Resumption of Sexual Activity After Voluntary Medical Male Circumcision: Data from a Population Based Cohort in Rakai, Uganda, 2013 to 2020

Introduction Voluntary medical male circumcision (VMMC) reduces the risk of heterosexual acquisition of HIV by 50%–60%. The Uganda Ministry of Health recommends abstinence 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, a cross-sectional study were analyzed. Data included consenting men aged 15–49 years in who self-reported having received VMMC in one of four successive surveys, (June 2013 to January 2015), (February 2015 to September 2016), (October 2016 to May 2018), and (June 2018 to October 2020). ESR prevalence and associated risk factors using modified Poisson regression to estimate adjusted prevalence ratios (aPR) were estimated. Results Overall, 1,832 men participated in the study. ESR decreased from 45.1% in 2013 to 14.9% in 2020 (p<0.001). Across the three surveys, ESR prevalence was consistently higher among married than never married men, 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 men who reported more than one sexual partner than men with one partner, aPR=1.59, 95% CI: [1.16,2.20]. In the fourth survey (2018-2020), ESR prevalence was significantly higher among men with primary education than men with post-primary, aPR=2.38, 95% CI: [1.31, 4.30] while ESR prevalence was lower among men aged at least 45 men with no sexual relationship in the past 12 months but self-reported to have resumed sex activities, aPR= 0, 95% CI: [1.86-07, 2.69-06] and aPR=0, 95% CI: [3.61e-07, 2.12e-06], respectively. Overall, men 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 can help decrease post-VMMC ESR. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Yes ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The RCCS is approved by the Uganda Virus Research Institute (UVRI) Research and Ethics Committee (REC), the Western IRB, and the Uganda National Council Science & Technology. All data were de-identified and participants had provided written informed consent I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data files will be available upon request.