BRIEWE

Unhygienic male circumcision procedures and HIV transmission

To the Editor: Connolly and colleagues report one of the most detailed observational investigations of the association between male circumcision and HIV infection in sub-Saharan Africa to date.¹ They found no overall association between circumcision and prevalent HIV infection in South Africans. Connolly and colleagues also suspect that the often unhygienic circumcision procedures among black South Africans may facilitate HIV transmission.

Evidence from Kenya, Lesotho and Tanzania is consistent with this hypothesis.² Circumcised males in these countries are typically circumcised in adolescence or early adulthood. In each country, circumcised virgins were substantially more likely to be HIV infected than sexually experienced males. Similarly, circumcised adolescent males were more likely to be infected than their uncircumcised counterparts. (In Lesothoan young men circumcision was also associated with HIV infection, perhaps reflecting an older age at circumcision for Lesothoans than for Kenyans and Tanzanians.) However, in older age groups circumcised men were less likely to be infected than uncircumcised men. This pattern could partially be explained by increased mortality among circumcised adolescents and young adults (due to circumcision-related HIV infection), thus reducing HIV prevalence (or slowing its growth) relative to uncircumcised men in older age groups.² A delayed protective effect of circumcision, HIV-specific immunity acquired from circumcision-related exposures, and other factors might also account for this pattern.

For decades, substantial fractions of youth throughout southern and eastern Africa have identified circumcision as a risk for HIV transmission.^2-10 It is therefore crucial that more rigorous investigations beyond analyses of cross-sectional data be conducted to resolve the matter with confidence.² Future work might include detailed observations of circumcision procedures in different settings combined with prospective studies of adolescent and young adult males in communities where circumcision is common. Intervention trials of safer circumcision (compared with existing procedures) might also provide critical evidence, as might sequencing of infected youths' HIV DNA in both observational and intervention studies that focus on circumcision in specific communities.

Devon D Brewer

Interdisciplinary Scientific Research
Seattle, USA
interscientific@yahoo.com

John J Potterat

Independent consultant
Colorado Springs, USA

John M Roberts, Jr

University of New Mexico
Albuquerque, USA

Stuart Brody

University of the West of Scotland
Paisley, UK

1. Connolly C, Simbayi LC, Shanmugam R, Nqeketo A. Male circumcision and its relationship to HIV infection in South Africa: results of a national survey in 2002. S Afr Med J 2008; 98: 789-794.         [ Links ]

2. Brewer DD, Potterat JJ, Roberts JM, jr., Brody S. Male and female circumcision associated with prevalent HIV infection in adolescents in Kenya, Lesotho, and Tanzania. Ann Epidemiol 2007; 17: 217-226.         [ Links ]

3. UNICEF, African Child Policy Forum. What children and youth think, Botswana: a statistical presentation of opinions and perceptions of children and youth in Botswana, 2006. Addis Ababa: African Child Policy Forum, 2006. http://www.africanchildforum.org/Documents/botswana.pdf (accessed 28 December 2006).         [ Links ]

4. UNICEF, African Child Policy Forum. What children and youth think, Burundi: a statistical presentation of opinions and perceptions of children and youth in Burundi, 2006. Addis Ababa: African Child Policy Forum, 2006. http://www.africanchildforum.org/Documents/Burundi.pdf (accessed 28 December 2006).         [ Links ]

5. UNICEF, African Child Policy Forum. What children and youth think, Ethiopia: a statistical presentation of opinions and perceptions of children and youth in Ethiopia, 2006. Addis Ababa: African Child Policy Forum, 2006. http://www.africanchildforum.org/Documents/Ethiopia.pdf. (accessed 28 December 2006).         [ Links ]

6. UNICEF, African Child Policy Forum. What children and youth think, Malawi: a statistical presentation of opinions and perceptions of children and youth in Malawi, 2006. Addis Ababa: African Child Policy Forum, 2006. http://www.africanchildforum.org/Documents/malawi.pdf (accessed 28 December 2006).         [ Links ]

7. UNICEF, African Child Policy Forum. What children and youth think, Rwanda: a statistical presentation of opinions and perceptions of children and youth in Rwanda, 2006. Addis Ababa: African Child Policy Forum, 2006. http://www.africanchildforum.org/Documents/Rwanda.pdf (accessed 28 December 2006).         [ Links ]

8. UNICEF, African Child Policy Forum. What children and youth think, Somalia: a statistical presentation of opinions and perceptions of children and youth in Somalia, 2006. Addis Ababa: African Child Policy Forum, 2006. http://www.africanchildforum.org/Documents/somalia.pdf (accessed 28 December 2006).         [ Links ]

9. UNICEF, African Child Policy Forum. What children and youth think, Tanzania: a statistical presentation of opinions and perceptions of children and youth in Tanzania, 2006. Addis Ababa: African Child Policy Forum, 2006. http://www.africanchildforum.org/Documents/Tanzania.pdf (accessed 28 December 2006).         [ Links ]

10. Lukobo MD, Bailey RC. Acceptability of male circumcision for prevention of HIV infection in Zambia. AIDS Care 2007; 19: 471-477.         [ Links ]