Long-term population effect of male circumcision in generalised HIV epidemics in sub-Saharan Africa

Author: Michel Garenne

Contact: Institut Pasteur, Unité d’Epidémiologie des Maladies Emergentes, 25 Rue du Docteur Roux, 75724 Paris Cedex 15, France  e-mail:

Source: African Journal of AIDS Research, Volume 7, Number 1, May 2008 , pp. 1-8(8)

This paper examines the complex relationship between male circumcision and HIV prevalence and incidence in sub-Saharan African countries that have generalised epidemics. In South Africa, the mean yearly HIV incidence and an estimate of the net reproduction rate of the epidemic (R0) (in this case, the ratio of the number of HIV-infected persons between 1994 and 2004 to the number of persons infected in 1994 from which they were presumed to have become infected) were computed from antenatal clinic data for the period 1994–2004, and then compared, by province, to prevailing levels of male circumcision (high, medium and low). In South Africa, mean yearly HIV incidence and net reproduction rate of the epidemic were not lower in provinces with higher levels of male circumcision. For thirteen other countries where Demographic and Health Survey data were available, male HIV prevalence in circumcised and non-circumcised groups was compared. 

A meta-analysis of that data, contrasting male HIV seroprevalence according to circumcision status, showed no difference between the two groups (combined risk ratio [RR] = 0.99, 95% CI = 0.94–1.05). Individual case study analysis of eight of those countries showed no significant difference in seroprevalence in circumcised and uncircumcised groups, while two countries (Kenya and Uganda) showed lower HIV prevalence among circumcised groups, and three countries (Cameroon, Lesotho and Malawi) showed higher HIV prevalence among circumcised groups. In most countries with a complex ethnic fabric, the relationship between men’s circumcision status and HIV seroprevalence was not straightforward, with the exception of the Luo in Kenya and a few groups in Uganda. These observations put into question the potential long-term effect of voluntary circumcision programmes in countries with generalised HIV epidemics. 





Objectives: To determine circumcision prevalence and its association with HIV and STI in a male United States military population.

Design: Case-control study of HIV-infected U.S. military personnel (n = 232) from 7 military medical centers and male U.S. Navy controls (n = 516) from an aircraft carrier. 

Methods: Cases and controls completed similar self-administered HIV behavioral risk surveys. Case circumcision status was abstracted from medical charts while control status was reported on the survey. Cases and controls were frequency matched on age. Multiple logistic regressions were constructed separately to evaluate the role of circumcision in the acquisition of HIV and STI.

Results: Cases (84.9%) and controls (81.8%) reported similar proportions of circumcision. Prevalence of circumcision among United States-born men was higher (85.0%) than those born elsewhere (58.1%). After adjustment for demographic and behavioral risk factors, lack of circumcision was not found to be a risk factor for HIV (OR = 0.9; 95% CI, 0.51–1.7) or STI (OR = 1.08; 95% CI, 0.52–2.26). The odds of HIV infection were 2.6 higher for irregular condom users, 5 times higher for those reporting STI, 6.2 times higher for those reporting anal sex, 2.8–3.2 times higher for those with 2- 7+ partners, nearly 3 times higher for Blacks, and 3.5 times higher for men who were single or divorced/separated.

Conclusions: Although known HIV risk factors were found to be associated with HIV in this military population, there was no significant association with male circumcision. Randomized clinical trials currently underway should shed more light on this pressing topic.

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