Circumcision, HIV and Sexually Transmitted Infections in the U.S. Navy



Anne G. Thomas, Ph.D.
Ludmila N. Bakhireva, M.D., M.P.H.
Stephanie K Brodine, M.D.
Richard A. Shaffer, Ph.D.

Naval Health Research Center 
P.O. Box 85122
San Diego, CA 92186-5122

Graduate School of Public Health Division of Epidemiology and Biostatistics San Diego State University
San Diego, CA 92182-4162

Report No. 04-10, was supported in part by Cooperative Agreement DAMD17-93-V 3004 between the U.S. Army Medical Research and Material Command, Fort Detrick, Maryland, and the Henry M. Jackson Foundation for the Advancement of Military Medicine, Rockville, Maryland, and the Army Reimbursable Work Unit #6916. The views expressed in this article are those of the authors and do not reflect the official policy or position of Department of the Navy, Department of Defense, or the U.S. Government. Approved for public release; distribution unlimited.

This research has been conducted in compliance with all applicable federal regulations governing the protection of human subjects in research.


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.


With an estimated 5 million new infections, 3 million deaths, and 40 million prevalent infections in 2003, reducing the incidence of HIV infection remains a critical, worldwide goal. In recent years, several studies conducted among sub-Saharan African male populations report circumcision to be associated with reduced risk of HIV infection [1–5]. Compelling evidence from studies conducted among sub-Saharan African populations of circumcision’s protective effect against HIV acquisition, is now considered substantial enough that many are advocating for male circumcision as one component of a comprehensive HIV prevention package [5,6].

Whether circumcision of male infants should be recommended as a method of HIV prevention in developed countries such as the United States remains the subject of heated controversy. Thus far, the majority of studies investigating the association of circumcision and HIV have been conducted among Sub-Saharan African populations, which differ substantially from developed nations in terms of HIV risk factors, sexual practices, and medical care availability.

Ulcerative sexually transmitted infections (STIs), such as genital herpes, syphilis, and chancroid, known risk factors for HIV infection [2,7–11], are more prevalent among sub-Saharan African populations, the same populations with low levels of circumcision. This may be a major source of residual confounding in the HIV–circumcision association.

Relatively few studies have been conducted in the United States or other developed nations investigating the association between circumcision status and STI acquisition, and, to our knowledge, none have been of large enough scale to report any significant finding regarding an association with HIV acquisition. With respect to STI acquisition, these studies have yielded inconsistent results, with several showing a protective effect of circumcision [11–13] while others found an increased risk for STIs among circumcised males [14].

In addition to STI acquisition, several studies among western populations have shown circumcision to have a strong protective effect against urinary tract infections (UTIs) among male infants [15–17] and penile cancer in middle-aged and older men [18– 20]. However, there is still controversy surrounding the practice of male circumcision, as opponents argue that the medical benefits do not outweigh the risks, and that the neonatal procedure causes unnecessary pain, reduced penile sensitivity, and violates the human rights of the unconsenting child [14,21–23]. This case-control study describes the prevalence and demographic determinants of circumcision in a U.S. military population and the association of circumcision and HIV/STI acquisition.


Study population

HIV seropositive case participants in this case-control study were male, active- duty U.S personnel from all branches of the military recruited from 7 military medical referral centers throughout the United States as a part of a larger case-series study. Enrollment and study procedures are described elsewhere [24,25]. All cases had documented HIV seroconversion and completed a self-administered behavioral risk factor questionnaire.

Control participants from a general Navy aircraft carrier population completed similar questionnaires. Controls were assumed to be HIV seronegative. U.S. Department of Defense policy stipulates that all military personnel undergo predeployment HIV screening and test negative.

Case and control participants had to meet two criteria for inclusion in this study. First, their circumcision status had to be available. Case circumcision status was abstracted from previously collected medical data, with 51.2% (294/574) having this information available. The control population was limited to those who answered the circumcision question (yes/no) on the self-administered survey (93.3%; 859/ 921). Second, using a combination of survey questions, cases and controls had to be categorized as having had sex during their reporting time frame (286 cases and 801 controls).

Case participants reported behaviors occurring within their seroconversion window (SCW), the time between the last negative and first positive HIV test. To reduce variability in the length of the SCW, and recall bias, only cases with a SCW of 3 or less years (median = 1 year) were included (n = 234). Providing comparable reporting time frames controls were asked to report their behaviors within last 12 months.

The Institutional Review Boards of participating institutions approved both studies; all participants provided informed consent.

Data collection

Case participants’ data collection occurred between February 1997 and June 2001. Demographic characteristics, sexual risk behaviors, and STI history were assessed. Circumcision status for cases was abstracted from medical records obtained during the case study.
Circumcision and HIV/STI association 6

The control survey was conducted in April 2002 during a “safety stand-down,” a period of time when all personnel at a military command engage in safety training rather than performing their regular jobs. Controls were administered a questionnaire comparable to that of the cases, with the deletion of questions not applicable for an HIV- seronegative population, and the addition of questions regarding circumcision status, HIV testing, and supplemental condom use questions.

Demographic characteristics, including age, ethnicity, country, and state of birth (U.S.-born), marital status, education, and rank were collected. HIV risk behaviors, including number of sexual partners, engaging in anal or group sex, geographic location of sex (U.S. or foreign), STI history, and condom use during vaginal, anal, and oral sex were collected.

Statistical analysis

Since cases were significantly older than controls, and age was thought to be associated with both HIV risk and prevalence of circumcision, frequency matching on age was performed. Eight strata were created with matching ratios varying from 1:1 to 1:4 depending upon the number of available controls. The final sample comprised 232 cases and 516 frequency matched controls.

Comparisons of demographics and sexual risk behavior by case status were performed using analysis of variance (ANOVA) and chi-square tests. Circumcision prevalence was compared using chi-square tests.

Unconditional logistic regression was used to examine the effect of circumcision on HIV infection after adjustment for demographic, and sexual behavior risk variables. Accounting for age frequency matching, 7 dummy variables were created and included in all models. For model building purposes, all demographic and sexual risk behavior variables univariately associated with HIV were initially included in the models. The final logistic regressions included variables that remained significantly (p ≤ .05) associated with HIV status. Likewise, multivariate logistic regression models were used to examine the independent association between circumcision status and STI history.

Potential participation biases were examined through demographic comparisons of men with (participants) and without (nonparticipants) circumcision status available using ANOVA and chi-square tests. All statistical analyses were performed using SAS (Release 9.0, SAS Institute, Inc., Cary, NC, 2002).


Among the cases, availability of circumcision status differed greatly by participation site (p < 0.001). However, after adjusting for site, there were no significant demographic differences between cases who had (n = 294; 51.2%) and did not have (n = 280; 48.8%) their circumcision status available. Furthermore, among the controls, no demographic differences were found between those who reported their circumcision status (n = 859; 93.3%) and who did not (n = 62; 6.7%).

The proportion of circumcised men did not significantly differ between cases (84.9%) and controls (81.8%). Case participants were more likely to be Black, single or divorced, and have some college or a bachelor’s degree or higher, and be of E4-E6 military ranks than the controls (Table 1).

The prevalence of circumcision among this U.S. military population was particularly high (more than 85%) for birth-years 1945-1964 and 1970-1979, with a decline during 1965-1969 (77.1%) and the 1980s (74.2%) (Table 2). Prevalence of circumcision differed dramatically by ethnicity, with the highest prevalence among whites (92.4%) and the lowest among Hispanics (44.1%). There was a significantly higher proportion of circumcised men among those born in the United States (85.0%) as compared with men born in other countries (58.1%). There were some regional differences, with the highest prevalence of circumcision among men born in the Midwest (90.2%) and Northeast (86.8%), followed by the West (85.0%) and the South (82.0%).

Case and control participants differed significantly with respect to sexual risk characteristics (Table 3). A higher proportion of cases did not use condoms regularly (91.0%), had sex in either a foreign country or both a foreign country and the United States (27.6%), reported anal sex (72.8%), group sex (29.5%), had more sexual partners (almost 75% had 3 or more partners), and had higher prevalence of STIs (22.8%), as compared with controls.

In multivariate logistic regression analysis (Table 4), lack of circumcision was not found to be associated with HIV (OR = 0.90; 95% CI, 0.51–1.70) after controlling for significant demographic and sexual risk covariates. These data confirmed an association between HIV and inconsistent condom use (OR = 2.60; 95% CI, 1.36–4.98), recent history of STI (OR = 5.04; 95% CI, 2.46, 10.32), and anal sex (OR = 6.24; 95% CI, 3.98– 9.78). Having multiple sexual partners was also associated with increased risk of being HIV positive, with OR = 2.83 (95% CI, 1.21–6.59) for those with two partners, OR = 3.88 (95% CI, 1.98–7.63) for men with 3-6 sexual partners, and OR = 3.24 (95% CI, 1.60–6.58) for those who had 7 or more sexual partners. Demographic characteristics associated with HIV-infection included Black ethnicity (OR = 2.97; 95% CI, 1.81–4.87), single marital status (OR = 3.51; 95% CI, 1.85–6.63), and being divorced/separated (OR = 3.53; 95% CI, 1.62–7.70).

No statistically significant association was found between circumcision status and history of STI either univariately or multivariately (data not shown). For the entire group, odds of having a history of STIs among uncircumcised men were not different from those for circumcised men (OR = 1.08; 95% CI, 0.52–2.26) after adjusting for age, ethnicity, marital status, history of anal sex, and condom use. Similarly, no associations were observed when the circumcision–STI association was examined separately among HIV cases and controls.


This case-control study of the role of circumcision status in HIV acquisition among a U.S. military population provides evidence that lack of male circumcision is not a risk factor for HIV or STI acquisition in this population, with no significant association found either univariately or after adjustment for demographic and sexual risk factors. In fact, the direction of the association indicated lack of circumcision to be protective for HIV infection, although without statistical significance. Known HIV risk factors, including: having multiple partners, inconsistent condom use, history of STI, anal sex, and demographic characteristics of Black ethnicity and single or divorced marital status, were strongly associated with HIV status in this population.

During the past 20 years in the United States, overall rates of male circumcision have declined; in part due to changes in attitudes, and in part due to changes in the country’s ethnic distribution. Caucasians have the highest prevalence of circumcision in the United States, whereas Hispanics and Blacks report significantly lower rates.

Differences in changes by ethnicity and geography are evident, with the West experiencing the most dramatic decline, from 64% to 37% [26], attributed largely to the increasing Hispanic population. However, circumcision rates have increased in the Midwest and South, and among Blacks [12,14]. Given the heavy burden of HIV among U.S. Black and Hispanic populations, and the lower rates of circumcision among these racial/ethnic groups [26], it was anticipated that an association between circumcision and HIV would be found, hence a possible means to reduce the burden of HIV/AIDS in these communities. The findings of this study indicate that it is unlikely that lack of circumcision is contributing to the ethnic disparity in HIV rates in the United States.

The few case-control studies conducted among high-risk populations in Africa showed mixed results for circumcision as a risk factor for HIV [27–29]. This study’s findings of no significant association between circumcision status and both HIV and STI contradict a number of studies, finding an association, conducted principally among African populations [30,31]. However, one case-control study of a general population in Senegal [32] also found a protective effect for lack of circumcision on HIV status.

Studies of HIV or STI and circumcision status conducted in developed nations have yielded contradictory findings [12,13,33]. Results from cross-sectional and cohort analyses of the project RESPECT study group, U.S. sexually transmitted disease clinic- based populations, showed slightly elevated risk for gonorrhea and syphilis among uncircumcised men, while there was essentially no risk difference found for chlamydial infection. Biological and mechanical mechanisms for increasing risk through microabrasion and the inherent infectiousness of the organisms may explain these findings.

An analysis of data from the 2000 British National Survey of Sexual Attitudes and Lifestyles (Natasal), found an overall circumcision rate of 15.8% with no statistically significant difference in cumulative STI incidence by circumcision status [34]. Although the British population has relatively low rates of circumcision, and the United States has moderately high rates, the British population’s circumcision rates likewise differ by ethnicity and country of origin. However, the associations were opposite those seen in the United States, with ethnic minority men in Britain more likely to report circumcision, as were men born outside the country. Considering “developed” countries as monolithic in terms of the role of circumcision in STI and HIV risk may be misleading. Nonetheless, there are similarities in sanitary conditions and relative access to healthcare.

Differences in the various study findings may be due to uncontrolled confounding by religion [35,36], hygiene practices, restrictive social rules limiting partners outside of marriage, or differences in sexual practices and risk behaviors [7,37,38], rather than circumcision, per se. Basic health and sanitation conditions, as well as access to healthcare in the United States, are generally better and more comprehensive than in many African nations, which can greatly influence the role of circumcision, or lack thereof, in HIV transmission.

In our study, while there were differences in the method of circumcision reporting between cases and controls, and differences in the rates of available circumcision status, no differences in demographics were seen after adjustment for participation location. Site-specific history-taking practices, and differences in clinical report forms account for reporting differences, not biases, with respect to patient characteristics. Some reporting bias could be present due to differences in clinician versus self-report data, although the direction of the bias is unclear [39]. The rates of circumcision found among the cases (85%) and controls (81%) are quite similar to the rates reported by the Centers for Disease Control and Prevention [26].

As discrepant evidence regarding the role of male circumcision in HIV/STI transmission has surfaced and societal perceptions of circumcision have changed, the policy of the American Academy of Pediatrics (AAP) regarding routine neonatal circumcision in the United States was reassessed. In 1999, the AAP Task Force on Circumcision issued a policy statement recognizing the existing scientific evidence demonstrating medical benefits of neonatal circumcision, and yet concluded that the data remain insufficient to recommend routine neonatal circumcision; thus leaving the decision up to parents with the guidance of their pediatrician.[20]

This study adds weight to the evidence that lack of circumcision is not a risk factor for HIV in the general population of a developed country. Although known HIV risk factors such as inconsistent condom use, history of STI, multiple partners, and anal sex 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.
See references here.

Kenya: Ugunja DC's AIDS Warning

Source: All Africa

The recently circumcised men in Ugunja district are engaging in unprotected sex, area DC Kipkech Lotiatia has warned. Lotiatia said reports reaching his office indicated that the young men who recently underwent voluntary circumcision are engaging in unprotected sex, especially with schoolgirls.
"We fear that the youths have unprotected sex assuming that undergoing VMC protects them from HIV virus," said the DC who directed the health officials to conduct a follow-up and counsel them. He said unless the vice is stopped, the spread of HIV/Aids in the district will increase.
He was speaking yesterday at Sigomere health centre in Ugunja district during official handover of newly-constructed wards to the public. They wards were funded by Ugenya CDF to the tune of Sh1.2 million.
The DC was flanked by Ugenya CDF chairman John Gowa Ochieng Peter Ochiel (secretary), Jackson Omari (funds manager)and Aggrey Omondi Member among other CDF Officials.
He however said he will work closely with the local leaders and stakeholders to mobilize more young men for the VMMC exercise adding that during the recent exercise at Sigomere sub location, over 200 youths underwent the cut.

Have WHO and UNAIDS gotten the wrong message from studies of circumcision to reduce men’s risk for HIV?

Contact Author:

In 2003-06, a study team funded by the US National Institutes of Health (NIH) recruited HIV-negative intact (uncircumcised) men in Rakai, Uganda, circumcised some, and then followed and retested both circumcised and intact men to see who got HIV.[1] The most widely reported data from this study say that men in the intervention (circumcised) group got HIV at the rate of 0.66% per year vs. 1.33% per year for men in the control (intact) group. These data have been used to motivate efforts to circumcise 20 million African adults by 2015 as well as to introduce routine infant circumcision.

Circumcise vs. wait and wipe

However, other data from the same study show a more effective, less dangerous, less culturally intrusive, and less expensive option for intact men to protect themselves from HIV after sexual contact – simply waiting at least 10 minutes after coitus before doing anything to clean one’s penis, and then just wiping it with a dry cloth, without water (Table). (Condom use reliably protects men from acquiring HIV from sexual partners; this note discusses waiting and wiping as an alternative to circumcision, not as an alternative to condom use.)

While all intact men in the NIH-funded Rakai trial got HIV at the rate of 1.33% per year, HIV infections in intact men concentrated in men who cleaned their penises within 3 minutes after coitus (2.32% per year) and men who used water alone to do so at any time after coitus (2.26% per year). On the other hand, intact men who cleaned their penises after coitus but waited at least 10 minutes to do so got HIV at the rate of 0.39% per year. Intact men who cleaned their penises after coitus by wiping with a dry cloth (within 3 minutes or later) got HIV at the rate of 0.55% per year. Notably, intact men who waited at least 10 minutes to clean and/or cleaned with a dry cloth were at less risk for HIV than circumcised men; and intact men who waited at least 10 minutes to clean were even at less risk than men who reported no sex partners (see Table).

According to Ronald Gray, the head of the Rakai study team, one message from the study is “there ought to be a little time left for postcoital cuddling before you go and wash. Don’t just finish and jump out of bed.”[5]

Why did intact men who cleaned later without water have lower risk for HIV?

Frederick Makumbi and other members of the Rakai study team, as well as other AIDS experts, speculated that washing could remove enzymes in vaginal fluid that neutralize HIV, that “the acidity of vaginal secretions may impair the ability of the AIDS virus to survive,” and that water with its neutral pH may facilitate viral survival.[5,6]

The study team did not consider that men’s prepuce and its secretions as well as semen – like women’s sexual organs and secretions – might also have viral defenses that are damaged by washing immediately after coitus. Years before the Rakai circumcision trial, Fleiss and colleagues’ 1998 review of the “hygienic and immunological properties of the prepuce and intact penis” noted commensal bacteria and secretions with anti-bacterial and anti-viral activity associated with the foreskin.[7]

Another possibility is that reported post-coital cleaning had little or no impact on HIV risk but was linked to other behaviors that accounted for a lot of the infections. Sixteen of the 67 incident infections recorded during the NIH-funded Rakai trial occurred in men who reported no sex partners (6 infections) or 100% condom use (10 infections),[1] which suggests that many infections came from blood exposures.[8] If men who were most worried about HIV from sex both washed immediately after sex and went for injections for (suspected) sexual infections, their greater risk for HIV may have been from unsafe injections rather than sex.

Table: Selected behaviors associated with HIV incidence among men in Rakai, Uganda
Trial, behavior, post-coital penis cleaning practices
Incident cases/ person-years
Incidence per 100 person-years
Adjusted incidence rate ratio (95% confidence interval)
Results from NIH funded study, 2003-06

All men, circumcised and intact

Number of sex partners during follow-up


1 or more

Intervention group (circumcised)

Control group (intact)

Intact, washed after some or no partners

Intact, washed after all partners

Time from sex to penile washing

0-3 minutes

>3-10 minutes
0.62 (0.29 1.31)*

>10 minutes
0.13 (0.03 0.54)*

Method of post-coital cleansing

Cloth alone

Cloth + washing
1.7  (0.20 4.55)*

Washing alone
3.7 (0.48  29.07)*
Combined results from NIH- and Gates-funded studies, 2003-07

All men, circumcised and intact

Number of sex partners during past year


1 or more

Wash genitals after intercourse


3.04 (1.11-8.33)†
* Adjusted for condom use, marital status, age, non-marital partnerships, alcohol use with sex, perceived partners’ HIV status, sexual frequency, number of sexual partners.
† Adjusted for age, occupation, marital status, non-marital relationships, number of sexual partnerships, condom use, alcohol use, genital ulcer disease, urethral discharge, dysuria, circumcised, baseline syphilis, HSV-2.
Sources: Results for all men in the NIH-funded trial are from Gray and colleagues[1]; results for penis washing among intact men are from Makumbi and colleagues[2,3]; combined results from NIH- and Gates-funded trials are from Tobian and colleages.[4]

Other studies of penis cleaning vs. HIV
At least four studies of risks for prevalent HIV infection in Africa have reported various data on intact men’s penile hygiene vs. HIV infection. In a 1999 survey in South Africa, intact men who reported washing their penis less than once a day were 2.7 times more likely to be HIV-positive compared to men who washed at least once a day.[9] Another study in South Africa among intact men attending a sexually transmitted infections clinic reported that men with “subpreputial penile wetness” were 2.3 times more likely to be HIV-positive compared to men without wetness; wetness was in turn less common among men who reported washing after sex (with no information on time between coitus and washing).[10]

In a case control study among intact men recruited for the 2002-06 trial of circumcision to protect men in Kisumu, Kenya, men who reported “wash[ing] genitals immediately after last sexual intercourse” (without specifying the number of minutes between coitus and washing) were 0.2 times as likely to be HIV-positive as men who reported not doing so.[11] A 1999 survey in Kenya found that intact men without “adequate” genital hygiene were 1.3 times more likely to be HIV-positive compared to intact men with “adequate” hygiene (men reporting fully retracting their foreskins when washing and with no smegma on the glans penis during examination).[12]

None of these studies reported information on the timing of post-coital cleaning or on wiping vs. washing. Furthermore, in studies of risks for HIV prevalence, reverse causation could explain some of the findings; eg, men with HIV and weakened immune symptoms are more likely to get genital infections causing subpreputial wetness.

Did post-coital penile cleaning influence HIV incidence among intact men in the South African and Kenyan studies of male circumcision to protect men?

Two other trials of circumcision to protect men – in Orange Farm, South Africa, 2002-05, and in Kisumu, Kenya, 2002-06 – reported that HIV incidence in intact men was more than double HIV incidence in circumcised men.[13,14] The study team for the South African trial has not reported post-coital cleaning practices for intact men. In 2010, the study team for the Kisumu trial reported that 21% of men in the control (intact) group “washed” their penis within one hour after coitus; but the study team has not reported if or how penile cleaning was related to HIV incidence.[15] Neither team has said what information they collected about post-coital cleaning (and have not reported). The study teams have also not reported what if any advice they gave to intact men about post-coital cleansing.

Has post-coital cleaning contributed to high HIV incidence among intact men in later and continuing studies?

Post-trial studies in Orange Farm, South Africa, and in Rakai, Uganda, reported higher rates of HIV incidence in intact men compared to rates observed during the trial. In Orange Farm, a cross-sectional survey in 2007-08 reported a rate of HIV incidence in intact men of 5.6% per year (using the BED assay to identify incident infections).[16] A follow-up study in Rakai among men in the two (NIH- and Gates-funded) circumcision trials found that men who remained intact after the trials acquired HIV over the following two years at the rate of 1.93% per year compared to 1.14% per year during the trial.[17] Neither of these studies reported any information about post-coital cleansing. Similarly, neither has reported what if any advice the study team gave to intact men on when and how to clean their penises after coitus.

Some other recent studies in Africa have reported HIV incidence in intact vs. circumcised men but without any information about post-coital cleaning practices. For example, a study of HIV transmission among discordant couples with or without anti-retroviral therapy[18] asked about circumcision but not post-coital cleaning (in this reference,[19] click on “agree,” then on “individual CRFs: international sites,” then on “partner circumcision assessment” and “partner sexual history assessment”).


Data from Rakai, Uganda, discussed in this note have multiple implications for HIV prevention and research in Africa.

First, all interested parties should mobilize all available channels (newspapers, NGOs, churches, etc) to get two public messages to intact African men:

(a) Don’t go for circumcision. If a partner is HIV infected, you are safe with condoms. If for some reason you are exposed, according to available evidence you are safer if you are intact and wait at least 10 minutes to clean your penis than if you have been circumcised.

(b) Wait at least 10 minutes after coitus to clean your penis, and then do so by wiping with a cloth, without water or other fluid.

Second, programs to circumcise men and babies in Africa should be suspended pending further evidence on the impact of post-coital penile cleaning on HIV incidence.

Third, researchers should urgently report and/or collect and report information on HIV incidence among intact men according to post-coital cleaning practices. All relevant collected but unreported information should be disclosed (including information on post-coital cleaning, incidence of sexually transmitted disease, and injections and other blood exposures). Questions about post-coital cleaning can be added to ongoing studies of risks for HIV incidence to get information within 6-12 months. Considering the urgency of this information, it would be unwise to wait for findings from a new trial, which could take years. Moreover, considering the observed high risk for HIV associated with early cleaning and cleaning with water, it is arguably not ethical to follow men without warning them to avoid such practices.

Fourth, individuals and groups that have been opposing circumcision in Africa should independently collect information on:

(a) post-coital cleaning practices in Africa and elsewhere;

(b) official advice about post-coital cleaning in Africa; and

(c) scientific evidence about the effect of various post-coital cleaning practices on the microbiological defenses of the foreskin.

These four recommendations are not intended to be complete or decisive. This is a preliminary note. Hopefully people with relevant information and expertise will help to resolve questions raised by Rakai data on post-coital cleaning and will suggest additional questions and steps.


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