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The Lancet, Volume 355, Issue 9207, Page 926, 11 March 2000
doi:10.1016/S0140-6736(05)74127-1Cite or Link Using DOI

Male circumcision and HIV infection

Malcolm Potts a
Danieal Halperin and Robert Bailey1 cite cross-sectional and prospective studies idicating an assocation between lack of male circumcision and heterosexual HIV transmission in developing countries, that have a high frequency of sexually transmitted infections, and where men often have multiple sexual partners. In the investigators' analysis of attributable risk, they ause an odds ratio of 2.5 (the low end of the odds ratio found in five significant prospective studies).2 A recent metaanalysis of male circumcision and HIV transmission recorded similar results.3
How many HIV infections have been prevented by male circumcision in developing countries with all the classic risk factors for a widespread heterosexual AIDS epidemic? Most of west Africa has high levels of sexually transmitted infections, sex work, polygamy, or other forms of multiple sexual partnering, and generally low levels of condom use, but there is also widespread practice of male circumscision.4 Parts of south and southeast Asia also have, if generally to a lesser extent, many of these characteristics. HIV-1 frequency in west Africa clusters between 1% and 5% of those aged 15—49. In comparison, the predominately non-circumcising east and southern African nations have rates approaching 25% and among the eight nations Halperin and Bailey cite, the average is around 20%. (In the Ivory Coast, the one west African country where substantial numbers of men are uncircumcised, frequency is 10%.)
Let us assume that male circumcision accounts for about half the disparity in heterosexual HIV rates between low frequency circumcising, and high frequency non-circumcising countries, and that some unidentified factors account for the other half of these large and continuing regional differences. With available census figures and the June, 1998, WHO/UNAIDS HIV seroprevalence data, it can be estimated that if male circumcision had not been a widespread practice, HIV frequency would have reached at least 10% in the 11 West African countries in Halperin and Bailey's study. This estimate suggests that about 6 million additional adults would now be infected in the region. In addition, vertical transmission would have occurred in many children.
A similarly conservative estimate of the impact in the four south and southeast Asian countries with a high male circumcision rate would be the following. In the absence of male circumcision, HIV frequency in Pakistan and Bangladesh might now be half that found in India (—ie, about 0.4%), and in Indonesia and the Philippines it might be around 1%, still under half the frequency in Thailand and Cambodia, where absence of male circumcision is postulated as a factor driving spread.5 Under these assumptions, an additional 2 million adults would now be infected in these four Asian countries.
Hence, it is possible that 8 000 000 or more adult HIV infections have been prevented by male circumcision in 15 African and Asian countries. Even though these is no doubt that if the relation between absence of male circumcision and increased risk of HIV is valid then the numbers of HIV infections prevented are large.
We suggest that male circumcision services should be more widely available. Clearly, as Halperin and Bailey conclude, absence of male circumcison should not be considered in isolation from other AIDS prevention strategies. For example, several anecdotal reports by medical anthropologists and other observers from various countries suggest that some uncircumcised men have greater difficulty or discomfort in the use of condoms.


1 Halperin DT, Bailey RC. Male circumcision and HIV infection: ten years and counting.. Lancet 1999; 354: 1813-1815. Full Text | PDF(35KB) | CrossRef | PubMed
2 Moses S, Plummer F, Bradley J, et al. Male circumcision and the AIDS epidemic in Africa.. Health Transition Review 1995; 5: 100-103. PubMed
3 R Hayes, HA Weiss. Meta-analysis on the relatioships between male circumcision and HIV infection. Presented at the International Society and STD Research, 13th Annual Meeting, Denver, CO, USA, July 11—14, 1999.
4 Gerbose AC, Rowley JT, Mertens TE. Global epidemiology of sexually transmitted disease.. Lancet 1998; 351 (suppl 3): 2-4. Full Text | PDF(49KB) | CrossRef | PubMed
5 Weniger BG, Brown T. The march of AIDS through Asia.. N Engl J Med 1996; 355: 343-345. CrossRef | PubMed
a School of Public Health, Earl Warren Hall, University of California, Berkeley CA 94720, USA
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