District-level coverage and unmet need for medical and traditional circumcision among men aged 10-29 years in sub-Saharan Africa


BACKGROUND: In 2016, UNAIDS developed a Fast-Track strategy that targeted 90% coverage of male circumcision (MC) among men aged 10-29 years by 2021 in priority countries in sub-Saharan Africa (SSA) to reduce HIV incidence. There is substantial variation across subnational regions within countries in both traditional male circumcision (TMC) practices and progress towards implementation of voluntary medical male circumcision (VMMC). Tracking progress and remaining gaps towards VMMC HIV prevention targets requires detailed district-level circumcision coverage data.
METHODS: We analysed self-reported data on male circumcision from 40 nationally representative household surveys conducted in 16 SSA countries between 2006-2020. A spatio-temporal Bayesian competing-risks time-to-event model was used to estimate rates of traditional and medical circumcision by age, location, and time. Circumcision coverage in 2020 was projected assuming continuation of estimated age-specific rates, with probabilistic uncertainty.
RESULTS: Across 16 countries, from 2010 to 2020 an estimated 26.4 million men (95% CI 22.0-31.9 million) were newly circumcised, of whom 22.3 million (17.3-28.5 million) were medically circumcised, and 4.1 million (3.9-4.6 million) traditionally circumcised. In 2020, MC coverage among men 10-29 years ranged from 30.3% (20.8%-48.7%) in Zimbabwe to 95.5% (91.9%-98.7%) in Togo. MMC coverage ranged from 24.6% (22.7%-27.9%) in Malawi to 62.1% (55.9%-67.9%) in Tanzania, and TMC coverage from 0.6% (0.4%-0.8%) in Eswatini to 62.1% (59.6%-64.2%) in Ethiopia. The largest increase in MMC coverage was in Lesotho from 10.2% to 57.9%. Within countries, the median difference in MC coverage between the districts with lowest and highest coverage was 58.0%, with the smallest variation in Eswatini (42.4% to 48.3%) and largest in Zambia (8.9% to 98.7%). 17 million men aged 10-29 need to be circumcised to reach 90% coverage in all countries.
CONCLUSIONS: VMMC programmes have made substantial, but uneven, progress towards male circumcision targets. Granular district and age-stratified data provide information for focusing further programme implementation.

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