Sexually Transmitted Infections467 467
ejaculated semen into your mouth. Furthermore, in light of the often substantial con-
centration of HIV in vaginal uids, you might also be cautious about engaging in cun-
nilingus with a female partner who has not tested negative for HIV. Finally, even though
there is some risk of HIV transmission via oral sex, the current consensus of experts is
that unprotected oral sex is an eective risk reduction strategy compared to unprotected
vaginal or anal penetration (Shapiro & Ray, 2007).
In the early 1980s, before the U.S. government required screening of donated blood for
HIV, contaminated blood and blood products infected an estimated 25,000 transfusion
recipients and people with blood-clotting disorders (such as hemophilia) in the United
States (Graham, 1997). However, since early 1985, donated blood and blood products
have been screened with extensive laboratory testing for the presence of HIV antibod-
ies. “e risk of transfusion transmitted HIV infections has been almost eliminated by
A number of health professionals and researchers have
suggested that circumcision may signicantly reduce the
risk of HIV infection by removing an entry point for the
virus—the thin foreskin with its high concentrations of cells
that are easily infected by HIV. This contention is supported
by several observational studies revealing that HIV infection
is less prevalent in circumcised men than in uncircumcised
Reynolds et al., 2004; WHO/UNAIDS, 2007). There is
also strong empirical evidence from experimental clinical
trials that circumcision provides some protection against
HIV infection (Heisea et al., 2011). Three well-designed inves-
tigations, conducted in South Africa, Kenya, and Uganda,
demonstrated that study participants who underwent
circumcision experienced a 60%, 53%, and 51% reduc-
tion, respectively, in their risk of acquiring an HIV infection
(Auvert et al., 2005; Bailey et al., 2007; Gray et al., 2007).
It is important to emphasize that circumcision does
not in any way provide complete protection against HIV.
Rather, it is best viewed as an additional strategy in the
arsenal of tools used to prevent heterosexually acquired
HIV infection in men (WHO/UNAIDS, 2007). Recent research
indicates that circumcision may not provide protection
from HIV transmission that occurs during insertive anal
sex (Sanchez et al., 2011). Moreover, it appears that male
circumcision may have no effect on the transmission of HIV
from men to women (Berer, 2007; WHO/UNAIDS, 2007).
Studies conducted in Uganda and Zimbabwe found no
signicant association between women’s risk of acquir-
ing an HIV infection and the circumcision status of their
primary sexual partner (Turner et al., 2007). In addition,
these investigations found no association between male
circumcision and women’s risk of acquiring chlamydia,
gonorrhea, or trichomonal infections (Turner et al., 2007).
There is, however, evidence that men who are circumcised
are less vulnerable than uncircumcised men to infection by
PV (Auvert et al., 2008). A recent study of over 5,000 men
found that circumcision signicantly reduced the incidence
of HPV and genital herpes infections as well as providing
protection against HIV infection (Tobian et al., 2011).
The clear evidence that male circumcision for HIV
prevention provides partial protection for HIV-negative men
but not for their female partner(s) is highly problematic,
as recently described by Marge Berer (2008), an expert in
women’s sexual and reproductive health and rights. Berer
points out that while partners of circumcised men have an
equal right to protection against HIV, the circumcised status
of their male partners may in fact increase their vulner-
ability to HIV infection. For example, a circumcised man,
falsely believing that he is not at risk for HIV infection, may
choose not to practice safer sex, such as using condoms,
thereby subjecting his partner to greater risk of infection. If
a circumcised man “thinks he is protected, and he contin-
ues depositing semen in his partner’s body unimpeded
every time they have sex, then as I see it, his partner is
in a worse position than before” (Berer, 2008, p. 172). A
man who elects to be circumcised is able to achieve some
protection for himself without any changes in his behavior.
But for his sex partner(s) to achieve protection, safer sex is
necessary. Thus, equity for partners of circumcised men is
an issue that will be discussed and debated concurrently
with the implementation of male circumcision programs in
African nations in coming years.
Finally, two studies revealed potential obstacles to
large-scale circumcision programs in Africa. In one study
about one third of 1,007 young Kenyan men experienced
complications (lacerations, scarring, etc.) after being cir-
cumcised (Bailey et al., 2008). The second study revealed
that circumcision of all HIV-negative men in sub-Saharan
Africa would be markedly less cost-effective than distribut-
ing free condoms to men who need them (McAllister et al.,
2008). The authors of this report concluded that prevent-
ing one HIV infection via circumcision would cost almost
$6,000—more than 100 times the cost of preventing a
single infection with condoms.
Circumcision as a Strategy for Preventing HIV Infection
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