In 2019, one-half of all new HIV infections globally occurred in Eastern and Southern Africa,¹ and in 2021 it was estimated that 12.5% of the population in Mozambique was HIV positive.² Voluntary male medical circumcision (VMMC) can reduce the risk of acquiring HIV among heterosexual men by 60%, as well as decreasing the risk of HIV transmission to female partners.^1,3 Since 2007, the WHO and the United Nations Joint Programme on HIV/AIDS (UNAIDS) have recommended VMMC, particularly in countries with a high HIV prevalence, as part of a combination HIV prevention package to prevent sexually acquired HIV in men.⁴

VMMC carries cultural importance in most African societies.^4–7 Among certain ethnic groups, male circumcision is performed for cultural reasons, often as an initiation ritual and a rite of passage into manhood. Thus, community involvement before, during and after traditional male circumcision is strong.^3,4,8 Consequently, to further increase the rate of VMMC and maintain community support, WHO/UNAIDS (2007) recommended that the sociocultural context of traditional male circumcision be promoted in collaboration with medical male circumcision programs.⁴

Based on recommendations by the WHO and UNAIDS, in 2012, the Ministry of Health of Mozambique approved the Strategic Plan for the Expansion of Circumcision. The plan, enacted from 2013 to 2017, established a goal of circumcising 2 million males aged 10– 49 y in seven priority provinces with high HIV prevalence and low male circumcision rates, including Maputo City.⁹ Although the target was not achieved, community sensitization and the increased focus on VMMC resulted in the construction of 40 additional medical circumcision health centers, both fixed and mobile, and the circumcision of >1 million boys and men in 4 y.⁹

A 2015 national health survey found that 63% of males aged 15–49 y were circumcised in Mozambique, although the proportion differed by province, ranging from 95% in Niassa to 9% in Tete.¹ In the capital, Maputo City, nearly three-quarters of men (71%) were circumcised.¹ By 2020, national circumcision rates had increased to 73.3% among males aged 15–49 y and to 80.2% in Maputo City.²

Approximately 10 y since the implementation of the Strategic Plan, this study seeks to determine the coverage of male circumcision and the sociodemographic and behavioral determinants of uncircumcision in a peri-urban neighborhood in Maputo City, Mozambique. By providing insights into the remaining uncircumcised cohort, this study aims to contribute to public health policies with an emphasis on sexual health, especially HIV prevention.

Our study determined that the majority of men, nearly 80%, living in a peri-urban setting in Maputo, Mozambique, and interviewed as part of the HIV risk factors assessment of the HDSS Polana Caniço, were circumcised. Compared with Maputo City in 2015, male circumcision in our survey is 11% higher, which is similar to a national increase from 59% in 2009 to 69% in 2015.¹ Consistent with the recent expansion of VMMC programs in Mozambique beginning in 2013, a greater proportion of young men aged 15–19 y were circumcised.¹¹ Furthermore, the percentage of circumcised men steadily decreased as age increased.

Both lower levels of education and belonging to lower wealth quintiles were significantly associated with being uncircumcised, suggesting that communications emphasizing the health benefits of circumcision were more successful in reaching those who completed all levels of schooling. Unlike our findings, the report from the National Circumcision Program did not find a link between circumcision and level of education.⁹ However, similar to our results, which detected a difference of 18% in circumcision status between those with a primary education level and a secondary or higher education, the report did observe a difference of 32% in circumcision status between primary and higher education levels.⁹

This similarity may reinforce the idea that circumcision sensitization programs reach adolescents attending school, particularly those who complete higher schooling levels. Strengthening appropriate messages regarding the benefits of male circumcision can help to close the gap among those with higher education levels who remain uncircumcised. Notably, in 2015, of men with a primary education level, 33% in HDSS Polana Caniço were uncircumcised compared with 42% nationally,¹¹ suggesting that the implementation of the Strategic Plan for Male Circumcision is reaching these subgroups, but at a slower rate than those with a higher level of education.

The vast majority of those who practice the religion of Islam in HDSS Polana Caniço were circumcised (92.5%), which was similar to national findings in 2015 (93%), 2011 (83%) and 2009 (88%).¹ Men practicing no religion or a religion other than Islam were three to four times more likely to be uncircumcised, indicating a strong need to prioritize other religious groups in VMMC campaigns. Additionally, considering that both Islamic religion and education were positively associated with circumcision, further investigation into the relationship between Islam and participants’ education level may provide a valuable insight for effectively targeting groups with a lower circumcision prevalence. Most men in HDSS Polana Caniço reported being circumcised by a health professional (85%), which differs from national findings, where the majority of circumcisions were performed by a traditional medical practitioner/friend/family member (33%) and fewer by a health professional (27%).¹¹ Taking into consideration that Polana Caniço is a peri-urban neighborhood with urban influence, this difference could be partially explained by better access to health professionals in urban vs rural areas.¹¹

STI diagnosis (aOR 1.57 [95% CI 1.13 to 2.16]) and a lack of condom us (aOR 1.23 [95% CI 1.01 to 1.51]) were associated with being uncircumcised, highlighting the need for continued emphasis on protective sexual health behaviors, particularly the importance of condom use in conjunction with VMMC to prevent the spread of HIV and other STIs.² Interestingly, one of the main criticisms of the global VMMC program is that circumcised men may adopt riskier sexual behaviors;¹¹ however, this study found the opposite, suggesting a need for investigation into combination preventative health messaging within this community.

This study was subject to field limitations, including difficulties in accessing households during the rainy season and the unavailability of adults, especially during weekdays. Because of the nature of in-person interviews, the findings in this study may be subject to stigma, social desirability bias or recall bias, where men may not have correctly reported their circumcision status, sexual behaviors, or an HIV or STI diagnosis. Interviewers minimized stigma and social desirability bias by ensuring participants’ privacy during the interview and the confidentiality of their responses. While wealth quartiles were analyzed to align with other research, this variable may not accurately identify those most at risk, as household commodities in peri-urban settings are more similar than in national settings, where urban–rural differences are greater. A particular strength of this study is the location of CISPOC within the Polana Caniço neighborhood, allowing the data collection team to flag data inconsistencies, verify questionnaires with interviewers and confirm answers with HDSS participants.

In Mozambique, the proportion of uncircumcised men is decreasing over time. Supported by findings that those who do not complete all levels of schooling are more likely to be uncircumcised, targeted interventions aimed at those unable to attend or complete schooling are needed to close the gap among those uncircumcised. As per our findings, of those circumcised, >60% were circumcised between the ages of 0 and 14 y, overlapping with primary school in Mozambique. Future public health interventions should therefore continue to direct preventative health messaging at children attending primary and secondary schools and their parents, to capture those at ages when circumcision is more likely to occur. It will also be necessary to increase the scope of outreach programs to include communities, targeting those with lower education levels. Both a history of STIs and a lack of condom use were associated with being uncircumcised. Because condom use and male circumcision are included in combination HIV and STI prevention programs, future HIV prevention programs may emphasize the benefits of both to further reduce the risk of HIV and STI transmission.