MALE CIRCUMCISION, SEXUALLY-TRANSMITTED DISEASE, AND RISK OF HIV

Our objective was to describe associations among male circumcision, be havioral and demographic variables, ulcerative and nonulcerative sexua lly transmitted disease (STD), and human immunodeficiency virus (HIV) infection via a cross-sectional study in Kigali, the capital of Rwanda . Our subjects were 837 married men who volunteered for HIV testing an d counseling. Uncircumcised men had a relatively low-risk profile in t hat they reported fewer lifetime sexual partners and prostitute contac ts than circumcised men and were more likely to live in rural areas wi th lower HIV prevalence rates. Uncircumcised men were also less likely to report a history of sexually transmitted disease (64% versus 73%, p = 0.01), although they were more likely to report genital ulceration (GUD) (24% versus 17%, p < 0.03) and to have inguinal adenopathy note d on physical exam (42% versus 29%, p = 0.009). Despite the low-risk p rofile, uncircumcised men had a higher prevalence of HIV infection tha n circumcised men (29% versus 21% HIV positive, p = 0.02), which was m ost marked in men reporting five or more lifetime sex partners (36% ve rsus 23% HIV positive, p = 0.005) or contact with prostitutes (35% ver sus 23% HIV positive, p = 0.009). Circumcision remained a predictor of HIV infection in multivariate analyses (multivariate odds ratio 1.69, 95% confidence interval 1.16-2.47). Lack of circumcision is associate d with a higher risk of HIV infection in Rwandan men. Further research is needed to determine whether this higher risk is due in part to poo r hygiene or to complex mechanisms operating through the acquisition o f other sexually transmitted diseases. Circumcision may be an appropri ate risk reduction approach for men with known exposures to the virus when there are constraints to alternatives, such as condom use.