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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.
As mass circumcision programs have started, resuming sex before wound healing is common. In a 2009 survey among newly circumcised men in Kenya, 69% of married men resumed sex before wound healing (see page 28 in: WHO, Scaling up male circumcision programmes in the Eastern and Southern Africa Region). In another study about men circumcised in Zambia in 2010, 24% of men resumed sex early, before the end of the recommended 6 week period of abstinence after surgery (see Hewett et al, Sex with stitches…).
Allowing women (and men) to think sex without condoms with a partner who may be HIV-positive is safe
Disturbingly, many women think circumcised men are safe and/or are reluctant to ask them to use condoms. In recent surveys among women in Kenya, Namibia, South Africa, Swaziland, and Uganda, 37%-52% said they would be “not at all comfortable” asking partners to use a condom after circumcision (from: AVAC, Making Male Medical Circumcision Work for Women).
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
||New infections (%/year) in women whose partners are:
||Relative risk for HIV in women with circ’d vs intact partners
|Botswana, Kenya, Rwanda, South Africa, Tanzania, Uganda, Zambia, 2004-08[iii]
[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.
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