title: Male circumcision and HIV acquisition and transmission: cohort studies in Rakai, Uganda. Rakai Project Team.
abstract: BACKGROUND
  Male circumcision is associated with reduced HIV acquisition.
  
  
  METHODS
  HIV acquisition was determined in a cohort of 5507 HIV-negative Ugandan men, and in 187 HIV-negative men in discordant relationships. Transmission was determined in 223 HIV-positive men with HIV-negative partners. HIV incidence per 100 person years (py) and adjusted rate ratios (RR) and 95% confidence intervals (CI) were estimated by Poisson regression. HIV-1 serum viral load was determined for the seropositive partners in HIV-discordant couples.
  
  
  RESULTS
  The prevalence of circumcision was 16.5% for all men; 99.1% in Muslims and 3.7% in non-Muslims. Circumcision was significantly associated with reduced HIV acquisition in the cohort as a whole (RR 0.53, CI 0.33-0.87), but not among non-Muslim men. Prepubertal circumcision significantly reduced HIV acquisition (RR 0.49, CI 0.26-0.82), but postpubertal circumcision did not. In discordant couples with HIV-negative men, no serconversions occurred in 50 circumcised men, whereas HIV acquisition was 16.7 per 100 py in uncircumcised men (P = 0.004). In couples with HIV-positive men, HIV transmission was significantly reduced in circumcised men with HIV viral loads less than 50000 copies/ml (P = 0.02).
  
  
  CONCLUSIONS
  Prepubertal circumcision may reduce male HIV acquisition in a general population, but the protective effects are confounded by cultural and behavioral factors in Muslims. In discordant couples, circumcision reduces HIV acquisition and transmission. The assessment of circumcision for HIV prevention is complex and requires randomized trials.
authors.affiliation: Johns Hopkins University, School of Hygiene and Public Health, Department of Population and Family Health Sciences, Baltimore, MD 21205, USA. rgray@jhsph.edu
authors.forename: R H
authors.initials: RH
authors.lastname: Gray
authors.forename: N
authors.initials: N
authors.lastname: Kiwanuka
authors.forename: T C
authors.initials: TC
authors.lastname: Quinn
authors.forename: N K
authors.initials: NK
authors.lastname: Sewankambo
authors.forename: D
authors.initials: D
authors.lastname: Serwadda
authors.forename: F W
authors.initials: FW
authors.lastname: Mangen
authors.forename: T
authors.initials: T
authors.lastname: Lutalo
authors.forename: F
authors.initials: F
authors.lastname: Nalugoda
authors.forename: R
authors.initials: R
authors.lastname: Kelly
authors.forename: M
authors.initials: M
authors.lastname: Meehan
authors.forename: M Z
authors.initials: MZ
authors.lastname: Chen
authors.forename: C
authors.initials: C
authors.lastname: Li
authors.forename: M J
authors.initials: MJ
authors.lastname: Wawer
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D002944:Circumcision, Male; D015331:Cohort Studies; D005191:Family Characteristics; D005260:Female; D015658:HIV Infections / Q000175:diagnosis / Q000635:transmission*; D018023:HIV Seronegativity; D006679:HIV Seropositivity; D006801:Humans; D008297:Male; D008875:Middle Aged; D012067:Religion; D012307:Risk Factors; D012747:Sexual Partners; D019562:Viral Load