Report on the Global HIV/AIDS epidemic

Report on the global HIV/AIDS epidemic - June 2000

they also had sex with women. A study of men attending a clinic for sexually transmitted infections in the southern Indian city of Pune showed that men reporting
receptive anal sex with men were 2.6 times more likely to be HIV infected than men
who reported no anal sex, even after taking into account other risk factors.
In Thailand, the impressive success in reducing heterosexual transmission of HIV has
exposed a failure to focus on other important groups, including men who have sex with
men. In a study of military conscripts in an area of northern Thailand with a high prevalence of HIV infection, 134 of over 2000 young men said they had sex with men and
all but three of these men also had sex with women. The men reporting male-male sex
were nearly three times as likely to be infected with HIV as the men who had sex only
with women, even after taking into account other factors such as sexually transmitted
infections. Although male-male sex was reported by less than 7% of the men, it was
responsible for 13% of the HIV infections in this population in 1995.
Box 15. Male circumcision and HIV infection
For several years, researchers have been debating the relationship between male circumcision and HIV. Several studies have indicated that circumcised men are less
likely to become infected with HIV than uncircumcised men. However, because circumcision is usually linked to culture or religion, it has been argued that the apparent protective effect of the procedure is likely to be related not to removal of the foreskin but to the behaviours prevalent in the ethnic or religious groups in which male
circumcision is practised. In addition, some researchers have assumed that any
association between circumcision and HIV must be complicated by the presence of
other sexually transmitted infections, which have been found to be more common
among uncircumcised men.
Clearly, the correlations are not straightforward. In the higher-income countries, the
rates of HIV infection among men who have sex with men do not vary greatly even
though the circumcision rates do: few men in Europe and Japan but four-fifths of
men in the United States are circumcised. In Africa, however, circumcision seems to
confer some protection. A study in Nyanza Province, Kenya, among men from the
same ethnic group, the Luo, found that one-quarter of uncircumcised men were
infected with HIV, compared with just under one-tenth of circumcised men. The protective effect remained even after other factors, such as sexual behaviour and sexually transmitted infections, had been taken into account. A study of over 6800 men
in rural Uganda has suggested that the timing of circumcision is important: HIV infection was found in 16% of men who were circumcised after the age of 21 and in only
7% of those circumcised before puberty. A recent review of 27 published studies on
the association between HIV and male circumcision in Africa found that, on average,
circumcised men were half as likely to be infected with HIV as uncircumcised men.
When African men with similar socio-demographic, behavioural and other factors
were compared, circumcised men were nearly 60% less likely than uncircumcised
men to be infected with HIV.

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