Among HIV-uninfected men who were uncircumcised, 51.4% (95% CI: 46.0 to 56.8) were aged 15–24 years and 52.5% (95% CI: 47.0% t 58.0%) had never married or cohabited (Table 3). The majority (61.2%, 95% CI: 53.9 to 68.5) were from the Luo ethnic tribe, and nearly half (46.7%, 95% CI: 39.2 to 54.3) lived in the Nyanza region. The majority of sexually active HIV-uninfected and uncircumcised men (84.6%, 95% CI: 79.8 to 89.5) were not using condoms at all times with their last sexual partner in the past 12 months, and 40.4% (95% CI: 34.2 to 46.7) reported never having been tested for HIV. The majority (72.1%, 95% CI: 66.1 to 78.1), however, knew circumcision protected men somewhat from HIV, and over half (53.0%, 95% CI: 46.7 to 59.2) reported that they intended to be circumcised in the future. Intention to be circumcised was highest among young men aged 15–24 years (69.6%, 95% CI: 61.7 to 77.4) and men who had never married or cohabited (73.6%, 95% CI: 66.1 to 81.1) (data not shown).
In Nyanza region, of the 772 men we surveyed, 13.4% (95% CI: 8.7 to 18.2) (n = 104) were HIV-uninfected and recently circumcised (past 3 years), and 26.3% (95% CI: 18.9 to 33.7) (n = 198) were HIV-uninfected and uncircumcised (data not shown). Over half (51.8%, 95% CI: 41.2 to 62.3) of men aged 15–24 years compared with 93.9% (95% CI: 87.6 to 100.0) of men aged 45–64 years were HIV-uninfected and uncircumcised (Table 4). Seventy-five percent (75.8%, 95% CI: 67.1 to 84.4) of men with secondary or higher level of education were HIV-uninfected and uncircumcised compared with 59.1% (95% CI: 50.1 to 68.1) of men who had completed primary level education. A higher proportion of men who were married or cohabiting (80.5%, 95% CI: 72.3 to 88.8) were HIV-uninfected and uncircumcised compared with men who had never married or cohabited (46.6%, 95% CI: 36.0 to 57.2). Overall, 81.9% (95% CI: 74.1 to 90.0) of men who did not use a condom consistently with the last sex partner in the past 12 months compared with 50.5% (95% CI: 36.4 to 64.5) of men who did were HIV-uninfected and uncircumcised. Moreover, 74.3% of men who reported 4 or more lifetime number of sex partners compared with 42.0% (95% CI: 21.3 to 62.7) of men who reported no partners were HIV-uninfected and uncircumcised.
In multivariable logistic regression, being younger [aged 15–24 years (aOR: 0.12, 95% CI: 0.03 to 0.55) and 25–34 years (aOR: 0.13, 95% CI: 0.03 to 0.57)] was significantly associated with lower odds of being HIV-uninfected and uncircumcised compared with men aged 45–64 years. In addition, men who reported condom use with the last sexual partner in the past 12 months had significantly lower odds of being HIV-uninfected and uncircumcised (aOR: 0.31, 95% CI: 0.16 to 0.60).
We found a significant increase in the proportion of men aged 15–64 years who reported being circumcised from 2007 to 2012. The highest increase in VMMCs was observed in regions and subpopulations where Kenya's National VMMC program has targeted since 2008, including Nyanza region, men from the Luo tribe, and men aged 15–44 years. The gains made in VMMC coverage over the past 5 years can be attributable to adoption of focused strategies for scaling up VMMC.
Kenya's minimum VMMC package includes provider-recommended and offered HIV testing and counseling, risk-reduction counseling and behavior change communication, sexually transmitted infection screening and treatment, condom promotion and provision, and medical circumcision surgery as per World Health Organization guidelines. Circumcised men are also advised to abstain from sex for 6 weeks after circumcision to allow for healing and to use condoms when sexual behavior resumes.11 The vast majority of recently circumcised men reported ever having been tested for HIV. Almost half of the HIV-uninfected men who were recently circumcised reported consistently using condoms, and over half reported using a condom at last sex, suggesting that risk compensation is not as widespread as was originally feared, and that many of those who were recently circumcised are heeding the prevention messages included in the complete package of circumcision services.16
Conversely, HIV-uninfected uncircumcised men are still engaging in risky behaviors, with only 21% reporting that a condom was used with the last sexual partner in the past 12 months. However, the difference in condom use between those recently circumcised compared with uncircumcised HIV-uninfected men may also be because of the factors unrelated to exposure to prevention messages in the minimum package. Recently circumcised men may be more disposed to prevention approaches overall, leading to an increase in uptake of both circumcision and condom use. It is also possible that many of the uncircumcised men are older and in monogamous married relationships and therefore feel no need to adhere to either prevention intervention.
It is critical that Kenya's VMMC program remains robust and explores approaches to promote and encourage HIV-uninfected uncircumcised men to access VMMC, offered as part of a comprehensive HIV prevention package, which allows access to other prevention benefits, including risk-reduction counseling, HIV testing, and condom use. Targeted strategies are needed for those men in Nyanza region who are HIV-uninfected and uncircumcised, the majority of whom are aged 15–24 years, report first sex between the ages of 15–19 years, live in rural areas, have never married or cohabited, and have previously been tested for HIV infection. A positive finding is that more than half of all uncircumcised men stated an intention to be circumcised. This finding was strongest among young men aged 15–24 years and men who had never been married or cohabited.
We recognize the limitations of our study, including the fact that comparison of the KAIS 2007 and KAIS 2012 data must be done with caution because the sampling frameworks of the 2 surveys were slightly different. North Eastern region was not included in KAIS 2012 and had high rates of circumcision in KAIS 2007, so overall prevalence of circumcision in KAIS 2012 is potentially underestimated. Circumcision status, condom use, and sexual behavior were measured through participants' self-report, and, therefore, responses may have been biased toward socially desirable answers. Some noncircumcising tribes, for example, Turkana and Teso, were combined with other smaller tribes and could not be analyzed separately. Additionally, sample sizes were small for some subgroups and resulted in reduced precision in the estimates presented. Finally, because of the cross-sectional study design, the directionality of associations cannot be established.
Notwithstanding these limitations, our study presents nationally representative population-based data on VMMC that demonstrated substantial progress toward bringing an evidence-based biomedical intervention to scale within a short period. The success of the Kenyan VMMC program should encourage other countries that are at various stages of scaling up VMMC to continue implementing VMMC actively for HIV prevention. For example, the success of Kenya's 2009, 2010, and 2011 Rapid Results Initiative informed the Swaziland Male Circumcision Task Force's decisions to adopt surgical, nonsurgical, and human resource efficiencies in scaling up VMMC.17 Overall, KAIS 2012 data show increased uptake of VMMC across Kenya, demonstrating the success of the national VMMC program. Despite this accomplishment, the Nyanza region remains below the target to circumcise 80% of all eligible men aged 15–49 years between 2009 and 2013, with the aim of averting an estimated 900,000 HIV infections over 20 years.11 Moreover, KAIS 2012 found that men with the highest HIV prevalence were aged 45–49 years.18 Therefore, strategies are needed to continue targeted messaging about the benefits of VMMC is needed, especially in Nyanza region and among older men.
Furthermore, as new cohorts of young men enter into adulthood, they will also require consistent targeting. Finally, as part of the long-term strategy of the national VMMC program, implementation and scale-up of infant circumcision services, integrated into routine maternal and child health services, is expected to maximize the long-term public health impact of VMMC on the HIV epidemic.2 To ensure sustainability of the VMMC program, continued financial resources and coordinated planning are necessary.
The authors thank Kevin De Cock, Anthony Gichangi, Amanda Viitanen, and Rennatus Mdodo for reviewing and providing input in the development of the article. The authors also thank those individuals who participated in this survey, as well as the field workers and supervisors who collected the data; and the KAIS Study Group for their contribution to the design of the survey and collection of the data set: Willis Akhwale, Sehin Birhanu, John Bore, Angela Broad, Robert Buluma, Thomas Gachuki, Jennifer Galbraith, Anthony Gichangi, Beth Gikonyo, Margaret Gitau, Joshua Gitonga, Mike Grasso, Malayah Harper, Andrew Imbwaga, Muthoni Junghae, Mutua Kakinyi, Samuel Mwangi Kamiru, Nicholas Owenje Kandege, Lucy Kanyara, Yasuyo Kawamura, Timothy Kellogg, George Kichamu, Andrea Kim, Lucy Kimondo, Davies Kimanga, Elija Kinyanjui, Stephen Kipkerich, Danson Kimutai Koske, Boniface O. K'Oyugi, Veronica Lee, Serenita Lewis, William Maina, Ernest Makokha, Agneta Mbithi, Joy Mirjahangir, Ibrahim Mohamed, Rex Mpazanje, Silas Mulwa, Nicolas Muraguri, Patrick Murithi, Lilly Muthoni, James Muttunga, Jane Mwangi, Mary Mwangi, Sophie Mwanyumba, Francis Ndichu, Anne Ng'ang'a, James Ng'ang'a, John Gitahi Ng'ang'a, Lucy Ng'ang'a, Carol Ngare, Bernadette Ng'eno, Inviolata Njeri, David Njogu, Bernard Obasi, Macdonald Obudho, Edwin Ochieng, Linus Odawo, Jacob Odhiambo, Caleb Ogada, Samuel Ogola, David Ojakaa, James Kwach Ojwang, George Okumu, Patricia Oluoch, Tom Oluoch, Kenneth Ochieng Omondi, Osborn Otieno, Yakubu Owolabi, Boniface O. K'Oyugi, Bharat Parekh, George Rutherford, Sandra Schwarcz, Shahnaaz Sharrif, Victor Ssempijja, Lydia Tabuke, Yuko Takenaka, Mamo Umuro, Brian Eugene Wakhutu, Wanjiru Waruiru, Celia Wandera, John Wanyungu, Anthony Waruru, Paul Waweru, Larry Westerman, and Kelly Winter.
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Keywords:© 2014 by Lippincott Williams & Wilkins
circumcision; HIV; VMMC; Kenya; prevention