Clinical Update: Contraceptive Pearl
(July 2002)

Male Circumcision and National HIV Infection Rates

Question: Does the prevalence of male circumcision (MC) help explain why HIV is increasing rapidly in some countries, but not in others?

Answer: Probably so, though such cross-country comparisons are tricky and involve other factors. Notably, HIV has increased most rapidly in Eastern and Southern Africa where MC is uncommon (e.g. Botswana, Zimbabwe, Zambia, Malawi, Rwanda, Swaziland). In contrast, although HIV probably originated in West Africa, HIV prevalence there tends to be much lower and MC tends to be very common.

Of course MC is very common in Islamic countries, and Islamic faith might also relate to lower behavioral risk of HIV. However, some countries are not predominantly Islamic but have high MC rates and comparatively low HIV (e.g., Philippines, Ghana, Benin, Nigeria, Liberia, Gabon, Madagascar). 

In other countries the pattern seemingly doesn't support the argument. For example Kenya has high overall circumcision and relatively high HIV (though HIV is notably high among the Luo, the only major ethnic group that doesn't practice circumcision). Latin America and Europe have low HIV even though male circumcision is not common.

To view a rough grouping of MC for most countries in Africa and Asia visit the MAQ website at http://www.jhuccp.org/pearls/2002/06-20.shtml, and scroll down to the table titled "Male Circumcision Prevalence."

Reference: (Table adapted from) Halperin DT and Bailey RC. Male circumcision and HIV infection: 10 years and counting. Lancet 1999; 1813-15.

Demand for Male Circumcision

Question: I can see that there might be some health benefit from male circumcision, but is there significant demand for it from men?

Answer: Yes, several studies from Africa at least, indicate that demand for circumcision among uncircumcised men is substantial. Interestingly, the demand appears to be largely for reasons of "hygiene," cleanliness and prevention of local infections/STIs and not particularly for reduced risk of HIV specifically. Female partners also appear to support circumcision for similar reasons.

References: 

1. Soori N et al. Dynamics of male circumcision practices in Northwest Tanzania. STI 2001; 28:214-8. 
2. Bailey RC et al. The acceptability of male circumcision to reduce HIV infections in Nyanza Province, Kenya. AIDS Care 2002;14:27-40.
3. Kebaabetswe P et al. Male circumcision: An acceptable strategy for HIV prevention in Botswana. Unpublished manuscript (Also Abstract accepted for 2002 Barcelona AIDS Conference.)
4. Fritz K et al. The feasibility of adult male circumcision for HIV prevention in Zimbabwe. (Submitted)

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These "Pearls" were prepared by Dr. James D. Shelton, Senior Medical Scientist, Office of Population, United States Agency for International Development (USAID).

Jim Shelton's Pearls online

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