title: The association of female circumcision with HIV status and sexual behavior in Mali: a multilevel analysis.
abstract: OBJECTIVE
  In the regions of Africa where female circumcision (FC) is practiced, it is often regarded as a protective against HIV infection because it is believed to help women resist "illicit" sexual acts. This study examines the association between FC, HIV status, and sexual risk behavior in Mali, while taking into account multilevel factors. The following hypothesis was tested: FC is associated with HIV-positive status but not with decreased sexual behavior.
  
  
  METHODS
  The sample consists of 13,015 Malian women of reproductive age (15-49 years old). The sample is a nationally representative survey of randomly selected respondents using a stratified multistage sampling strategy. Measures included biospecimens for HIV antibody testing and survey results reporting on number of partners, sexual debut, premarital sex, and sociodemographics.
  
  
  METHODS
  Multilevel modeling was used to assess the significance of difference in HIV status and sexual behavior with FC. Multilevel modeling was also used to adjust for age, education, ethnicity, wealth, religion, region, household, and community membership. Multiple imputation with 10 imputations corrected for 10% missing data.
  
  
  RESULTS
  Participants with FC were at 2.100 (P < 0.001; 95% confidence interval: 1.844 to 2.389) higher odds of being HIV positive. Women with FC did not significantly differ from women without FC in number of sexual partners (P = 0.634), age of sexual debut (P = 0.888), or odds of having premarital sex (P = 0.575).
  
  
  CONCLUSIONS
  FC is associated with HIV-positive status but not with a decrease in sexual risk behavior. These findings have important implication for FC and HIV prevention.
authors.affiliation: School of Social Work, Columbia University, New York, NY.
authors.forename: Alex
authors.initials: A
authors.lastname: Smolak
mesh_terms: D000293:Adolescent; D000328:Adult; D019093:Circumcision, Female; D005260:Female; D015658:HIV Infections / Q000453:epidemiology*; D006801:Humans; D008302:Mali / Q000453:epidemiology; D008875:Middle Aged; D055361:Multilevel Analysis; D012309:Risk-Taking; D012725:Sexual Behavior / Q000706:statistics & numerical data*; D055815:Young Adult