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The Impact of Choice: Examining the potential links between

Male Circumcision and HIV Prevention



Ashley E. Getz

PSY 268, Health Psychology

Professor Schlundt

20 September 2006






According to


“Male Circumcision could significantly reduce the burden of HIV in Africa, a study suggests…The operation could avert about six million HIV infections and three million deaths in sub-Saharan Africa over the next 20 years.” [BBC News, 2006]

“There is a tremendous potential for male circumcision to have an effect on the HIV epidemic.” [Hankins, BBC News, 2006]

Other news sources report…

“Male circumcision, a practice thousands of years old, is slowly becoming recognized as a potentially powerful weapon to combat the spread of HIV infection.” [Nordqvist, Medical News Today, 2006]

“Male circumcision lowers risk of HIV infection by 60%”                   [Laurance, The Independent, 2006]

Global view of HIV infection             []


Introduction: Claiming the Need for HIV Prevention


The most recent statistics report that in 2005 alone, 4.9 million people world wide were newly infected with the human immunodeficiency virus, HIV, a virus that kills or damages the cells of the body's immune system and progressively destroys the body's ability to fight infections and certain cancers (CDC, 2004), bringing the total number of people infected to 40.3 million (UNAIDS, 2005). Beyond the sheer magnitude of new cases, AIDS, acquired immunodeficiency syndrome, a disease resultant from the human immunodeficiency virus [defined by the CDC to include all HIV-infected people who have fewer than 200 CD4+ T cells per cubic millimeter of blood. A healthy adult usually holds a CD4+ T-cell counts of 1,000 or more)] (CDC, 2004), killed around 3.1 million people within the past year (UNAIDS, 2005).

The continent of Africa, especially sub-Saharan Africa, home to 60 percent of people living with AIDS (UNAIDS, 2005), has been hardest hit by the epidemic. The people have been left particularly defenseless to the virus and their problems exacerbated by the infection’s link to relatively low levels of economic development, lack of political stability, famine, lack of access to clean water sources, poor sanitation, overwhelming problems of infectious disease, a history of harmful foreign influence, and overall poverty. 

With such a large number of people globally suffering from the implications of HIV and the complications of AIDS, there is urgent need not only for available and sufficient treatment, but strategic, preventative care in order to thwart new cases.

According to Szabo & Short, 75 to 80 percent of HIV infection has most likely occurred through sexual activity, citing that the majority of men have been infected with the virus through the penis [2000]. Specifically among African adults, over 90 percent of infection can be attributed to heterosexual intercourse [In light of the most common mode of transmission, recent world news reports have called specific attention to the inclusion of male circumcision in preventative approaches to new infection. Due to the procedures reported dramatic HIV risk reduction, scientists and public health professionals have once again ignited discussion and speculation surrounding the global advocation for male circumcision [MC].

MC is not being advocated as an alternative preventative measure to abstinence, the use of condoms, or other known prevention strategies, but as a matter of individual, community, and cultural choice—a one time procedure that could lower susceptibility to those already at high-risk for infection. 

Possible Intervention Strategy: Male Circumcision


The World Health Organization defines MC as the surgical removal of all or part of the foreskin of the penis [2006]. Globally, an estimated 20% of men are circumcised, 35% of which are from developing countries [UNAIDS, July 2005]. Much of the attention of MC research and randomized clinical trials have taken place in sub-Saharan Africa due to the regional location of the highest HIV prevalence and MC rates under 20 percent [WHO, 2006].




Historically, MC has been performed for various reasons, with the first documented use of MC dating back to the Egyptians. The procedure is viewed by some cultures as a rite of passage into manhood, is viewed by others as a necessity for hygiene, and used by others for purely aesthetic reasons and sexual preference. The choice to practice MC is inextricably linked to ideals of both culture and religion. With improvements to western medicine, rates of neonatal infant circumcision rose throughout the 20th century with an increasing number of parents opting for the procedure. Today, MC is a completely optional, typically out-of-pocket expense for parents per their request [].

 Egyptian bas-relief from 2400 BC




Jewish infant circumcision                                        Candidates for Circumcision in Kenya

[]                               []




Rationale: What is the link between Circumcision and prevention of HIV?



The potential for MC to affect an individual’s susceptibility to the HIV infection can be explained by several biological factors.



Human Immunodeficiency Virus [HIV]



The removal of the foreskin, through circumcision, reduces the risk of the infections ability to penetrate the skin of the penis, due to the fact that the skin underneath the foreskin is less keratinized [toughened] and thinner than the glans penis [UNAIDS, July 2005; Patterson et al., 2002]. The underside of the foreskin also serves as the location for several different immunological cells, such as Langerhans cells, which are one of the most efficient receptor cells through which the virus gains excess into the body [UNAIDS, July 2005; Moses, 2006]. The Langerhans cells can be found predominantly in the inner mucosa of the human foreskin. [Moses, 2006]. During heterosexual intercourse, the foreskin retracts down the shaft of the penis, exposing the inner surface of the foreskin to vaginal secretions,  and providing an area rich in Langerhans cells for transmission to take place [Szabo & Short, 2000].

    It is also possible for small tears in the unkeratinized skin of the inner surface of the foreskin to occur during sexual intercourse, allowing for a portal of entry for HIV [WHO, 2006]. In relation to the risks associated with the foreskin, uncircumcised males additionally are at greater risk of other sexually transmitted infection and urinary tract infection, which can increase the likelihood of HIV transmission [UNAIDS, July 2005]. Overall, MC offers improvements in hygiene, a reduced risk of sexually transmitted infections, and a reduced risk of HIV infection [Krieger et al., 2005]


Effectiveness and Safety of Circumcision



The current research on the subject makes clear that MC is not a ‘prevention’ or complete protection from acquiring HIV, but can serve as a public health intervention to reduce the male’s risk of infection, along with such methods as consistent condom use and reduction in the number of sexual partners [UNAIDS, July 2005]. An individual is not guaranteed immunity from the virus, but is certainly at better odds than the individual who is uncircumcised.

It is only within the last six years that three significant studies have been completed, citing evidentiary support for the connection between male circumcision and lowered risk of infection. Up to this point there have been several observational studies of the relationship between MC and rates of HIV transmission in the context of specific regional and cultural arenas. The studies that have been published on the subject have all indicated statistically significant evidence for the advocacy for MC in areas of high risk of HIV infection. However, it was not until the publication of the most recent randomized trials that more definitive research was made available on the significance of the relationship between MC and HIV prevention, as well as the feasibility of implementing such a procedure. All three of the following studies were completed in the region of sub-Saharan Africa within distinct regional areas in three different countries.

1st: First study: Rakai, Uganda

In 2000, Gray et al. studied a cohort of 5507 HIV negative men looking at the effects of circumcision on HIV acquisition in a population of Ugandan men with moderate potential HIV exposure. Of the cohort, 16.5 percent of the men were previously circumcised. The authors note that there was no difference in educational attainment, condom use, or number of extramarital sexual partners. The final results of the study indicated that circumcision was significantly linked to reduced HIV acquisition.

2nd : Second study: Kisumu District, Kenya

Krieger et al. recruited healthy, uncircumcised, and HIV seronegative men from Kisumu District, Kenya for the purpose of developing a standard procedure for male circumcision in developing countries with lack of access to medical resources and supplies [2005]. Only 3.5 percent of the men who underwent the procedure reported any adverse effects and there was a 99 percent satisfaction rate. Overall, the study indicated that MC services could be carried out in developing countries, potentially countries with very high rates of infection, should the procedure ever be advocated as a public health intervention.

3rd : Third study: Gauteng Province, South Africa

The most recent of the three studies, Auvert Et al. [2005] completed a randomized, controlled intervention trial to test the hypothesis that MC may offer bodily defense against HIV-1 infection. 3274 uncircumcised men were either assigned to a control or intervention group. MC was carried out with the intervention group and at the final follow up there were 20 HIV infections among the group. Among the control group there were 49 HIV infections, thus indicating the rate of protection offered by the procedure to be 60 percent. The authors concluded that MC could play a significant role in reducing the spread of HIV infection, specifically in sub-Saharan Africa.

            In thinking about the encouragement of MC as a mode of risk reduction, one must not forget about the potential risks associates with the procedure. If the procedure is not performed under the right conditions, such as qualified staff, sterile equipment, proper after-care, there is the danger of infection, which could lead to more serious complications and even death [USAIDS, July 2005]. Complications surrounding the actual procedure are not the only concerns of with the recommendation of MC as an intervention for HIV transmission. The greatest concern with the public health claims deal with the lack of data from randomized clinical trials [Krieger, 2005]. Significant measures to circumcise male community members will not take place until there is more clinical support for the intervention strategy.


Works Cited


Auvert, B., Taljaard, D., Lagarde, E., Sitta, R., Puren, A. et al. [November 2005]. Randomized,

Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial. Plos Medicine, 2, 11.


Centers for Disease Control and Prevention. [2004]. HIV/AIDS Surveillance Report.

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention,7, 2.


“Circumcision ‘could cut HIV risk’”. BBC News. 10 July 2006. Retrieved September 15, 2006





Gray, R., Kiwanuka, N., Quinn, T., Sewankambo, N., Serwadda, D. et al. [October 2000]. Male

circumcision and HIV acquisition and transmission: cohort studies in Rakai, Uganda. AIDS: Official Journal of the International AIDS Society. 14, 15, 2371-2381.


Krieger, J, Bailey, r., Opeya, J., Ayieko, B., Opiyo, F. et al. [November, 2005]. Adult male

circumcision: results of a standardized procedure in Kisumu District, Kenya. BJU International, 96, 1109.

Laurance, J.  The Independent, “Male circumcision lowers risk of HIV infection by 60%.” 09       August 2006 Retrieved September 10, 2006 from  


Moses, S. Briefing Sheet on Male Circumcision and HIV Infection. University of Manitoba:

Departments of Medical Microbiology and Medicine and Community Health Sciences.


Nordqvist, C. Medical News Today. “Male Circumcision Potential Weapon Against HIV/AIDS        Spread.” 18 Aug 2006 Retrieved September 10, 2006 from  


Patterson, B., Landay, A., Siegel, J., Zareefa, F., Pessis, D., Chaviano, A. et al. [2002].

Susceptibility to Human Immunodeficiency Virus-1 Infection of Human Foreskin and Cervical Tissue Grown in Explant Culture. American Journal of Pathology, 161, 867-873.


Szabo, R., & Short, R. [10 June 2000]. How does male circumcision protect against HIV

infection? BMJ, 320, 1592-1594.


UNAIDS: Joint United Nations Programme on HIV/AIDS 2005. [2005]. HIV/AIDS Fact Sheet.


UNAIDS: Joint United Nations Programme on HIV/AIDS. [July 2005]. Male Circumcision and

HIV Fact Sheet.


World Health Organization. [July 2006]. How Could Male Circumcision protect against HIV?.

Bulletin of the World Health Organization, 84, 7.


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