Don't Get Stuck With HIV

Protect yourself from HIV during healthcare and cosmetic services

Circumcision vs. new HIV infections in men

[return to first circumcision page]

A number of studies in Africa and elsewhere have recruited HIV-negative men – some circumcised and some intact – and then followed and tested them from time to time to see who gets a new HIV infection.

During the 1990s, several studies in Tanzania showed higher HIV incidence (rate of new infections) in circumcised vs. intact men, while several studies in Malawi showed higher incidence in intact men. On the other hand, 1990s studies in Kenya, Uganda, and India showed much lower HIV incidence in circumcised vs. intact men (see Table below).

The table below lists studies according to how men were recruited: from the general population; from high risk venues such as clinics treating sexually transmitted disease (STD); and from discordant couples (with one partner HIV-positive, and the other HIV-negative).

During the 1990s, the relative risks for HIV incidence in intact vs. circumcised men varied between countries and also between various groups within countries (eg, between Muslims and others in Uganda). After 2000, most studies that looked at HIV incidence in circumcised vs. intact men went to countries where 1990s studies had found higher incidence in intact men, such as Kenya and Uganda — and avoided countries where earlier studies had found lower incidence in intact men. Another post-2000 study found the same result in South Africa.

With two exceptions, these studies did not determine the source of men’s infections. The two exceptions are studies that followed men with known HIV-positive wives – that is, men in HIV-discordant couples. The largest such study – that followed discordant couples in 7 countries – reported a 0.63 relative risk for HIV incidence in circumcised vs. intact men (see Table). This suggests that circumcision reduces men’s risk to acquire HIV through sex by 37%.

Those who promote circumcision for HIV prevention in Africa rest their case on three influential studies. These three studies are bolded in the table below. Because researchers for these three studies have withheld relevant data, and simply did not collect other relevant information, it’s not clear what happened. Click here for a critique of the three studies.

The table below lists all studies in Africa and elsewhere that report HIV incidence in circumcised vs. intact men. We exclude studies in which most men got HIV from receptive anal sex or injections of illegal drug; for such men, having or not having a foreskin is presumably irrelevant to their risk for HIV. (If you know of any study we’ve missed and should include, please tell us).

Table: Rate of getting new HIV infections (HIV incidence) in circumcised vs. intact men (all studies that report these data)

Country, year, men followed Rate of new HIV infections (%/year) in: Relative risk for HIV in circ’d vs intact men
Circ’d men Intact men
General population men
Uganda, 1990-97[i] NR NR 0.31*
Zimbabwe, 1998-2003[ii] 1.9 2.0 0.96
Tanzania, 1991-94[iii] NR NR 1.27*
Tanzania, 1991-96 [iv] 1.04 1.06 1.0
Uganda, 1994-98[v] 1.1 1.5 0.72
Uganda, 1994-98[vi] 1.1 1.8 0.59
     Muslim 1.0 0 ∞ (very large, >>1)
     Non-Muslim 1.6 1.8 0.87
Malawi, 1994-99[vii] NR NR 0.68
Malawi, 1998-99[viii] NR NR 0.84
South Africa, 2002-05[ix] 0.85 2.11 0.40
Kenya, 2002-06[x] 1.0 2.1 0.47
Kenya, 2003-06[xi] 0.79 2.48 0.31
     Luo 3.39 3.10 1.1
     Non-Luo 0.71 0.73 1.0
Uganda, 2003-06[xii] 0.66 1.33 0.49
Uganda, 2003-07[xiii] 0.78 1.44 0.54
Uganda, 2006-10[xiv] 0.50 1.93 0.26
From STD clinics, truckers
Kenya, 1986-88[xv] 10 70 0.14
Kenya, 1993-98[xvi] 2.5 5.9 0.42
Kenya, 1993-97 [xvii] NR NR 0.53*
India, 1993-2000[xviii] 0.7 5.5 0.13
With HIV-positive wives
Uganda, 1994-98[xix] 0 16.7 0
Botswana, Kenya, Rwanda, So Africa, Tanzania, Uganda, Zambia, 2004-08[xx] 1.17 1.85 0.63

Note: NR: not reported. *These data are from case control studies, which do not report incidence; the risk ratio in the table is the reported odds ratio with the fewest adjustments.

[i] Quigley MA, Morgan D, Malamba SS, et al. Case-control study of risk factors for incident HIV infection in rural Uganda. J Acquir Immune Defic Syndr 2000; 23: 415-425

[ii] Lopman B, Nyamukapa C, Mushati P, et al. HIV incidence in 3 years of follow-up of a Zimbabwe cohort – 1998-2000 to 2001-2003: contributions to proximate and underlying determinants to transmission. Int J Epidemiol 2008; 37: 88-105.

[iii] Todd J, Grosskurth H, Changalucha J, et al. Risk factors influencing HIV infection incidence in a rural African population: a nested case-control study. J Infect Dis 2006; 193: 458-466.

[iv] Senkoro KP, Boerma T, Klokke AH, et al. HIV incidence and HIV-associated mortality in a cohort of factory workers and their spouses in Tanzania, 1991-96. J Acquir Immune Defic Syndr 2000; 23: 194-202.

[v] Wawer MJ, Sewankambo NK, Serwadda D, et al. Control of sexually transmitted diseases for AIDS prevention in Uganda: a randomized community trial. Lancet 1999; 353: 525-535.

[vi] 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.

[vii] Kumwenda NI, Taha TE, Hoover DR, et al. HIV-1 incidence among male workers at a sugar estate in rural Malawi. J Acquir Immune Defic Syndr 2001; 27: 202-208.

[viii] Kumwenda NI, Taha TE, Hoover DR, et al. HIV-1 incidence among male workers at a sugar estate in rural Malawi. J Acquir Immune Defic Syndr 2001; 27: 202-208.

[ix] Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trial. PLoS Med 2005; 2(11): e298.

[x] Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007; 369: 643-656.

[xi] Shaffer DN, Bautista CT, Sateren WB, et al. The protective effect of circumcision on HIV incidence in rural low-risk men circumcised predominantly by traditional circumcisers in Kenya: two year follow-up of the Kericho HIV cohort study. J Acquir Immune Defic Syndr 2007; 45: 371-379.

[xii] Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomized trial. Lancet 2007; 369: 657-666.

[xiii] Gray RH, Serwadda D, Tobian AAR, et al. Effects of genital ulcer disease and herpes simplex virus type 2 on the efficacy of male circumcision for HIV prevention: analyses from the Rakai trials. PLoS Med 2009; e1000187.

[xiv] Gray R, Kigozi G, Kong X, et al. The effectiveness of male circumcision for HIV prevention and effects on risk behavior in a post-trial follow up study in Rakai, Uganda. AIDS 2012, 26: published on-line before print.

[xv] Cameron DW, Simonsen JN, D’Costa LJ, et al. Female to male transmission of human immunodeficiency virus type 1: risk factors for seroconversion in men. Lancet 1989; ii: 403-407.

[xvi] Reynolds SJ, Shepherd ME, Risbud AR, et al. Male circumcision and risk of HIV-1 and other sexually transmitted infections in India. Lancet 2004; 363: 1039-1040.

[xvii] Lavreys L, Rakwar JP, Thompson ML, et al. Effect of circumcision on incidence of human immunodeficiency virus type 1 and other sexually transmitted diseases: a prospective cohort study of trucking company employees in Kenya. J Infect Dis 1999; 180: 330-336.

[xviii] MacDonald KS, Malonza I, Chen DK, et al. Vitamin A and risk of HIV-1 seroconversion among Kenyan men with genital ulcers. AIDS 2001; 15: 635-639.

[xix] 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.

[xx] Celum C, Wald A, Lingappa JR, et al. Acyclovir and transmission of HIV-1 from persons infected with HIV-1 and HSV-2. N Engl J Med 2010; 362: 427-439.

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