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. 2024 Nov 21;19(11):e0297240. doi: 10.1371/journal.pone.0297240

Population-based cohort data used to assess trends in early resumption of sexual activity after voluntary medical male circumcision in Rakai, Uganda

Alex Daama 1,2,*, Fred Nalugoda 1, Edward Kankaka 1, Asani Kasango 1,2, Betty Nantume 2, Grace Nalwoga Kigozi 1, Robert Ssekubugu 1, Juliana Namutundu 2, Absalom Ssettuba 1, Tom Lutalo 1, Joseph Kagaayi 1,2, Gertrude Nakigozi 1, Stella Alamo 3, Lisa A Mills 3, Geoffrey Kabuye 3, Ron Gray 1,4, Maria Wawer 1,4, David Serwadda 1,2, Nelson Sewankambo 1,2, Godfrey Kigozi 1
Editor: Hamufare Dumisani Mugauri5
PMCID: PMC11581352  PMID: 39570929

Abstract

Introduction

Voluntary medical male circumcision (VMMC) reduces the risk of heterosexual acquisition of HIV by 50%–60%. The Uganda Ministry of Health recommends abstinence of sex for 42 days after VMMC to allow complete wound healing. However, some men resume sex early before the recommended period. We estimated trends in prevalence and risk factors of early sex resumption (ESR) among VMMC clients in Rakai, Uganda, from 2013–2020.

Methods

Data from the Rakai Community Cohort Study (RCCS), a cross-sectional study, were analyzed. Data included consenting males aged 15–49 years in RCCS who self-reported having received VMMC between the period of 2013 to 2020. ESR prevalence and associated risk factors were assessed using modified Poisson regression to estimate adjusted prevalence ratios (aPR).

Results

Overall, 1,832 participants were included in this study. ESR decreased from 45.1% in 2013 to 14.9% in 2020 (p<0.001). Across the first three surveys, ESR prevalence was consistently higher among the married participants than the never married participants, aPR = 1.83, 95% CI: [1.30,2.57]; aPR = 2.46, 95% CI: [1.50,4.06]; aPR = 2.22, 95% CI: [1.22,4.03]. ESR prevalence was higher among participants who reported to have more than one sexual partner than participants with one partner, aPR = 1.59, 95% CI: [1.16,2.20]. In the fourth survey from 2018–2020, ESR prevalence was significantly higher among participants with primary education than participants with post-primary, aPR = 2.38, 95% CI: [1.31, 4.30]. However, ESR prevalence was lower among participants aged at least 45 years than participants aged 15–19 years, aPR = 0.0, 95% CI: [1.86e-07, 2.69e-06]. Overall, participants who reported primary school as their highest level of education reported ESR more often than those with post-primary education aPR = 2.38, 95% CI: [1.31, 4.30]. Occupation and known HIV status were not associated with ESR.

Conclusions

Self-reported ESR after VMMC declined between 2013 and 2020. Targeted efforts for counseling focusing on married men, men who had multiple sex partners, and men with lower levels of education may decrease ESR.

Introduction

Voluntary medical male circumcision (VMMC) stands as a significant intervention in the global battle against HIV/AIDS, with substantial evidence showcasing its effectiveness in reducing the risk of heterosexual HIV acquisition by 50%–60%in men [1–3]. Originating from recommendations by the World Health Organization (WHO), VMMC was embraced by the Uganda Ministry of Health in 2007 [4]. Essential to the success of VMMC is adherence to a critical recovery period, during which men are advised to abstain from sexual activity for 42 days to ensure complete wound healing [5, 6].

In South Africa, VMMC has been integrated into the national response to HIV/AIDS, underscoring its pivotal role in the National Strategic Plan [7]. Despite its recognized potential as a preventive measure, concerns linger regarding health risks associated with the procedure, particularly regarding the increased vulnerability to HIV transmission during the post-circumcision healing period [8]. Studies, such as those conducted in Zambia and Botswana shed light on the intricate dynamics at play, suggesting that early sex resumption (ESR) post-VMMC could potentially negate the program’s intended benefits [9, 10].

While efforts in Uganda, supported by initiatives like the President’s Emergency Plan for AIDS Relief (PEPFAR), strive to provide VMMC services free of charge and offer comprehensive pre- and post-circumcision counseling. The challenges of early resumption of sex after voluntary medical male circumcision persist among Ugandan men in settings such as Rakai. The recommended six weeks of abstinence after circumcision is perceived as excessively long by many sexually active men. This duration can lead to discomfort and increased temptation, particularly if partners are present, making it difficult for men to adhere to the guidance during the healing period [11]. In Uganda, approximately 5, 350, 707males aged 10 years and above have received Voluntary Medical Male Circumcision (VMMC) services since the program’s inception [12]. Overall coverage since its adoption in 2010, VMMC uptake has increased but remains below the recommended targets. As of 2020, only 57.5% of men aged 15–49 had undergone the procedure, falling short of the WHO target of 80% coverage [13, 14]. Post-operative guidance for men who undergo VMMC typically includes recommendations to avoid sexual activity for a specified period to ensure proper healing for example no vaginal sex for at least six weeks post-surgery and avoiding all sexual activity, including masturbation, during the initial healing phase [15, 16]. Previous research underscores the tendency for circumcised men to engage in sexual activity before the recommended healing period, thereby heightening the risk of HIV acquisition and transmission to their partners. Other risks include wound disruption, bleeding, wound swelling, and pain. Cross-sectional studies indicate that between 25% to 50% of men undergoing VMMC resume sex before the recommended 42 days of abstinence [9, 17–19]. Research indicates that factors associated with early sex resumption include older age, lower education and unemployment [20], being married [17] and polygamy or multiple sex partners [19]. However, temporal changes in the prevalence of ESR and associated factors are unknown.

This study was implemented through the RCCS. The RCCS is an open population-based cohort which enrolled about 20,000 consenting participants 15–49 years of age in 40 communities across the greater Rakai region. The survey occurs every ~18 months capturing data on socio-demographic characteristics, sexual behaviors in the past 12 months, HIV, sexually transmitted infections (STIs) including HIV prevention and treatment services, self-reported circumcision status and non-communicable diseases [21]. HIV testing was part of the VMMC program and HIV-positive men were eligible for VMMC. The communities include agrarian, peri urban/trading, and fishing communities along the shores of Lake Victoria. HIV prevalence ranges from 5.2% in agrarian communities to 44.3% in fishing communities [22]. Our overall objective was to estimate trends in prevalence of ESR and associated risk factors among men undergoing VMMC in Rakai, Uganda; over an eight -year period (2013–2020).

Materials and methods

Study design and setting

We used cross-sectional data from the Rakai Community Cohort Study (RCCS) and the same standardized questions were asked in all four rounds of the survey. The RCCS is comprised of four districts including Kyotera, Rakai, Lyantonde and Masaka. Circumcised participants were asked if they resumed sex and if “Yes” when they resumed sex after circumcision (Have you had sex with any one since you were circumcised? If yes, how soon after circumcision did you resume sex?). All variables were self-reported and circumcision status included only participants who self-reported to have been medically circumcised. Participants who reported being circumcised were asked when they received the service and where they received the service.

Participants

We included males aged 15–49 years who reported circumcision in any of four successive RCCS survey rounds (June 2013-January 2015), (February 2015- September 2016), October 2016 to May 2018), and (June 2018 to October 2020). Participants were censored for all surveys and we considered participants who reported recent circumcision (< = 3 years) at the time of interview or data collection at each survey visit. Formal written consent was obtained from each participant aged 18 years and above prior to data collection. We also obtained assent from all participants less than 18 years prior to participation. All consenting participants who received VMMC services provided blood samples for HIV testing and were archived for future testing. We conducted a multivariate analysis for each survey round.

Data analysis

Frequencies and proportions were used to describe participant characteristics by survey round for categorical variables, and means and medians were estimated for continuous variables. At each round, the prevalence and 95% confidence intervals (CIs) were estimated for recently circumcised participants reporting early sex resumption < 42 days (ESR). Risk factor analyses was conducted and the dependent variable was ESR; and independent variables included age, number of sexual partners in the past 12 months, education, occupation, marital status, and HIV status. Modified Poisson regression was used to estimate unadjusted and adjusted prevalence ratios (aPR) of ESR at each round. The multivariable model included variables with p-value < = 5% identified during bivariate analyses. Analyses were performed using Stata version 14.0 (StataCorp, 2015). We checked for effect modification including multi-collinearity and found that the mean of VIF of 1.32 hence indicating no relationship between factors.

Ethical considerations

The RCCS is approved by the Uganda Virus Research Institute (UVRI) Research and Ethics Committee (REC), the Johns Hopkins University School of Medicine (IRB), and the Uganda National Council Science & Technology. All data were de-identified and participants aged 18 years and above had provided written informed consent. Assent was obtained from all participants less than 18 years prior to participation.

Results

Changes in socio-demographic characteristic of circumcised participants over four successive survey periods (2013–2020)

From Table 1 below, majority of the respondents were aged (25–34) years representing 37.11% (167/450) in 2013/2015, this was similar across two survey rounds (2016/2018& 2018/2020) reporting 34.19% (212/620) and 27.97% (73/261) respectively, however, this was dissimilar in 2015/2016 representing 29.94% (150/501). This was followed by participants aged (20–24) years in 2013/2015 reporting 28.00% (126/450), this was similar across one survey round (2016/2018) representing 25.81% (160/620). However, this was dissimilar across two survey rounds (2015/2016 & 2018/2020) representing 31.14% (156/501) & 25.67% (67/261) respectively. This was followed by respondents aged (35–44) years under 2013/2015 representing 16.70% (75/450) and this was only similar with one survey round (2016/2018) representing 20.48% (127/620), however, this was dissimilar across two survey rounds (2015/2016 & 2018) reporting 16.57% (83/501) and 16.48% (43/261) respectively. The fourth age group in 2013/2015 was 15–19 years representing 13.30% (60/450), this finding was only similar with only survey round (2016/2018) representing 15.32% (95/620), however this was dissimilar across two survey rounds (2015/2016 & 2018/2020) reporting 18.36% (92/501) & 27.20% (71/261) respectively. The least age group in 2013/2013 were those aged at least 45 years representing 04.89% (22/450) and this was similar across all the three survey rounds (2015/2016, 2016/2018 & 2018/2020) representing; 03.99% (20/501), 04.19% (26/620) and 02.68% (07/261) respectively.

Table 1. Shows baseline socio-demographic characteristics over time (2013–2020).

Variable Survey round 2013/2015 Survey round 2015/2016 Survey round 2016/2018 Survey round 2018/2020
Frequency %tage Frequency %tage Frequency %tage Frequency %tage
Age group
15–19 60 13.30 92 18.36 95 15.32 71 27.20
20–24 126 28.00 156 31.14 160 25.81 67 25.67
25–34 167 37.10 150 29.94 212 34.19 73 27.97
35–44 75 16.70 83 16.57 127 20.48 43 16.48
45+ 22 04.89 20 3.99 26 4.19 7 2.68
Education
Post-primary 129 28.70 156 31.14 167 26.94 133 50.96
Primary 298 66.20 334 66.67 429 69.19 123 47.13
None 23 5.11 11 2.20 24 3.87 5 1.92
Marital status
Never married 158 35.10 226 45.11 238 38.39 133 50.96
Currently married 236 52.40 233 46.51 305 49.19 94 36.02
Not married 56 12.40 42 8.38 77 12.42 34 13.03
Occupation
Trading 73 16.20 93 18.56 82 13.23 53 20.31
Agrarian 245 54.40 272 54.29 319 51.45 155 59.39
Fishing 132 29.30 136 27.15 219 35.32 53 20.31
HIV status
Negative 384 85.30 437 87.23 509 82.10 228 87.36
Positive 66 14.70 64 12.77 111 17.90 33 12.64
Sexual partners
One partner 220 48.90 263 52.50 313 50.48 117 44.83
More than 1 partner 187 41.60 226 45.11 284 45.81 130 49.81
None 43 09.56 12 02.40 23 03.71 14 05.36
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In terms of education status in 2013/2015, majority of the participants had primary level of education representing 66.2% (298/450) and this was similar in 2015/2016 & 2016/2018 representing 66.67% (334/501) and 69.19 (429/620) respectively, however this was dissimilar in 2018/2020 with 47.13% (123/261). Participants with post-primary level of education in 2013/2015 were the second representing 28.7% (129/450), this finding was similar across two survey rounds (2015/2016 & 2016/2018) reporting 31.14% (156/501) and 26.94% (167/620) respectively. However, this was dissimilar in 2018/2020 which had 50.96% (133/261). Participants without formal education were the least category across all survey rounds ranging from 1.9% to 5.1%.

Regarding marital status, majority of participants were currently married in three rounds except in 2018/2020 representing 52.40% (236/450), 46.51% (233/501) and 49.19% (305/620) respectively. This was only dissimilar in 2018/2020 which had 36.02% (94/261). Participants who never married were the second across three surveys representing 35.10% (158/450), 45.11% (226/501) and 38.39% (238/620) respectively. However, in 2018/2020 this was different representing 50.96% (133/261). All participants who had never married were the least category across all survey rounds representing 12.40% (56/450), 08.38% (42/501), 12.42% (77/620) and 13.03% (34/261) respectively.

In terms of occupation, out of 1,832 circumcised participants, majority were doing agriculture across all survey rounds representing 54.40% (245/450), 54.29% (272/501), 51.45% (319/620) and 59.39% (155/261) respectively. This was followed by participants who doing fishing in all survey rounds representing 29.30% (132/450), 27.15% (136/501), 35.32% (219/620) and 20.31 (53/261) respectively. Traders were the least category, and this was similar across all survey rounds representing 16.20% (73/450), 18.56% (93/501), 13.23% (82/620) and 20.31% (53/261) respectively.

Regarding HIV status, majority of the participants self-reported being HIV negative across all four survey rounds representing 85.30% (384/450), 87.23% (437/501), 82.10% (509/620) and 87.36% (228/261) respectively, while participants with HIV negative results were the least, this was similar across all survey periods representing 14.70% (66/450), 12.77% (64/501), 17.90% (111/620), & 12.64% (33/261) respectively.

Lastly, in terms of number of sexual partners, circumcised participants who self-reported having one partner were the majority across all three survey periods representing 48.90% (220/450), 52.50% (263/501), and 50.48% (313/111) respectively except in 2018/2020 with 44.83% (117/261). Participants who had more than one sexual partner were the second, and this was similar across three survey periods representing 41.60% (187/450), 45.11% (226/501), and 45.81% (284/620) respectively. However, this was dissimilar in 2018/2020 reporting 49.81 (130/261). Finally, circumcised participants who had no sexual partner were similar across all four survey periods representing 09.56% (43/450), 02.40% (12/501), 03.71% (23/620) and 05.36% (14/261) respectively.

Characteristics of participants by ESR and survey round

Table 2 presents data on participants who were previously circumcised prior to participation in the survey. The prevalence of ESR declined from 45.1% in 2013/2015 to 21.8% in 2015/2016, and 21.8% in 2016/2018 to 14.9% in 2018/2020 [Fig 1]. Prevalence of ESR was higher among participants aged 35–44 years across three survey rounds; 64.0% in 2013/15, 30.1% in 2015/16 and 25.6% in 2018/20 than other age groups (Table 2).

Table 2. ESR prevalence and socio-demographic characteristics over time, 2013–2020, Rakai, Uganda.

Socio-demographic characteristics 2013–2015 2015–2016 2016–2018 2018–2020
This includes the number that resumed sex<42 days n = 203, Total number resumed N = 450 n/N (%) This includes the number that resumed sex <42 days n = 109, Total number resumed N = 501 n/N (%) This includes the number that resumed sex <42 days n = 135, Total number resumed N = 620 n/N (%) This includes the number that resumed sex <42 days n = 39 Total number resumed N = 261 n/N (%)
Overall prevalence of ESR 203/450(45.11) 109/501(21.76) 135/620(21.77) 39/261(14.94)
Age in years
15–19 16/60(26.67) 9/92(9.78) 7/95(7.37) 6/71(8.45)
20–24 49/126(38.89) 29/156(18.59) 22/160(13.75) 11/67(16.42)
25–34 79/167(47.31) 42/150(28.00) 64/212(30.19) 14/73(19.18)
35–44 48/75(64.00) 25/83(30.12) 33/127(25.98) 11/43(25.58)
45+ 11/22(50.00) 4/20(20.00) 5/26(19.23) 0/7(0.00)
Marital Status
Currently married 135/236(57.20) 76/233(32.62) 88/305(28.85) 22/94(23.40)
Previously married 23/56(41.07) 7/42(16.67) 22/77(28.57) 5/34(14.71)
Never married 45/158(28.48) 26/226(11.50) 21/238(8.82) 15/133(11.28)
HIV Status
Negative 174/384(45.31) 89/437(20.37) 95/509(18.66) 38/228(16.67)
Positive 29/66(43.94) 20/64(31.25) 36/111(32.43) 4/33(12.12)
Number of Sexual Partners (in the past 12 months)
One partner in the past 12 months 89/220(40.45) 51/263(19.39) 50/313(15.97) 16/117(13.68)
More than one in the past 12 months 95/187(50.80) 58/226(25.66) 80/284(28.17) 26/130(20.00)
Occupation
Trading 28/73(38.36) 18/93(19.35) 14/82(17.07) 11/53(20.75)
Agrarian 107/245(43.67) 59/272(21.69) 54/319(16.93) 22/155(14.19)
Fishing 68/132(51.52) 32/136(23.53) 63/219(28.77) 9/53(16.98)
Highest Education
Post primary 49/129(37.98) 30/156(19.23) 27/167(16.17) 13/133(9.77)
Primary 142/298(47.65) 78/334(23.35) 95/429(22.14) 28/123(22.76)
No formal education 12/23(52.17) 1/11(9.09) 9/24(37.50) 1/5(20.00)
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Fig 1. Trends in ESR per survey round by age group.

Fig 1

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ESR prevalence was highest among currently married participants across the four surveys, compared to participants who were divorced or separated (Table 2). ESR was more common among participants reporting more than one sex partner than participants with one partner. ESR was higher among fishermen compared to all other occupations across the first three survey rounds in 2013/15, 2015/16, and 2016/18. However, in 2018/20 ESR was lower among fishermen than participants who reported to be engaged in trading.

ESR prevalence was also higher among those with primary education in two survey rounds, 23.4% in 2015/16 and 22.8% in 2018/20 compared to those who completed post-primary education and men without formal education.

Trends in prevalence of ESR stratified by age across survey periods

We observed similar trends among individuals after stratification by age where ESR declined over time. However, ESR increased from 4.7% (CI = 3.8–5.9) in (2013/15) to 28.0% (CI = 21.1–36.0) in (2015/16) among individuals aged 25–34 years, with a slight reduction to 23.0% in 2018/2020 (Fig 1).

In bivariate analysis, ESR prevalence was similarly higher among those aged 35–44 years than men aged 15–19 years across all the four study periods in 2013/15, 2015/16, 2016/18 and 2018/20 [Table 3]. In addition, ESR prevalence was significantly higher among currently married participants than participants who never married across all surveys (Table 3).

Table 3. Unadjusted early sexual resumption prevalence ratios post-circumcision by survey round 2013–2020 in Rakai, Uganda.
Factor 2013–2015 2015–2016 2016–2018 2018–2020
Unadjusted PR[95% CI] Unadjusted PR [95% CI] Unadjusted PR [95% CI] Unadjusted PR [95% CI]
Education level
Post-primary 1 1 1 1
Primary 1.25[0.98, 1.61] 1.21[0.83,1.77] 1.37[0.93,2.02] 2.33[1.26,4.29] **
No formal education 1.37 [0.88, 2.15] 0.47 [0.07,3.15] 2.32 [1.25,4.32] * 2.05[0.33, 12.77]
Age group
15–19 1 1 1 1
20–24 1.46[0.91, 2.34] 1.90 [0.94,3.84] 1.87[0.83,4.20] 1.94[0.76,4.97]
25–34 1.77[1.13, 2.78] 2.86 [1.46,5.60] * 4.10[1.95,8.61] *** 2.27[0.92,5.58]
35–44 2.40[1.53, 3.78] *** 3.08[1.53,6.22] * 3.53[1.63,7.63] ** 3.03[1.20,7.67] *
45+ 1.88[1.04, 3.39] * 2.04[0.70,5.99] 2.61[0.90,7.56] 0[9.50e-07, 8.03e-06] ***
Occupation
Trading 1 1 1 1
Agrarian 1.14 [0.82, 1.57] 1.12[0.70,1.80] 0.99[0.58,1.69] 0.68[0.36,1.32]
Fishing 1.34 [0.96, 1.88] 1.22[0.73,2.03] 1.68[1.00,2.84] * 0.82[0.37,1.81]
Sexual partners in the past 12 months
One partner in the past 12 months 1 1 1 1
More than 1 partner in the past 12 months 1.26[0.94, 1.68] 1.32[0.91, 1.93] 1.95 [1.48, 2.589] *** 1.58 [.97, 2.58]
HIV status
Negative 1 1 1 1
Positive 0.97[0.72,1.30] 1.53[1.02,2.31] * 1.74[1.26,2.40] ** 0.73[0.28,1.91]
Marital status
Never married 1 1 1 1
Currently married 2.01 [1.53, 2.63] *** 2.84[1.89,4.26] *** 3.27[2.10,5.10] *** 2.08[1.14,3.79] *
Previously married 1.44[0.97, 2.15] 1.45[0.67,3.12] 3.24[1.89,5.56] *** 1.30[0.51,3.34]
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***p<0.001,

**p<0.01 &

*p<0.05

ESR prevalence was significantly higher among HIV-positive participants compared to HIV-negative participants in 2015/2016 and 2016/2018; PR = 1.53, 95% CI: [1.02,2.31]; and PR = 1.74, 95% CI: [1.26,2.40] respectively. However there we no significant difference in rounds 2013/2015 and 2018/2020.

ESR was significant in participants with multiple sex partners than those reporting one sexual partner in one survey round, 2016/2018 aPR = 1.95, 95% CI: [1.48, 2.58]. However, this was not significant in three survey rounds, 2013/15, 2015/16 and 2018/20, aPR = 1.26, 95% CI: [0.94, 1.68], aPR = 1.32, 95% CI: [0.95, 1.84] and aPR = 1.46, 95% CI: [0.83,2.59], respectively. In 2016/2018, ESR was significantly higher among fisher men compared to traders; PR = 1.68, 95% CI: [1.00,2.84] and in 2016/18 ESR was higher among participants with no formal education compared to participants with post-primary education; PR = 2.32 95% CI: [1.25,4.32]. ESR was more prevalent among participants with primary education than participants with post-primary education; PR = 2.33, 95% CI: [1.26,4.29] in 2018/2020.

Multivariate analysis of risk factors associated with ESR across all study periods (2013–2020)

Table 4 shows the multivariate analysis, in 2018/2020 and after adjusting for marital status, age, HIV status, occupation, and number of sexual partners in the past 12 months ESR was significantly higher among participants who reported primary education as their highest level of completed education than participants with post-primary education; aPR = 2.38, 95% CI: [1.31, 4.30]. ESR was also significantly higher among participants who were currently married than participants who never married, and this was similar across three study periods in 2013/15, 2015/16, 2016/18 and it was not significant in 2018/2020. In 2016/2018, ESR was also significantly higher among unmarried participants than participants who never married; aPR = 1.96, 95% CI: [0.99,3.90]. In 2016/2018, ESR was higher among participants who had more than one sexual partner than those who had one sexual partner, aPR = 1.76, 95% CI: [1.32,2.34]. However, this finding was not significant across three study survey periods.

Table 4. Adjusted early sexual resumption post-circumcision by round 2013–2020 in Rakai, Uganda.
Factor 2013/2015 2015/2016 2016/2018 2018/2020
Adjusted PR (aPR)[95% CI] Adjusted PR (aPR) [95% CI] Adjusted PR (aPR) [95% CI] Adjusted PR (aPR) [95% CI]
Education level
Post-primary 1 1 1 1
Primary 1.23[0.97,1.56] 1.17 [0.80,1.71] 1.12[0.75,1.68] 2.38[1.31, 4.30] **
No formal education 1.25[0.80,1.94] 0.53[0.08,3.61] 1.53 [0.85,2.75] 2.21[0.34, 14.50]
Age group
15–19 1 1 1 1
20–24 1.22 [0.74,2.00] 1.36[0.65,2.86] 1.19[0.50, 2.83] 1.56[0.64, 3.84]
25–34 1.16 [0.70,1.94] 1.37[0.63,2.97] 1.79[0.70,4.54] 1.68[0.62, 4.51]
35–44 1.55[0.92,2.63] 1.38[0.60,3.16] 1.39[0.53,3.64] 2.17[0.76, 6.15]
45+ 1.16[0.59,2.25] 0.95[0.29,3.11] 0.99[0.29,3.39] 7.08e-07[1.86e-07 2.69e-06] ***
Occupation
Trading center 1 1 1 1
Agrarian 1.05 [0.77,1.44] 1.25[0.80,1.95] 1.16[0.69,1.95] 0.78[0.37, 1.63]
Fishing 1.20[0.86,1.67] 0.94[0.56,1.58] 1.30[0.77,2.18] 0.67[0.28, 1.62]
Sexual partners in the past 12 months
One partner in the past 12 months 1 1 1 1
More than one partner in the past 12 months 1.18 [0.88,1.59] 1.26[0.86, 1.85] 1.76[1.32,2.34] *** 1.17 [0.70, 1.96]
HIV status
Negative 1 1 1 1
Positive 0.77[0.57,1.05] 1.24[0.80,1.92] 1.08 [0.78,1.50] 0.57 [0.22, 1.47]
Marital status
Never married 1 1 1 1
Currently married 1.83[1.30,2.57] ** 2.46[1.50,4.06] *** 2.22[1.22,4.03] ** 1.32[0.61, 2.84]
Previously married 1.29[0.82,2.01] 1.34[0.59,3.04] 1.96[0.99,3.90] * 0.83[0.30, 2.27]
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***p<0.001,

**p<0.01 &

*p<0.05

ESR was significantly lower among participants ≥45 years than participants aged 15–19 years in 2018/2020, aPR = 0, 95% CI: [9.50e-07, 8.03e-06]. Finally, occupation and HIV status were not associated with ESR across all study survey rounds.

Overall, ESR declined over time (Table 5) from 45.1% in 2013/2015 to 21.8% in 2015/2016; 21.1% in 2016/2018 and 14.9% in 2018/2020.

Table 5. Overall merged ESR prevalence, unadjusted and adjusted early sexual resumption prevalence ratios post-circumcision all four surveys (2013–2020) in Rakai, Uganda.
Overall ESR Prev. Prevalence of ESR Univariate analysis Multivariate analysis
n/N % PR(95% CI) pvalue PR (95% CI) pvalue
Survey Round
2013/2015 203/450(45.11) 1.0 1.0
2015/2016 109/501(21.76) 0.48[0.40, 0.59]*** 0.51[0.42, 0.62]***
2016/2018 135/620(21.77) 0.47[0.39, 0.56]*** 0.47[0.39, 0.56]***
2018/2020 39/261(14.94) 0.36[0.27, 0.48]*** 0.42[0.31, 0.56]***
Age in years
15–19 38/318(11.95) 1.0
20–24 111/509(21.81) 1.82[1.30, 2.57]** 1.33[0.94, 1.89]
25–34 199/602(33.06) 2.77[2.01, 3.81]*** 1.45[1.00, 2.10]*
35–44 117/328(35.67) 2.99[2.14, 4.16]*** 1.55[1.05, 2.27]*
45+ 20/75(26.67) 2.23[1.38, 3.60]** 1.07[0.64, 1.79]
Marital Status
Never Married 107/755(14.17) 1.0
Currently Married 321/868(36.98) 2.61[2.15, 3.17]*** 2.01[1.57, 2.57]***
Previously Married 57/209(27.27) 1.92[1.45, 2.55]*** 1.41[1.02, 1.95]*
Hiv Status
Negative 396/1,558(25.42) 1.0 1.0
Positive 89/274(32.48) 1.28[1.06, 1.55]* 0.95[0.78, 1.15]
Sexual Partners in the past 12 months
One Partner in the past 12 months 206/913(22.56) 1.0 1.0
More Than One Partner in the past 12 months 259/827(31.32) 1.49[1.26, 1.76]*** 1.36[1.15, 1.61]***
Occupation
Trading Center 71/301(23.59) 1.0 1.0
Agrarian 242/991(24.42) 1.04[0.82, 1.30] 1.08[0.87, 1.34]
Fishing 172/540(31.85) 1.35[1.06, 1.71]* 1.10[0.88, 1.39]
Education
Post-Primary 119/585(20.34) 1.0
Primary 343/1,184(28.97) 1.42[1.19, 1.71]*** 1.29[1.08, 1.53]**
No formal education 23/63(36.51) 1.79[1.25, 2.58]** 1.36[0.96, 1.92]
Open in a new tab

***p<0.001,

**p<0.01 &

*p<0.05

In addition, recent survey visits in 2016/18 and 2018/20, ESR significantly increased, for instance ESR prevalence was significantly higher among participants aged 25–44 years than participants aged 15–19 years. ESR prevalence was significantly higher among married participants and previously married participants compared to participants who never married. ESR prevalence was significantly higher among participants with primary level of education than post-primary aPR = 2.38, 95% CI: [1.31, 4.30] in 2018/20. ESR prevalence was significantly higher among participants with multiple sexual partners than participants without sexual partners aPR = 1.36, 95% CI: [1.15, 1.61].

Discussion

We observed twofold decline in ESR following VMMC over the 8-year period (2013–2020). A prevalence greater than 35% reported between 2013–2015 is consistent with the prevalence reported in Kenya between 2008 and 2010 [20] and a relative decline in prevalence noted in Uganda between 2015–2016 and 2016–2018 is comparable with an ESR prevalence reported in Kenya [18]. This decline over time could be due to comprehensive HIV programs which emphasized delayed resumption of sex after VMMC that started in 2016 where counseling services were strengthened [23]. Despite the decline, ESR prevalence remains higher than the recommended WHO target of zero [20]. This puts men at risk of complications and potentially HIV acquisition and transmission to female partners [10, 20]. In 2018–2020, we noted significant proportion differences in terms of age; 15–24 years, education [especially post-primary], differences in occupations including the largest decrease in ESR compared to the previous survey rounds. The potential explanation is that, there was generally low participation in visit four, which was potentially caused by the COVID-19 lockdown where people to people movement was strictly prohibited, including those using their private means, hence affecting participation in the survey-round activities.

We observed a relationship between marital status and ESR. Married men were consistently more likely to report ESR than unmarried men consistent with at least one other study [17]. This could be partly due to pressure from wives [24]. This result is also consistent with results from a qualitative study where men reported fear of losing their wives as a key driver to them resuming sex early [10].

Additionally, an association was observed between age and ESR following VMMC. Men aged 20–24 years and those aged 25–34 years were more likely to resume sex early compared to those aged 15–19 years. This finding is consistent with previous research conducted in Kenya [7, 8]. The explanation for this association could be because more men aged 20–24 years are sexually active than males aged 15–19 years. Strong post-circumcision counseling for older men is critical for controlling HIV incidence and prevalence in these populations [25].

Furthermore, participants who had multiple sexual partners were more likely to resume sex early compared to those who had one sexual partner. This finding is consistent with findings from Kenya. Health education and sensitization strategies that encourage complete wound healing and other safe sexual practices are recommended for men with multiple sexual partners to benefit from the benefits accrued from VMMC.

A limitation to this study is that sexual resumption questions were based on self-reports and is likely to be under-reported due to social desirability. Additionally, we think that VMMC status being only determined by self-report is could have affected these findings. Secondly, we could not tell if the client was HIV positive at the time of VMMC service uptake. Thirdly, we acknowledge recall bias since we included clients who had been circumcised almost 3 years ago. Further qualitative research to understand client and partner attitudes about early sexual resumption would be of value.

Conclusions

Generally, ESR declined between 2013 and 2020; and was more common among men who are married, had multiple sex partners, and lower levels of education. More strategic interventions are needed to reduce ESR among these men. Strategies like counseling, female partner participation, reminders in form of messages should be encouraged, intensive sensitization, health education, counseling services tailored to reduce prevalence of ESR have been proposed in this study.

Acknowledgments

We thank Rakai Health Sciences Program (RHSP) for availing the data. We would like to extend our gratitude to our RCCS participants for sparing time and participate in the study.

Data Availability

All data files will be available upon request. Data requests may be sent to the Rakai Health Sciences Program data management office (datarequests@rhsp.org), where data are archived across all the various projects run by the RHSP (original paper forms from the RCCS surveys, as well as the electronic datasets for each survey round).

Funding Statement

DS The RCCS study was funded by National Institute of Allergy and Infectious Diseases (R01AI110324, U01AI100031, R01AI110324, R01AI102939), the National Institute of Child Health and Development (RO1HD070769, R01HD050180), the Bill & Melinda Gates Foundation (22006.02), and the NIH Fogarty International Center (5D43TW009578–02). “This project has been supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention under the terms of [NU2GGH002009] the funders did not play any role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Decision Letter 0

Hamufare Dumisani Mugauri

13 Feb 2024

PONE-D-23-40397RESUMPTION OF SEXUAL ACTIVITY AFTER VOLUNTARY MEDICAL MALE CIRCUMCISION: DATA FROM A POPULATION BASED COHORT  IN RAKAI, UGANDA, 2013 TO 2020PLOS ONE

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Reviewer #1: Title: The title is ok. However perhaps word "early resumption" rather than just resumption of sexual activity is what is being studied so this should be inserted. The study method needs to be added - a cross sectionals survey

Abstract: The Abstract strikes me as been too lengthy and lacking in flow, there are too many brackets which interrupt the flow of the text, making the abstract difficult to read and assimilate easily. These should be minimised and only the essential information need be provided.

Introduction: This is mainly providing the justification for the study, without stating the background of the study population and the study objective. This should included some description of RCCS which is instead in the study methods. The study objective should be provided at the end of the introduction, this is missing.

Methods: The is some disparity between the WHO recommendation of 6 weeks to resume sexual activity and the MOH of Uganda's recommendation of 42 days. Some comments and justification should be provided on this. It is a little unclear how if the study is presumed to have been done in 2024 or 2023 how recent circumcision (<3 years) would have included those who had VMMC in cohorts (2013-2015,2016 to 2018 etc). Unless these surveys were summated, this should be made clear. It is not also clear if these participants were surveyed at the study time or the information was just pooled from the previous surveys in data base, because there is an issue of memory or recall Biase then in these participants. The authors need to make this clearer.

Results: The descriptive data which provides general information of the study population is missing. The results go straight into the analytic data. The results are presented in an unyielding manner with long tables with statistical numbers which give the impression of raw data. The results should be presented better and some descriptive data should be provided.

Discussion: This discussion is good. However the explanation that the decline in ESR is based on improvement in counselling services is not supported by this study itself. The author ought to be able to show that this is the case in this study based on their own data. Some discussion on early resumption sex with condom use may be useful

Conclusions

The conclusion is fair and accurate. However it adds little to what is already published, given the large cohort and the period studied the conclusion can be strengthen further.

Reviewer #2: Reviewer comments

1. The title should be “Population-based Cohort…”.

2. Line 7-8: A comma is missing: “Data from the Rakai Community Cohort Study, a cross-sectional study, were analyzed”. Also you refer to men aged 15-49 years, but men are aged ≥18 years. I’d recommend you refer to these clients as “males”.

3. Line 9-10: You should delete the parentheses around the years of these studies.

4. Line 13: For clarity with the 4 surveys, I would refer to this as “…participated in this analysis.”

5. Line 14: Previously you refer to 4 successive surveys, but here you refer to 3 surveys. Maybe say: “Across the first three surveys…” if that is what you mean here.

6. Line 20: The word “years” is missing after “45,” and there is a word missing, as the rest of this sentence does not make sense.

7. Line 21: Is the Adjusted Prevalence Ratio here 0? Also please check the CIs in lines 21-22, as something is wrong here.

8. Line 32: A comma is missing before “which”.

9. Line 33: The word “for” is missing after “allow”.

10. Line 42: These references are numbered out of order.

11. Line 47: This is an 8-year period.

12. General comment about the introduction section: There are several recent publications about sexual resumption following VMMC that have been excluded. I would recommend adding these. I also have a lot of remaining questions after reading the introduction like how many males have been circumcised for HIV prevention in Uganda? What is the specific guidance that circumcised males are given? Are there any particular challenges to Uganda that are related to wound healing or resumption of sexual activity?

13. Line 51: A comma is missing before “which”.

14. Line 54-55 says that the men self-reported their circumcision status, but in line 62 refers to only medically circumcised men. It’s unclear whether these males were identified through self-report or through medical records confirming their VMMC.

15. Line 85: Is the full name of this IRB the “Western IRB”?

16. Line 95: The word “years” is missing after “35-44”.

17. Line 99: “Fishermen” is one word.

18. Line 110: I’m not sure if this is a paragraph or a title.

19. Line 110-119: This doesn’t read as a cohesive paragraph in a Results Section.

20. Line 166: You should say “two-fold,” and this is an 8-year period.

21. Line 179: Reference #19 is missing.

22. Line 181-187: I would assume that more men aged 20-24 years are sexually active than males aged 15-19 years. Are there any data from Uganda that you could cite to support this?

23. General comment about the introduction and discussion section: More HIV-positive males that I would have expected were reported to have been circumcised and resumed sexual activity early. This is noteworthy as VMMC is usually promoted to males who are HIV-negative, though negative status is not required in order to be circumcised. The process for HTS before VMMC should be added to the introduction, and the fact that a high proportion of HIV-positive men were included in this analysis should be mentioned in the discussion section.

24. Line 193: If you think that VMMC status being only determined by self-report is a limitation, then that should be included in this paragraph.

25. Line 236: Reference #5 is incomplete.

26. This manuscript needs careful reviewing and proofreading throughout. Several sections lack specificity and detail, so more information is needed in the introduction and methods sections, especially. The results also needs careful attention.

**********

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Reviewer #1: Yes: kasonde Bowa

Reviewer #2: No

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PLoS One. 2024 Nov 21;19(11):e0297240. doi: 10.1371/journal.pone.0297240.r002

Author response to Decision Letter 0

27 Jul 2024

Point by point

S/N Comments Solution

SPECIFIC COMMENTS:

1 Reviewer #1: Title: The title is ok. However perhaps word "early resumption" rather than just resumption of sexual activity is what is being studied so this should be inserted. The study method needs to be added - a cross sectionals survey The title has been re-written having both early and the methods

2 Abstract: The Abstract strikes me as been too lengthy and lacking in flow, there are too many brackets which interrupt the flow of the text, making the abstract difficult to read and assimilate easily. These should be minimized and only the essential information need be provided. The abstract has been refined and some brackets have been removed to ease the flow and understanding

3 Introduction: This is mainly providing the justification for the study, without stating the background of the study population and the study objective. This should included some description of RCCS which is instead in the study methods. The study objective should be provided at the end of the introduction, this is missing. The RCCS description has been added and the overall objective included. These portions were removed from the methods section.

4 Methods: The is some disparity between the WHO recommendation of 6 weeks to resume sexual activity and the MOH of Uganda's recommendation of 42 days. Some comments and justification should be provided on this. It is a little unclear how if the study is presumed to have been done in 2024 or 2023 how recent circumcision (<3 years) would have included those who had VMMC in cohorts (2013-2015, 2016 to 2018 etc). Unless these surveys were summated, this should be made clear. It is not also clear if these participants were surveyed at the study time or the information was just pooled from the previous surveys in data base, because there is an issue of memory or recall Biase then in these participants. The authors need to make this clearer. Thank you so much for this important comment. Yes, there is a clear difference between WHO and Ugandan MOH definitions 6 weeks vs 42 days. However, for this particular study, our outcome was defined based on the Ugandan MOH definition of 42 days.

The recent circumcision (<3 years) was based on the particular year of the survey e.g survey one happened between 2013 and 2015 therefore the recent circumcision was <3 years on the day of interview or data collection for each survey visit. The most recent survey happened between 2018 and 2020. We have included this in our definition We understand and acknowledge this limitation (recall bias) and we have included this under study limitation.

5 Results: The descriptive data which provides general information of the study population is missing. The results go straight into the analytic data. The results are presented in an unyielding manner with long tables with statistical numbers which give the impression of raw data. The results should be presented better and some descriptive data should be provided. Thank you so much for this observation. We have included the descriptive data for the study population.

6 Discussion: This discussion is good. However the explanation that the decline in ESR is based on improvement in counselling services is not supported by this study itself. The author ought to be able to show that this is the case in this study based on their own data. Some discussion on early resumption sex with condom use may be useful Thank you for this comment. We have adjusted this to fit our own data.

7 Conclusions

The conclusion is fair and accurate. However it adds little to what is already published, given the large cohort and the period studied the conclusion can be strengthen further. Thanks, we have improved on the conclusion

Reviewer 1

1 The title should be “Population-based Cohort…” This has been changed to fit the suggestion

2 Line 7-8: A comma is missing: “Data from the Rakai Community Cohort Study, a cross-sectional study, were analyzed”. Also you refer to men aged 15-49 years, but men are aged ≥18 years. I’d recommend you refer to these clients as “males”. Thanks a lot. This has been addressed

3 Line 9-10: You should delete the parent heses around the years of these studies. Thanks, this has been removed

5 Line 13: For clarity with the 4 surveys, I would refer to this as “…participated in this analysis.” This has been corrected

6 Line 14: Previously you refer to 4 successive surveys, but here you refer to 3 surveys. Maybe say: “Across the first three surveys…” if that is what you mean here. Thanks. This has been addressed

7 Line 20: The word “years” is missing after “45,” and there is a word missing, as the rest of this sentence does not make sense. Thank you so much. This has been corrected.

8 Line 21: Is the Adjusted Prevalence Ratio here 0? Also please check the CIs in lines 21-22, as something is wrong here. Yes, the Prevalence Ratios are 0 and the CIs are also 0.0000018 and 0.0000026

9 Line 32: A comma is missing before “which”. Thank you , a comma has been added

10 Line 33: The word “for” is missing after “allow”. Thank you, the word for has been added

11 Line 42: These references are numbered out of order.

12 Line 47: This is an 8-year period. This was corrected as per tracked changes copy

13 General comment about the introduction section: There are several recent publications about sexual resumption following VMMC that have been excluded. I would recommend adding these. I also have a lot of remaining questions after reading the introduction like how many males have been circumcised for HIV prevention in Uganda? What is the specific guidance that circumcised males are given? Are there any particular challenges to Uganda that are related to wound healing or resumption of sexual activity? The introduction section has been refined

Circumcised men in Uganda are advised to resume sex after 42 days or 6 weeks (each week having 7 days) as per ministry of health guidelines.

14 Line 51: A comma is missing before “which”. Corrected

15 Line 54-55 says that the men self-reported their circumcision status, but in line 62 refers to only medically circumcised men. It’s unclear whether these males were identified through self-report or through medical records confirming their VMMC. All the information about circumcision was self-report by the participants.

We have corrected this in the main document.

16 Line 85: Is the full name of this IRB the “Western IRB”? Johns Hopkins University School of Medicine

17 Line 95: The word “years” is missing after “35-44”. The word years has been added

18 Line 99: “Fishermen” is one word. Thanks, this has been addressed

19 Line 110: I’m not sure if this is a paragraph or a title. This is a title and has been revised

20 Line 110-119: This doesn’t read as a cohesive paragraph in a Results Section. This has been improved

21 Line 166: You should say “two-fold,” and this is an 8-year period. This has been addressed

22 Line 179: Reference #19 is missing. Thanks. The reference

23 Line 181-187: I would assume that more men aged 20-24 years are sexually active than males aged 15-19 years. Are there any data from Uganda that you could cite to support this? Thanks, actually your assumption is correct and we have no data in Uganda that disagrees with that assumption.

This has been corrected

24 General comment about the introduction and discussion section: More HIV-positive males that I would have expected were reported to have been circumcised and resumed sexual activity early. This is noteworthy as VMMC is usually promoted to males who are HIV-negative, though negative status is not required in order to be circumcised. The process for HTS before VMMC should be added to the introduction, and the fact that a high proportion of HIV-positive men were included in this analysis should be mentioned in the discussion section The information has been added in the introduction

25 Line 193: If you think that VMMC status being only determined by self-report is a limitation, then that should be included in this paragraph. Thanks, this has been addressed

26 Line 236: Reference #5 is incomplete. This has been rectified. Thanks

27 This manuscript needs careful reviewing and proofreading throughout. Several sections lack specificity and detail, so more information is needed in the introduction and methods sections, especially. The results also needs careful attention. Thanks

Attachment

Submitted filename: Response to Reviewers.pdf

pone.0297240.s001.pdf (288.3KB, pdf)

Decision Letter 1

Hamufare Dumisani Mugauri

27 Aug 2024

PONE-D-23-40397R1POPULATION-BASED COHORT DATA USED TO ASSESS TRENDS IN EARLY RESUMPTION OF SEXUAL ACTIVITY AFTER VOLUNTARY MEDICAL MALE CIRCUMCISION IN RAKAI, UGANDA.PLOS ONE

Dear Dr. DAAMA,

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Kind regards,

Hamufare Dumisani Dumisani Mugauri, Ph.D. Public Health

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

**********

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Reviewer #1: Yes

Reviewer #2: Partly

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: The authors have adequately address all the key comments in the previous reviews in the areas of the abstract, the introduction, the methods, the results, the discussion and conclusions drawn

Reviewer #2: 1. Typos in the Methods and Results sections of the Abstract

2. In line 21, it’s awkward that you refer to men with “no sexual relationship” reporting resuming sexual activities. I’d recommend you clarify the language to make it clear that you’re referring to men who were not married or otherwise in relationships.

3. In line 34, your references are incorrect. You are missing the Gray manuscript from 2007, the Auvert manuscript from 2004, and you should include the meta-analysis by Weiss from 2000. The current reference #2 looks to be incorrect as well.

4. In line 34, you must add that VMMC reduces the risk of heterosexual HIV acquisition by 50-60% in men.

5. I’m not familiar with the recommendations by UNICEF, as mentioned in line 35. This should be cited or deleted.

6. It’s unclear if a new paragraph is supposed to start in line 56.

7. The introduction section is lacking some important information to orient the reader to VMMC and HIV prevention efforts in Uganda. The authors should include approximately how many males and the proportion of males that have been circumcised for HIV prevention in Uganda, what is the specific post-operative guidance that circumcised males are given regarding sexual activity post-VMMC (e.g., no vaginal sex, no sexual activity at all, no masturbation, etc.) Are there any particular challenges to Uganda that are related to wound healing or resumption of sexual activity that make adherence to the guidance particularly difficult? Note that this recommendation was included in the first review of this manuscript as comment #13.

8. I assume that boys aged <18 years provided assent, not written consent, as noted in line 80. Please clarify the language here if the current language is not right. Same comment in line 100.

9. See the original comment #2. Many study participants are aged <18 years, so referring to participants as “men” is incorrect. This issue has not been corrected throughout the manuscript.

10. The paragraph from rows 104-120 contains many errors that makes it difficult to read and understand. The use of the terms “consistent” and “inconsistent” is awkward here. Perhaps readability would be improved if the authors used “similar” and “dissimilar”.

11. The sentence in line 132 does not make sense.

12. What is R19 in line 134?

13. Figure 1 (lines 175-176) has two titles.

14. In Table 1, it appears as though survey round 4 (2018-2020) was significantly different than previous rounds (i.e., younger cohort, more post-primary education, differences in occupations, etc.). Also the largest decrease in ESR occurs in survey round 4. Is it possible that these cross-sectional cohorts include younger men that are different than prior surveys? The possible reasons for this should be discussed in the discussion section.

15. What is the target that is mentioned in line 242? This should be included here.

16. The list of references look inconsistent with each other and with the journal’s instructions.

17. In general, this manuscript still has several issues. There are many typos and awkward word choices that affect its readability. Careful review and copyediting is needed before resubmission.

**********

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Reviewer #1: Yes: Kasonde Bowa

Reviewer #2: No

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PLoS One. 2024 Nov 21;19(11):e0297240. doi: 10.1371/journal.pone.0297240.r004

Author response to Decision Letter 1

26 Oct 2024

S/N Comments Solution

SPECIFIC COMMENTS:

1 Reviewer #1: The authors have adequately address all the key comments in the previous reviews in the areas of the abstract, the introduction, the methods, the results, the discussion and conclusions drawn

Thanks

2 Reviewer #2: 1. Typos in the Methods and Results sections of the Abstract We have corrected typos in the methods and results sections

3 In line 21, it’s awkward that you refer to men with “no sexual relationship” reporting resuming sexual activities. I’d recommend you clarify the language to make it clear that you’re referring to men who were not married or otherwise in relationships. We corrected this, the confusing statements removed.

4 In line 34, your references are incorrect. You are missing the Gray manuscript from 2007, the Auvert manuscript from 2004, and you should include the meta-analysis by Weiss from 2000. The current reference #2 looks to be incorrect as well. We have corrected this and added these new references

5 In line 34, you must add that VMMC reduces the risk of heterosexual HIV acquisition by 50-60% in men. This has been added

6 I’m not familiar with the recommendations by UNICEF, as mentioned in line 35. This should be cited or deleted. This was sorted

7 It’s unclear if a new paragraph is supposed to start in line 56. Yes this was a new paragraph

8 The introduction section is lacking some important information to orient the reader to VMMC and HIV prevention efforts in Uganda. The authors should include approximately how many males and the proportion of males that have been circumcised for HIV prevention in Uganda, what is the specific post-operative guidance that circumcised males are given regarding sexual activity post-VMMC (e.g., no vaginal sex, no sexual activity at all, no masturbation, etc.) Are there any particular challenges to Uganda that are related to wound healing or resumption of sexual activity that make adherence to the guidance particularly difficult? Note that this recommendation was included in the first review of this manuscript as comment #13. This information has been included in the introduction

9 I assume that boys aged <18 years provided assent, not written consent, as noted in line 80. Please clarify the language here if the current language is not right. Same comment in line 100. This has been clarified

10 See the original comment #2. Many study participants are aged <18 years, so referring to participants as “men” is incorrect. This issue has not been corrected throughout the manuscript. This has been addressed

11 The paragraph from rows 104-120 contains many errors that makes it difficult to read and understand. The use of the terms “consistent” and “inconsistent” is awkward here. Perhaps readability would be improved if the authors used “similar” and “dissimilar”. Addressed

12 The sentence in line 132 does not make sense. Addressed

13 What is R19 in line 134? Removed

14 Figure 1 (lines 175-176) has two titles. Addressed

15 In Table 1, it appears as though survey round 4 (2018-2020) was significantly different than previous rounds (i.e., younger cohort, more post-primary education, differences in occupations, etc.). Also the largest decrease in ESR occurs in survey round 4. Is it possible that these cross-sectional cohorts include younger men that are different than prior surveys? The possible reasons for this should be discussed in the discussion section. We have included a potential explanation in discussion section

16 What is the target that is mentioned in line 242? This should be included here. Basically, WHO recommends zero persons resuming sex before the recommended period

17 The list of references look inconsistent with each other and with the journal’s instructions. Corrected

18 In general, this manuscript still has several issues. There are many typos and awkward word choices that affect its readability. Careful review and copyediting is needed before resubmission. Addressed

Attachment

Submitted filename: Response to Reviewers.docx

pone.0297240.s002.docx (19.1KB, docx)

Decision Letter 2

Hamufare Dumisani Mugauri

5 Nov 2024

POPULATION-BASED COHORT DATA USED TO ASSESS TRENDS IN EARLY RESUMPTION OF SEXUAL ACTIVITY AFTER VOLUNTARY MEDICAL MALE CIRCUMCISION IN RAKAI, UGANDA.

PONE-D-23-40397R2

Dear Dr. Daama,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Hamufare Dumisani Mugauri, Ph.D. Medicine and Health Sciences

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Acceptance letter

Hamufare Dumisani Mugauri

12 Nov 2024

PONE-D-23-40397R2

PLOS ONE

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At this stage, our production department will prepare your paper for publication. This includes ensuring the following:

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PLOS ONE Editorial Office Staff

on behalf of

Mr Hamufare Dumisani Mugauri

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    Attachment

    Submitted filename: Response to Reviewers.pdf

    pone.0297240.s001.pdf (288.3KB, pdf)
    Attachment

    Submitted filename: Response to Reviewers.docx

    pone.0297240.s002.docx (19.1KB, docx)

    Data Availability Statement

    All data files will be available upon request. Data requests may be sent to the Rakai Health Sciences Program data management office (datarequests@rhsp.org), where data are archived across all the various projects run by the RHSP (original paper forms from the RCCS surveys, as well as the electronic datasets for each survey round).

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