Abstract

PIP: Physicians from Kenya and Canada searched the MEDLINE and the MacMillan New Media AIDS CD-ROM databases to identify and review all the published literature examining the association between male circumcision and the risk for HIV infection. They found 30 epidemiological studies. Eighteen cross-sectional studies from the Cote d'Ivoire, Kenya, Rwanda, Uganda, US, and Zambia reported a significant association between the presence of the foreskin and risk for HIV infection (e.g., odds ratio = 2.4; p = .05 among male sexually transmitted disease [STD] patients in Zambia). These studies reported an increased risk (odds ratios or relative risks) ranging from 1.5 to 8.4. Four other cross-sectional studies (The Gambia, Mexico, Tanzania, and the US) found a trend towards an association. No association existed in 4 other studies (2 from Rwanda and 2 from Tanzania). The 2 prospective studies (both from Kenya) and the 2 ecological studies from Africa reported positive associations between presence of the foreskin and risk for HIV infection. 26 of the 28 nonecological studies examined HIV-1, while the other 2 examined both HIV-1 and HIV-2. All but 2 studies looked at heterosexual transmission. Population groups studied included male STD patients, male patients of hospital outpatient clinics, male patients of a hospital casualty department, male long-distance truck drivers, heterosexual and homosexual men attending HIV screening clinics, men living in rural communities, women attending family planning clinics, and women with pelvic inflammatory disease. Potential sources of error in the studies were sexual behavior related to religious practice or ethnicity, misclassification of circumcision status where it cannot be directly observed, and STDs. These findings suggest that, since current measures to reduce HIV transmission are not sufficiently effective, it may useful, at least in the short term, to introduce or expand the practice of male circumcision.