title: Male circumcision, religion, and infectious diseases: an ecologic analysis of 118 developing countries.
abstract: BACKGROUND
  Both religious practices and male circumcision (MC) have been associated with HIV and other sexually-transmitted infectious diseases. Most studies have been limited in size and have not adequately controlled for religion, so these relationships remain unclear.
  
  
  METHODS
  We evaluated relationships between MC prevalence, Muslim and Christian religion, and 7 infectious diseases using country-specific data among 118 developing countries. We used multivariate linear regression to describe associations between MC and cervical cancer incidence, and between MC and HIV prevalence among countries with primarily sexual HIV transmission.
  
  
  RESULTS
  Fifty-three, 14, and 51 developing countries had a high (>80%), intermediate (20-80%), and low (<20%) MC prevalence, respectively. In univariate analyses, MC was associated with lower HIV prevalence and lower cervical cancer incidence, but not with HSV-2, syphilis, nor, as expected, with Hepatitis C, tuberculosis, or malaria. In multivariate analysis after stratifying the countries by religious groups, each categorical increase of MC prevalence was associated with a 3.65/100,000 women (95% CI 0.54-6.76, p = 0.02) decrease in annual cervical cancer incidence, and a 1.84-fold (95% CI 1.36-2.48, p < 0.001) decrease in the adult HIV prevalence among sub-Saharan African countries. In separate multivariate analyses among non-sub-Saharan African countries controlling for religion, higher MC prevalence was associated with a 8.94-fold (95% CI 4.30-18.60) decrease in the adult HIV prevalence among countries with primarily heterosexual HIV transmission, but not, as expected, among countries with primarily homosexual or injection drug use HIV transmission (p = 0.35).
  
  
  CONCLUSIONS
  Male circumcision was significantly associated with lower cervical cancer incidence and lower HIV prevalence in sub-Saharan Africa, independent of Muslim and Christian religion. As predicted, male circumcision was also strongly associated with lower HIV prevalence among countries with primarily heterosexual HIV transmission, but not among countries with primarily homosexual or injection drug use HIV transmission. These findings strengthen the reported biological link between MC and some sexually transmitted infectious diseases, including HIV and cervical cancer.
authors.affiliation: University of Washington School of Medicine, Seattle, USA. pkdrain@u.washington.edu <pkdrain@u.washington.edu>
authors.forename: Paul K
authors.initials: PK
authors.lastname: Drain
authors.forename: Daniel T
authors.initials: DT
authors.lastname: Halperin
authors.forename: James P
authors.initials: JP
authors.lastname: Hughes
authors.forename: Jeffrey D
authors.initials: JD
authors.lastname: Klausner
authors.forename: Robert C
authors.initials: RC
authors.lastname: Bailey
mesh_terms: D017954:Africa South of the Sahara / Q000453:epidemiology; D000352:Africa, Northern / Q000453:epidemiology; D002835:Christianity; D002944:Circumcision, Male / Q000706:statistics & numerical data*; D003140:Communicable Disease Control; D003430:Cross-Sectional Studies; D003906:Developing Countries / Q000706:statistics & numerical data*; D005260:Female; D015658:HIV Infections / Q000453:epidemiology* / Q000517:prevention & control; D006801:Humans; D015994:Incidence; D007514:Islam; D016014:Linear Models; D008297:Male; D015999:Multivariate Analysis; D012068:Religion and Medicine; D012071:Religion and Sex; D012725:Sexual Behavior / Q000706:statistics & numerical data*; D012749:Sexually Transmitted Diseases / Q000453:epidemiology / Q000517:prevention & control; D002583:Uterine Cervical Neoplasms / Q000453:epidemiology*