the real-world contexts and ensure that the human rights of girls and women are protected.

Megameatus intact prepuce variant reconstruction: Long-term outcomes and comparison to post-circumcision hypospadias repair.

BACKGROUND: Megameatus intact prepuce (MIP) variant is considered a surgical challenge with associated high complication rates. It is usually diagnosed and corrected only after neonatal circumcision, which is discouraged in non-MIP hypospadias. OBJECTIVE: In order to determine whether the features of the MIP variant or the performance of a secondary reconstruction following circumcision comprise the cause of higher complication rates, we now compared the results of post-circumcision MIP hypospadias repair to the results of children who underwent repair of non-MIP hypospadias following neonatal circumcision. STUDY DESIGN: Reoperation rates of children operated for hypospadias repair following neonatal circumcision between 1999 and 2020 were compared between those with MIP and those with classic non-MIP hypospadias. RESULTS: In total, 139 patients who had undergone neonatal circumcision underwent surgical reconstruction at a mean age of 13 months. Sixty-nine had classic hypospadias and 70 had the MIP variant. The median follow-up was 10 years (interquartile range 6,13). The classic group had a higher rate of meatal location below the corona compared to the MIP variant group (53 % vs. 28 %, respectively, p = 0.002). The reoperation rate was comparable for the two groups (32 % vs. 27 %, p = 0.58, Table). Univariate analysis for the MIP hypospadias group showed no association between reoperation and the initial patient characteristics, while a higher probability of reoperation was demonstrated in the presence of ventral curvature (odds ratio 3.5, p = 0.02), and a higher grade of hypospadias (odds ratio 3.3, p = 0.03 for meatal location lower than the coronal sulcus) in the non-MIP group. DISCUSSION: The limitations of our work include its retrospective design wherein the patients' characteristics, including classification as MIP vs. non-MIP, are derived from medical records. More patients in the non-MIP group were documented to have penile curvature. The non-MIP group was composed of more patients with meatal location under the coronal sulcus, a factor which may increase the rates for reoperation in that group. Still, with the comparison of the largest reported cohort of circumcised MIP with circumcised non-MIP patients together with an extended follow-up period, we believe that we present strong evidence of the possible role of previous circumcision in the surgical challenge of reconstructing MIP hypospadias. CONCLUSIONS: Reoperation rates in MIP hypospadias are high but similar to those of classic hypospadias, both following circumcision, suggesting that circumcision, rather than the unique features of the variant, is the cause for complications.

Physician Perspectives on Performing Newborn Circumcisions: Barriers and Opportunities.

OBJECTIVE: Over half of infant boys born in the United States undergo newborn circumcision. However, available data indicate that boys who are publicly insured, or Black/African American, have less access to desired newborn circumcision, thus concentrating riskier, more costly operative circumcision among these populations. This study ascertains perinatal physician perspectives about barriers and facilitators to providing newborn circumcisions, with a goal of informing future strategies to ensure more equitable access. METHODS: Qualitative interviews about newborn circumcision care were conducted from April-June 2020 at eleven Chicago-Area hospitals. Physicians that provide perinatal care (pediatricians, family medicine physicians, and obstetricians) participated in qualitative interviews about newborn circumcision. Inductive and deductive qualitative coding was performed to identify themes related to barriers and facilitators of newborn circumcision care. RESULTS: The 23 participating physicians (78% female, 74% white, median 16 years since medical school graduation [range 5-38 years], 52% hospital leadership role, 78% currently perform circumcisions) reported multiple barriers including difficulty with procedural logistics and inconsistent clinician availability and training; corresponding suggestions for operational improvements were also provided. Regarding newborn circumcision insurance coverage and reimbursement, physicians reported limited knowledge, but noted that some insurance reimbursement policies financially disincentivize clinicians and hospitals from offering inpatient newborn circumcision. CONCLUSIONS: Physicians identified logistical/operational, and reimbursement-related barriers to providing newborn circumcision for desirous families. Future studies and advocacy work should focus on developing clinical strategies and healthcare policies to ensure equitable access, and incentivize clinicians/hospitals to perform newborn circumcisions.

Growth in Newborn Circumcisions Performed by Pediatric Urologists and Advanced Practice Providers Between 2010 and 2021 in the United States.

OBJECTIVE: To characterize changes in the proportion of newborn circumcisions performed by pediatric urologists and advanced practiced providers (APPs) in the United States over the last decade. METHODS: The Merative MarketScan Commercial Database was queried for newborn circumcision private health insurance claims (Common Procedural Terminology 54150) between 2010 and 2021. Setting (inpatient/outpatient), US Census Bureau region, clinician specialty, and patient age (days) were determined for the full study time period, and by study year. Simple linear regression assessed growth in proportion of newborn circumcisions performed by pediatric urologists and APPs (nurse practitioner/physician assistant/midwife), over time. RESULTS: In total, 1,006,748 newborn circumcisions (59% inpatient) were identified; while most were performed by obstetricians (45%) or pediatricians (33%); APPs performed 0.9%, and pediatric urologists performed 0.7%. From 2010-2021, the proportion of newborn circumcisions performed by pediatric urologists increased from 0.3% to 2.0% and by APPs in from 0.5% to 2.9% (P < .001 for both). Growth for both pediatric urologists and APPs occurred APPs predominantly from 2016 to 2021. Trends in proportion of newborn circumcision performed by pediatricians was stable [31.5% (2010) and 32.5% (2021)], but decreased for obstetricians [48.8% (2014) and 38.1% (2021)]. CONCLUSION: The proportion of newborn circumcisions performed by pediatric urologists and APPs increased more than 6-fold between 2010 and 2021, though both specialties still perform a minority of newborn circumcisions. These data provide important baseline information for newborn circumcision workforce planning, including evaluating collaborative care models where pediatric urologists train APPs to perform circumcision.

Voluntary medical male circumcision and educational gradient in relation to HIV infection among sexually active adult men in Eswatini: evidence from the national surveys in 2006-2007 and 2016.

BACKGROUND: To address knowledge gaps, this study examined social determinants, such as education attainment and HIV prevention, among sexually active men (SAM), with a focus on voluntary medical male circumcision (VMMC). METHODS: Two nationally representative surveys, the Eswatini Demographic and Health Survey 2006 and the Eswatini HIV Incidence Measurement Survey 2016, were used to estimate whether or not VMMC at the individual and community levels contributes to HIV disparities to any meaningful extent. Multilevel logistic regression models further explored the educational gradient in HIV infection for 2006-2007 and 2016 with regard to VMMC among SAM, while adjusting for household poverty, sexual practices and individual characteristics. RESULTS: Among SAM with tertiary education, HIV prevalence declined from 25.0% in 2006-2007 to 10.5% in 2016. A 51% decrease in HIV prevalence was found to be associated with an increase in VMMC (adjusted odds ratio 0.49; 95% CI 0.40 to 0.60). Compared with SAM with tertiary education, those who had a lower level of education were more likely to have HIV infection and this education gradient effect had become particularly profound in 2016. CONCLUSIONS: VMMC began to be promoted in 2008 in Eswatini and results suggest its effect, along with the education attainment effect, significantly resulted in a meaningful reduction in HIV prevalence among SAM by 2016.