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Intact vs. circumcised men have less HIV in many African countries

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Many official HIV/AIDS experts – in UNAIDS, WHO, governments, etc – say most HIV-positive adults in Africa got it from heterosexual sex, and that circ’ing reduces men’s risk to get HIV from sex by about 60%. If those assumptions are true, then in each African country intact men should have much more HIV than circ’d men. But that’s not the case.

National surveys in 26 countries report the percentages of intact and circ’d men who are HIV-positive. Intact men are LESS LIKELY to be HIV-positive in 16 of 26 countries (see Table below), and the median (middle) ratio of HIV in intact vs circ’d men is 0.80 — intact men are 20% less likely to be HIV-positive.

In nine countries only very small numbers of surveyed men were intact, so the ratios are less reliable (see countries and data in italics). Considering only the 17 countries in which at least 5% of surveyed men are intact, intact men are less likely to be HIV-positive in six countries. In these 17 countries, ratios of HIV in intact vs. circ’d men range from 0.23 in Cameroon to 4.4 in Kenya, and the median (middle) ratio is 1.2 — intact men are 20% more likely to be HIV-positive (see Table).

Survey data are available for 13 of the 14 countries where the US and partners target men for circ’ing (see starred countries in the Table). In 4 of these 13 countries, intact men have less HIV than circ’d men, and the median (middle) ratio is 1.2.

The wide range of ratios of intact vs. circ’d men who are HIV-positive suggests circ’ing has little to do with men’s HIV risk in Africa. This could be for many reasons, including: intact men may be more likely to seek (unsafe) treatment for genital symptoms; and intact men in some communities may be washing soon after sex, removing protective sexual fluids. There may be other reasons. In any case, the wide range of ratios leaves us with a puzzle: why do intact men have less HIV in some communities, but more in others?

Table: HIV infections in circumcised vs. intact men in countries in Africa

Country, year Ratio of intact vs. circ’d men who are HIV-positive %s of intact vs. circ’d men who are HIV-positive
     
Liberia, 2013 0 0 vs. 1.8
Chad, 2014-15 0 0 vs. 1.4
Dem Rep Congo, 2007 0 0 vs. 1.0
Mali, 2012-13 0 0 vs. 0.9
Sierra Leone, 2013 <0.08 <0.1 vs. 1.3
Ghana, 2014 0.08 0.2 vs. 1.2
Cameroon, 2011 0.23 0.7 vs. 3.0
Cote d’Ivoire, 2011-12 0.39 1.1 vs. 2.8
Togo, 2013-14 0.47 0.8 vs. 1.7
Benin, 2011-12 0.50 0.5 vs. 1.0
Gabon, 2012 0.55 1.2 vs. 2.2
Burundi, 2016-17 0.67 0.6 vs. 0.9
Ethiopia, 2011* 0.80 0.8 vs. 1.0
Median for all 26 countries 0.80
Malawi, 2015-16* 0.95 7.0 vs. 7.4
Swaziland, 2006-7* 0.89 19.5 vs. 21.8
South Africa, 2012* 0.98 12.0 vs. 12.3
Rwanda, 2014-15* 1.09 2.5 vs. 2.3
Zambia, 2013-14 * [this is the median for 17 countries with ≥5% of sampled men intact]  1.2 12.2 vs. 10.5
Lesotho, 2014* [this is the median for 13 starred countries, where WHO targets men for circ’ing] 1.2 21.8 vs. 18.7
Zimbabwe, 2015* 1.4 11.8 vs. 8.2
Uganda, 2004-5* 1.5 5.6 vs. 3.8
Namibia, 2013* 1.5 11.9/8.0
Tanzania, 2011-12* 1.6 5.2 vs. 3.3
Mozambique, 2015* 1.7 13.7 vs. 8.1
Burkina Faso, 2010 1.9 1.5 vs. 0.8
Kenya, 2008-9* 4.4 13.6 vs. 3.1

Sources: Data for all countries except South Africa are from the latest Demographic and Health Surveys and AIDS Information Surveys for each country available at: http://www.dhsprogram.com/Where-We-Work/Country-List.cfm (from this link, click on the country and then the survey, and then go to the chapter that reports HIV prevalence). Data for South Africa (for which there are no DHS or AIS data) are from: Connelly C et al., Male circumcision and its relationship to HIV infection in South Africa: results of a national survey in 2002. S Afr Med J, 2008; 98: 798-794. Abstract available at: https://www.ncbi.nlm.nih.gov/pubmed/19115756 (accessed 9 April 2018).

 

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