More than Foreskin: Circumcision Status, History of HIV/STI, and Sexual Risk in a Clinic-Based Sample of Men in Puerto Rico

Published in: The Journal of Sexual Medicine Volume 9, Issue 11, pages 2933–2937, November 2012 


Introduction.  Circumcision among adult men has been widely promoted as a strategy to reduce human immunodeficiency virus (HIV) transmission risk. However, much of the available data derive from studies conducted in Africa, and there is as yet little research in the Caribbean region where sexual transmission is also a primary contributor to rapidly escalating HIV incidence.
Aim.  In an effort to fill the void of data from the Caribbean, the objective of this article is to compare history of sexually transmitted infections (STI) and HIV diagnosis in relation to circumcision status in a clinic-based sample of men in Puerto Rico.
Methods.  Data derive from an ongoing epidemiological study being conducted in a large STI/HIV prevention and treatment center in San Juan in which 660 men were randomly selected from the clinic's waiting room.
Main Outcome Measures.  We assessed the association between circumcision status and self-reported history of STI/HIV infection using logistic regressions to explore whether circumcision conferred protective benefit.
Results.  Almost a third (32.4%) of the men were circumcised (CM). Compared with uncircumcised (UC) men, CM have accumulated larger numbers of STI in their lifetime (CM = 73.4% vs. UC = 65.7%; P = 0.048), have higher rates of previous diagnosis of warts (CM = 18.8% vs. UC = 12.2%; P = 0.024), and were more likely to have HIV infection (CM = 43.0% vs. UC = 33.9%; P = 0.023). Results indicate that being CM predicted the likelihood of HIV infection (P value = 0.027).
Conclusions.  These analyses represent the first assessment of the association between circumcision and STI/HIV among men in the Caribbean. While preliminary, the data indicate that in and of itself, circumcision did not confer significant protective benefit against STI/HIV infection. Findings suggest the need to apply caution in the use of circumcision as an HIV prevention strategy, particularly in settings where more effective combinations of interventions have yet to be fully implemented. 
Rodriguez-Diaz CE, Clatts MC, Jovet-Toledo GG, Vargas-Molina RL, Goldsamt LA, and GarcĂ­a H. More than foreskin: Circumcision status, history of HIV/STI, and sexual risk in a clinic-based sample of men in Puerto Rico. J Sex Med 2012;9:2933–2937.

What does circumcising men do to women’s HIV risk?

Advocates for mass male circumcision have paid insufficient attention to protect women. Here are two ways these programs increase women’s risks for HIV.

Not protecting women from high risk to get HIV from a newly circumcised, HIV-positive partner

Only one study has followed wives of newly circumcised HIV-positive men to see what happens to their wives. That study, in Uganda, 2003-07, circumcised some HIV-positive men and left others intact, and then followed and tested their wives from time to time to see who got HIV. Over several years, wives of men circumcised for the study were 1.49 times more likely to get HIV than wives whose husbands remained intact (see Table below). Wives of circumcised men were at especially high risk if they resumed sex before their husbands’ circumcision wound healed – 5 (28%) of 18 who did so got HIV within 6 months after their husbands were circumcised.
Despite this risk, UNAIDS recommends: “The offer of male circumcision should neither depend on a person undergoing an HIV test, nor on a person being…HIV-negative.”[i] Donors and governments follow this advice – circumcising men without requiring them to take an HIV first and, if found to be HIV-positive, to bring their wives for couple counseling before proceeding with the circumcision.

Allowing women (and men) to think sex without condoms with a partner who may be HIV-positive is safe

Such beliefs conflict with available evidence. According to three studies, even with healed wounds, circumcised men transmit HIV to women. Whether they do so faster or slower than intact men is unknown. Two out of 3 studies that followed discordant couples — with HIV-positive men and HIV-negative wives – report that intact men transmit faster than circumcised men. The third study reports the opposite: that circumcised men transmit faster than intact men — not only in the first 6 months after circumcision, but continuing for the next 18 months as well (when the study ended).
Faster or slower? The jury is out. But what is clear from these studies is that women who want to be safe — not just safer — need to continue to use condoms with men who may be HIV-positive, whether they are circumcised or intact.
Table: Rate of new HIV infections (incidence) in women with HIV-positive partners who are circumcised or intact
Countries, yearsNew infections (%/year) in women whose partners are:Relative risk for HIV in women with circ’d vs intact partners
Uganda, 1994-98[ii]
Botswana, Kenya, Rwanda, South Africa, Tanzania, Uganda, Zambia, 2004-08[iii]2.043.470.61
Uganda, 2003-07[iv]

[i] Quote from p. 7 in: UNAIDS, 2008. Safe, Voluntary, Informed Male Circumcision and Comprehensive HIV Prevention Programming: Guidance for decision-makers on human rights, ethical and legal considerations. Available at: (accessed 1 December 2011).
[ii] Gray RH, Kiwanuka N, Quinn TC, et al. Male circumcision and HIV acquisition and transmission: cohort studies in Rakai, Uganda. AIDS 2000; 14: 2371-2381.
[iii] Baeten JM, Donnell D, Kapiga SH, et al. Male circumcision and risk of male-to-female HIV-1 transmission: a multinational prospective study in African HIV-1-serodiscordant couples. AIDS 2010; 24: 737-744.
[iv] Wawer MJ, Makumbi F, Kigozi G, et al. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomized controlled trial. Lancet 2009; 374: 229-237.


HIV/AIDS and circumcision: lost in translation

Marie Fox, Michael Thomson

School of Law, Keele University,
Staffordshire, UK
Correspondence to
Marie Fox, School of Law, Keele
University, Staffordshire ST5
5BG, UK;
Received 30 June 2010
Accepted 13 August 2010

In April 2009 a Cochrane review was published
assessing the effectiveness of male circumcision in
preventing acquisition of HIV. It concluded that there
was strong evidence that male circumcision, performed
in a medical setting, reduces the acquisition of HIV by
men engaging in heterosexual sex. Yet, importantly, the
review noted that further research was required to
assess the feasibility, desirability and cost-effectiveness
of implementation within local contexts. This paper
endorses the need for such research and suggests that,
in its absence, it is premature to promote circumcision
as a reliable strategy for combating HIV. Since articles in
leading medical journals as well as the popular press
continue to do so, scientific researchers should think
carefully about how their conclusions may be translated
both to policy makers and to a more general audience.
The importance of addressing ethico-legal concerns that
such trials may raise is highlighted. The understandable
haste to find a solution to the HIV pandemic means that
the promise offered by preliminary and specific research
studies may be overstated. This may mean that ethical
concerns are marginalised. Such haste may also obscure
the need to be attentive to local cultural sensitivities,
which vary from one African region to another,in
formulating policy concerning circumcision.

Rolling out male circumcision as a mass HIV/AIDS intervention seems neither justified nor practicable

Two articles1,2 published in this issue address male circumcision (MC).
Connolly et al.1 show in a national survey that MC, whether pre-pubertal or post-pubertal, has no protective effect on acquisition by males of HIV infection as measured by prevalence.
Sidler et al.2 state that neonatal MC continues to be promoted without adequate justification as a medicalised ritual, via an HIV prevention rationale. They caution that for MC to be a therapeutic as opposed to a non-therapeutic procedure, it is necessary to gather more corroborative and consistent evidence of its benefit, consider the potential harms (psychological, sexual, surgical and behavioural/disinhibition), examine the ethical implications, and examine effectiveness and efficiency (costs and benefits) at the population and societal levels. They point out that MC is not just a technical surgical intervention – it takes place in a social context that can radically alter the anticipated outcome. At the 2008 International AIDS Conference3 in Mexico cultural, political and educational issues raised by the intervention, such as decreased condom use and marginalisation of women, were hotly debated. Some cultural interpretations may view MC as a licence to have unprotected sex. A case in point is Swaziland, where men are flocking to be circumcised with the understanding that this means they no longer need to use other preventive methods (e.g. wear condoms or limit the number of sexual partners).4
The 2003 Cochrane review5 of observational studies of MC effectiveness concluded that there was insufficient evidence to support it as an anti-HIV intervention. Three randomised controlled trials (RCTs) from South Africa, Kenya and Uganda in 2006 - 2007 show a protective effect of MC. However, Garenne6 has subsequently shown from observational data that there is considerable heterogeneity of the effect of MC across 14 African countries. Despite the South African RCT showing a protective effect, he reports for the nine South African provinces that ‘there is no evidence that HIV transmission over the period 1994 - 2004 was slower in those provinces with higher levels of circumcision’. Interestingly, in both Kenya and Uganda, where two of the RCTs were done, a protective effect of MC was observed, but a harmful effect was observed in Cameroon, Lesotho and Malawi. The other eight countries showed no significant effect of MC.
These somewhat discordant findings are difficult to interpret. While RCTs are theoretically strong designs, it is conceivable that their findings are not generalisable beyond their settings. Furthermore, there have been no trials of neonatal MC. Study flaws such as inability to obtain double blinding, and loss to follow-up in RCTs, may effectively degrade their quality to that of observational studies. Meanwhile other disturbing findings referred to by Sidler et al. are emerging, including the reported higher risk for women partners of circumcised HIV positive men, disinhibition, urological complications, relatively small effect sizes of MC at the population level, and relative cost-inefficiency of MC.
Not all objections to MC as an HIV intervention have to do with evidence of effectiveness or cost. Sidler et al. raise ethical objections. Owing to the current climate of desperation with regard to the HIV epidemic, evidence in favour of MC frequently seems overstated. This reduces the scope for informed consent and autonomy for adult men considering the procedure. Further problems arise in the case of neonates whose parents may be considering the procedure. Whereas informed consent is at least possible for adult men, it is clearly not possible for neonates. Parents can only guess what the child’s wishes would be if he were presented with the information they have at their disposal. If it could be shown that circumcision was necessary in the neonatal period, parental consent on behalf of the neonate would be justified. But since no valid surgical indications for circumcision exist in this period, and the future benefit to the child in respect of HIV avoidance is not relevant before sexual debut, the duty of parents may well be to err on the side of caution, and defer the procedure until the child can make an autonomous decision. In the absence of compelling indications, a procedure such as circumcision could also be seen as a violation of the child’s right to bodily integrity. Furthermore, the ethical principle of non-maleficence cannot be upheld as there are clear harms attached to this practice, to which Sidler et al. refer in their article. Lastly, at a societal level MC may be unjust insofar as it could compete for resources with more effective and less costly interventions7 and disadvantage women.
Despite a strong pro-circumcision lobby driven by enthusiasts who have been promoting MC as an (HIV) intervention for many years, and impatience expressed by protagonists about the long delay after the 2006 - 2007 RCT results and the UNAIDS/WHO policy recommendations8 of March 2007, few mass campaigns have been launched in African countries.
Given the epidemiological uncertainties and the economic, cultural, ethical and logistical barriers, it seems neither justified nor practicable to roll out MC as a mass anti-HIV/AIDS intervention.
A Myers
Humanities student, University of Cape Town
J Myers
School of Public Health and Family Medicine
University of Cape Town

Corresponding author: J Myers (
  1. Connolly C, Simbayi LC, Shanmugam R, Nqeketo A. Male circumcision and its relationship to HIV infection in South Africa: Results from a national survey in 2002. S Afr Med J 2008; 98: 789-794.
  2. Sidler D, Smith J, Rode H. Neonatal circumcision does not reduce HIV infection rates. S Afr Med J 2008; 98: 764-766.
  3. Male Circumcision: To Cut or Not to Cut (dedicated session, 7 August). AIDS 2008 – Mexico City 3-8 August 2008 – XVII International AIDS Conference. PSession.aspx?s=41 (last accessed 8 August 2008).
  4. Swaziland: Circumcision gives men an excuse not to use condoms. http://www.irinnews. org/Report.aspx?ReportId=79557 (last accessed 7 August 2008).
  5. Siegfried N, Muller M, Volmink J, et al. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD003362. DOI: 10.1002/14651858.CD003362.
  6. Garenne M. Long-term population effect of male circumcision in generalised HIV epidemics in sub-Saharan Africa. African Journal of AIDS Research 2008; 7(1): 1-8.
  7. New study shows condoms 95 times more cost-effective than circumcision in HIV battle. (last accessed 7 August 2008).
  8. WHO/UNAIDS Technical Consultation Male Circumcision and HIV Prevention: Research Implications for Policy and Programming. Montreux, 6 - 8 March 2007. Conclusions and Recommendations. (accessed 25 August 2008).

Male circumcision and its relationship to HIV infection in South Africa: Results of a national survey in 2002

Catherine Connolly, Leickness C Simbayi, Rebecca Shanmugam, Ayanda Nqeketo

Objective. To investigate the nature of male circumcision and
its relationship to HIV infection.
Methods. Analysis of a sub-sample of 3 025 men aged 15 years
and older who participated in the first national populationbased
survey on HIV/AIDS in 2002. Chi-square tests and
Wilcoxon rank sum tests were used to identify factors
associated with circumcision and HIV status, followed by a
logistic regression model.
Results. One-third of the men (35.3%) were circumcised. The
factors strongly associated with circumcision were age >50,
black living in rural areas and speaking SePedi (71.2%) or
IsiXhosa (64.3%). The median age was significantly older
for blacks (18 years) compared with other racial groups (3.5
years), p <0.001. Among blacks, circumcisions were mainly
conducted outside hospital settings. In 40.5% of subjects,
circumcision took place after sexual debut; two-thirds of
the men circumcised after their 17th birthday were already
sexually active. HIV and circumcision were not associated
(12.3% HIV positive in the circumcised group v. 12% HIV
positive in the uncircumcised group). HIV was, however,
significantly lower in men circumcised before 12 years of
age (6.8%) than in those circumcised after 12 years of age
(13.5%, p=0.02). When restricted to sexually active men, the
difference that remained did not reach statistical significance
(8.9% v. 13.6%, p=0.08.). There was no effect when adjusted for
possible confounding.
Conclusion. Circumcision had no protective effect in the
prevention of HIV transmission. This is a concern, and has
implications for the possible adoption of the mass male
circumcision strategy both as a public health policy and an
HIV prevention strategy.
S Afr Med J 2008; 98: 789-794

The Cost to Circumcise Africa

a Georgetown University bWellness Associates c Independent Researchers

Male circumcision employed as a prophylactic surgical intervention for HIV transmission
reduction has been publicized in the media following recent results from
observational trials conducted in Africa. Yet in all of the discussions concerning
circumcision as a public health initiative, including a cost analysis performed on
circumcision as a prophylactic for reducing HIV transmission in Africa, none estimates
the endeavor’s scope or cost. Given the scale of the economics involved
in and the number of competing strategies available for addressing the HIV epidemic,
funding and cost effectiveness are vital concerns in the field. This raises the
question of which treatments and methodologies to fund, or not. In this study, we
use circumcision costs, census, and demographic data available from government
agencies and other published sources to estimate the cost to circumcise all HIVnegative
African adult males, including costs of complications. We compare that
cost to another androcentric penile alteration: using condoms (including their purchase
and distribution costs). Our findings suggest that behavior change programs
are more efficient and cost effective than surgical procedures. Providing free condoms
is estimated to be significantly less costly, more effective in comparison to
circumcising, and at least 95 times more cost effective at stopping the spread of
HIV in sub-Saharan Africa. In addition, condom usage provides protection for
women as well as men. This is significant in an area where almost 61% of adults
living with AIDS are women.

Read full text here.
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