EPIDEMIOLOGY AND PREVENTION A Cut Above the Rest: Traditional Male Circumcision and HIV Risk Among Xhosa Men in Cape Town, South Africa Brendan Maughan-Brown, PhD,* Atheendar S. Venkataramani, MD, PhD,† Nicoli Nattrass, DPhil,‡ Jeremy Seekings, DPhil,§ and Alan W. Whiteside, PhDjj Background: Randomized clinical trials have shown that medical male circumcision substantially reduces the risk of contracting HIV. However, relatively little is known about the relationship between traditional male circumcision and HIV risk. This article examines variations in traditional circumcision practices and their relationship to HIV status. Methods: We used data from the fifth wave of the Cape Area Panel Study (n = 473) of young adults in Cape Town, South Africa, to determine attitudes towards circumcision, whether men were circum- cised, at what age, and whether their foreskin had been fully or partially removed. Probit models were estimated to determine the association between extent and age of circumcision and HIV status. Results: There was strong support for traditional male circumci- sion. 92.5% of the men reported being circumcised, with 10.5% partially circumcised. Partially circumcised men had a 7% point greater risk of being HIV positive than fully circumcised men (P , 0.05) and equal risk compared with uncircumcised men. Most (91%) men were circumcised between the ages of 17 and 22 years (mean 19.2 years), and HIV risk increased with age of circumcision (P , 0.10). Conclusions: Efforts should be made to encourage earlier circumcisions and to work with traditional surgeons to reduce the number of partial circumcisions. Data on the extent and age of circumcision are necessary for meaningful conclusions to be drawn from survey data about the relationship between circumcision and HIV status. Key Words: HIV, AIDS, prevention, circumcision, foreskin, Africa (J Acquir Immune Defic Syndr 2011;58:499–505) INTRODUCTION Randomized clinical trials have shown that medical male circumcision substantially reduces the risk of contract- ing HIV, 1,2 leading many to espouse this practice as a means to combat HIV on a large scale. 3–5 However, relatively little is known about the relationship between traditional male cir- cumcision and HIV risk. Understanding this relationship is important for HIV prevention because many men in Africa continue to be circumcised by traditional providers, despite the scale-up of medical male circumcision. 6 Traditional male circumcision (hereafter referred to as circumcision) has long been practiced in many parts of Africa as part of a broader initiation process marking the transition between boyhood and manhood, and early ecological re- search suggested that it may help reduce HIV prevalence. 7 The relationship between traditional circumcision and HIV risk in Africa is, however, not obvious a priori. On the one hand, similar to medical circumcision, it may help reduce HIV infections. On the other, traditional circumcisions do not necessarily remove all the foreskin, 8,9 thereby providing continued viral access to resident immune cells 10,11 and po- tentially little or no HIV reduction benefit. And as traditional circumcisions in Africa typically occur after puberty, 6 it is possible that this also raises the risk of HIV infection relative to earlier circumcision. 12 Recent analysis of survey data from the African Demographic and Health Surveys (DHS) revealed an in- consistent relationship between HIV status and circumci- sion. 13–16 These findings have prompted some analysts to argue that behavioral disinhibition may be at work and, hence, that population-wide circumcision programs may not be effective in reducing incident HIV infections as implied by the randomized clinical trials. 14,17 However, an alternative explanation is that the aforementioned variations in age and extent of circumcision may lead to protective benefits for some individuals but not others, thus obscuring the relation- ship between circumcision and HIV at the population level. Unlike the DHS, which typically only asks respondents if they have been circumcised, the data set used in this study— a survey of Xhosa-speaking Africans living in Cape Town— goes further by asking the men about the extent and age of circumcision and attitudes toward traditional initiations. Fur- thermore, it is the first data set with information on both the Received for publication May 18, 2011; accepted August 26, 2011. From the *Southern Africa Labour and Development Research Unit, University of Cape Town, Cape Town, South Africa; †Department of Medicine, Mas- sachusetts General Hospital, Harvard Medical School, Boston, MA; ‡AIDS and Society Research Unit and Department of Economics; §Centre for Social Science Research and Department of Sociology, University of Cape Town, Cape Town, South Africa; and jjHealth Economics and HIV/AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa. The CAPS is a joint project of the universities of Cape Town and Michigan. Supported by the US National Institute for Child Health and Human Development, the Andrew W. Mellon Foundation, the National Institute on Aging, the Health Economics & HIV/AIDS Research Division (HEARD) at the University of KwaZulu-Natal, and the European Union. Further information is available from www.caps.uct.ac.za. The authors have no conflicts of interest to disclose. Correspondence to: Brendan Maughan-Brown, PhD, Southern Africa Labour and Development Research Unit (SALDRU), University of Cape Town, Private Bag, Rondebosch, 7701, Cape Town, South Africa (e-mail: bren- dan.maughanbrown@gmail.com). Copyright © 2011 by Lippincott Williams & Wilkins J Acquir Immune Defic Syndr  Volume 58, Number 5, December 15, 2011 www.jaids.com | 499