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Validation of self-reported male circumcision status and genital ulcer disease among Ugandan men
  1. Ronald Moses Galiwango1,
  2. Godfrey Kigozi1,
  3. Xinyi Feng2,
  4. Steven Reynolds2,3,
  5. Thomas Quinn3,4,
  6. Stephen Dalton Kiboneka5,
  7. Josephine Mpagazi1,
  8. John Baptist Kereba1,
  9. Annet Nakayijja1,
  10. Robert Ssekubugu1,
  11. Larry Chang2,
  12. Joseph Kagayi1,
  13. Aaron Tobian2,
  14. Mary K Grabowski2
  1. 1Rakai Health Sciences Program, Kalisizo, Central Region, Uganda
  2. 2Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  3. 3Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
  4. 4Division of Intramural Research, Johns Hopkins Medicine School of Medicine, Baltimore, Maryland, USA
  5. 5Baylor College of Medicine Children's Foundation Uganda, Kampala, Kampala, Uganda
  1. Correspondence to Dr Mary K Grabowski, Pathology, Johns Hopkins Medicine School of Medicine, Baltimore, Maryland, USA; mgrabow2{at}


Objective Voluntary medical male circumcision (MC) is a critical tool in combination HIV prevention programmes in Africa. Self-reported MC (SrMC) status is used in HIV epidemiological surveys to assess MC coverage but is subject to response bias with limited validation. This study evaluated the utility of SrMC status as a marker of MC as well as self-reported genital lesions for genital ulcer disease (GUD) among Ugandan men.

Methods Male participants aged 18–49 years in the cross-sectional Sexually Transmitted Infection Prevalence study, conducted between May and October 2019, responded to a questionnaire capturing SrMC status and current genital ulcer symptoms followed by clinical assessment to verify MC and presence of GUD.

Sensitivity, specificity, positive predictive value, negative predictive value and corresponding CIs (95% CI) for SrMC status and GUD were estimated.

Results There were 853 male participants, of whom 470 (55.1%) self-reported being circumcised and 23 (2.7%) self-reported GUD (SrGUD). MC was clinically confirmed in 50.2% (n=428) of participants with sensitivity of SrMC status at 99% (95% CI: 98% to 100%) and specificity 89% (95% CI: 86% to 92%). Specificity of SrMC was lowest among persons living with HIV and viremic (>1000 copies/mL) at 72% (95% CI: 46% to 90%). 18 participants had clinically confirmed GUD, but only 12 SrGUD symptoms, corresponding to a sensitivity and specificity of 67% (95% CI: 41% to 87%) and 99% (95% CI: 98% to 99%), respectively.

Conclusions SrMC status is a robust proxy for clinically confirmed MC status and may reliably be used to assess MC coverage in this setting. Conversely, GUD symptoms were under-reported, which may impact effective syndromic management of sexually transmitted infections and warrants further examination.

  • Circumcision, Male
  • Epidemiology
  • Genital Diseases, Male
  • HIV

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  • AT and MKG are joint senior authors.

  • Handling editor Merle Henderson

  • Contributors RMG interpreted results and wrote the manuscript. XF performed the analysis, interpreted results and manuscript writing. GK, SR, TQ, SDK, RS, LC and JK contributed to results interpretation and manuscript writing. SDK, JM, JBK and AN collected the data used. AT and MKG conceived the study, guided analysis, interpreted the results and assisted in writing the first draft of the manuscript. All authors contributed to writing, reviewing and editing of the manuscript.

  • Funding This work was supported by the Johns Hopkins Center for AIDS Research (grant number P30AI094189), National Institute of Allergy and Infectious Diseases (grant numbers R01A1143333, R01MH115799 and K01A1125086), National Institute of Mental Health (grant number R01MH107275), Eunice Kennedy Shriver National Institute of Child Health and Human Development (grant number R01HD091003) and the Division of Intramural Research of the National Institute of Allergy and Infectious Diseases.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.