title: Impact of Male Circumcision among heterosexual HIV cases: comparisons between three low HIV prevalence countries.
abstract: BACKGROUND
  Studies performed in high-HIV prevalence countries showed a strong epidemiological association between male circumcision (MC) and the prevention of HIV transmission. We estimated the potential impact of MC on the general heterosexual population in low-HIV prevalence countries.
  
  
  METHODS
  Cross-national comparisons, including data on newly diagnosed HIV cases among heterosexuals living in Israel (where almost all males undergo MC), to similar data from the Netherlands and France (where <10 % of males are circumcised) were performed. National data from HIV registers and Bureaus of Statistics for the period of 2004-2010, global rates, rates by sex, age, and year of HIV-diagnosis were compared. MC and potential biases were examined.
  
  
  RESULTS
  Annual rates of new HIV diagnoses per 100,000 were significantly lower in Israel compared to the Netherlands and France (for men: 0.26-0.70, 1.91-2.28, and 2.69-3.47, respectively; for women: 0.10-0.34, 1.10-2.10 and 2.41-3.08, respectively). Similarly, HIV-rates were much lower in Israel when comparing by age groups. Although Gross National Income per capita in 2010 was lower in Israel compared to the Netherlands and France, access to HIV testing and treatment were not different between countries. Also, the number of sexual-partners and condom-use in the general population showed a high similarity between the countries.
  
  
  CONCLUSIONS
  The lower rate of HIV among heterosexuals in Israel compared to the Netherlands and France might be explained by MC routinely practiced in Israel, since other parameters of influence on HIV transmission were rather similar between the countries. However, recommendation for systematic MC in low HIV prevalence countries requires further investigations.
authors.affiliation: Department of Tuberculosis and AIDS, Ministry of Health, P.O.B. 1176, Jerusalem, 944727 Israel.
authors.forename: Daniel
authors.initials: D
authors.lastname: Chemtob
authors.affiliation: Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands.
authors.forename: Eline
authors.initials: E
authors.lastname: Op de Coul
authors.affiliation: Stichting HIV monitoring, Amsterdam, The Netherlands.
authors.forename: Ard
authors.initials: A
authors.lastname: van Sighem
authors.affiliation: Department of Tuberculosis and AIDS, Ministry of Health, P.O.B. 1176, Jerusalem, 944727 Israel.
authors.forename: Zohar
authors.initials: Z
authors.lastname: Mor
authors.affiliation: HIV/AIDS-STI-Hepatitis B and C Unit, Department of Infectious Diseases, Institut de Veille Sanitaire, Saint Maurice, France.
authors.forename: Françoise
authors.initials: F
authors.lastname: Cazein
authors.affiliation: HIV/AIDS-STI-Hepatitis B and C Unit, Department of Infectious Diseases, Institut de Veille Sanitaire, Saint Maurice, France.
authors.forename: Caroline
authors.initials: C
authors.lastname: Semaille
keywords: France; HIV; Heterosexual transmission; Israel; Low HIV prevalence countries; Male circumcision; The Netherlands