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Peer-reviewedCC BYFrontiers in public health

The impact of male circumcision on risk of HIV infection in sub-Saharan Africa: a household fixed-effects analysis of 279,351 men from 29 countries.

  • Caroline A Bulstra1,2,3
  • Xiaochen Dai4,5
  • Kenneth Ngure6
  • Molly S Rosenberg7
  • Beatrice M Wamuti8,9
  • Jan A C Hontelez1,2
  • Joshua A Salomon10
  • Katrina F Ortblad11
  • Till Bärnighausen1,3,12
12 affiliations
  1. 1Heidelberg Institute of Global Health (HIGH), Heidelberg University Medical Center, Heidelberg, Germany.
  2. 2Department of Public Health, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands.
  3. 3Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA, United States.
  4. 4Institute for Health Metrics and Evaluation (IHME), University of Washington, Seattle, WA, United States.
  5. 5Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, United States.
  6. 6School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya.
  7. 7Department of Epidemiology and Biostatistics, Indiana University School of Public Health-Bloomington, Bloomington, IN, United States.
  8. 8Department of Global Health, University of Washington, Seattle, WA, United States.
  9. 9Harvard Center for Population and Development Studies, Cambridge, MA, United States.
  10. 10Department of Health Policy, Stanford University, Stanford, CA, United States.
  11. 11Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States.
  12. 12Africa Health Research Institute, KwaZulu-Natal, South Africa.
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Abstract

Introduction

While voluntary medical male circumcision (VMMC) reduces the individual-level risk of HIV acquisition by approximately 60% in randomised-controlled trials, little is known about the 'real-world' long-term effect of medical and traditional male circumcision on the cumulative risk of HIV infection. We estimate the association between these for the first time using a quasi-experimental study design-a household fixed-effects analysis-for sub-Saharan Africa, the global region with the largest HIV burden.Methods

We pooled individual-level cross-sectional data from the nationally-representative Demographic and Health Surveys and AIDS Indicator Surveys across all sub-Saharan African countries in which the surveys included data on both male circumcision and HIV status. We estimated the association between male circumcision and HIV status using modified Poisson regression models with household fixed-effects-which control for unobserved and observed confounding shared by men living in the same household-and included additional individual-level controls for demographic characteristics, socio-economic factors, and sexual behaviour.Results

We included individual data from 279,351 male participants in 48 nationally-representative surveys conducted in 29 countries between 2003 and 2018. The mean survey-level prevalence of male circumcision was 65.9% (median 84.5%, IQR 28.8-68.1%) and HIV was 5.6% (median 2.5%, IQR 1.2-10.2%). We estimated that male circumcision was associated with a significant nearly one-fifth reduction in the cumulative risk of HIV infection (adjusted risk ratio 0.81, 95% CI 0.73-0.89).Conclusion

Male circumcision was associated with a significant reduction in the risk of HIV infection in sub-Saharan Africa over the past two decades. Increased political and financial commitment to VMMC could likely lead to further reductions in HIV prevalence, especially when rolled out as a HIV prevention option in combination with other interventions.

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Cite

BibTeXRIS
BibTeX
@article{bulstra2026impact,
  title = {{The impact of male circumcision on risk of HIV infection in sub-Saharan Africa: a household fixed-effects analysis of 279,351 men from 29 countries.}},
  author = {Caroline A Bulstra and Xiaochen Dai and Kenneth Ngure and Molly S Rosenberg and Beatrice M Wamuti and Jan A C Hontelez and Joshua A Salomon and Katrina F Ortblad and Till Bärnighausen},
  journal = {Frontiers in public health},
  year = {2026},
  month = sep,
  doi = {10.3389/fpubh.2026.1810573},
  url = {https://europepmc.org/article/MED/42871344},
  note = {CC BY},
}
RIS
TY  - JOUR
TI  - The impact of male circumcision on risk of HIV infection in sub-Saharan Africa: a household fixed-effects analysis of 279,351 men from 29 countries.
AU  - Caroline A Bulstra
AU  - Xiaochen Dai
AU  - Kenneth Ngure
AU  - Molly S Rosenberg
AU  - Beatrice M Wamuti
AU  - Jan A C Hontelez
AU  - Joshua A Salomon
AU  - Katrina F Ortblad
AU  - Till Bärnighausen
PY  - 2026
DA  - 2026/09/29
JO  - Frontiers in public health
DO  - 10.3389/fpubh.2026.1810573
UR  - https://europepmc.org/article/MED/42871344
AB  - Introduction  While voluntary medical male circumcision (VMMC) reduces the individual-level risk of HIV acquisition by approximately 60% in randomised-controlled trials, little is known about the 'real-world' long-term effect of medical and traditional male circumcision on the cumulative risk of HIV infection. We estimate the association between these for the first time using a quasi-experimental study design-a household fixed-effects analysis-for sub-Saharan Africa, the global region with the largest HIV burden.Methods  We pooled individual-level cross-sectional data from the nationally-representative Demographic and Health Surveys and AIDS Indicator Surveys across all sub-Saharan African countries in which the surveys included data on both male circumcision and HIV status. We estimated the association between male circumcision and HIV status using modified Poisson regression models with household fixed-effects-which control for unobserved and observed confounding shared by men living in the same household-and included additional individual-level controls for demographic characteristics, socio-economic factors, and sexual behaviour.Results  We included individual data from 279,351 male participants in 48 nationally-representative surveys conducted in 29 countries between 2003 and 2018. The mean survey-level prevalence of male circumcision was 65.9% (median 84.5%, IQR 28.8-68.1%) and HIV was 5.6% (median 2.5%, IQR 1.2-10.2%). We estimated that male circumcision was associated with a significant nearly one-fifth reduction in the cumulative risk of HIV infection (adjusted risk ratio 0.81, 95% CI 0.73-0.89).Conclusion  Male circumcision was associated with a significant reduction in the risk of HIV infection in sub-Saharan Africa over the past two decades. Increased political and financial commitment to VMMC could likely lead to further reductions in HIV prevalence, especially when rolled out as a HIV prevention option in combination with other interventions.
SN  - 2296-2565
ER  -