Femaleto-Male Infectivity of HIV-1 among Circumcised and Uncircumcised Kenyan Men

Background. A lack of male circumcision has been associated with increased risk of human immunodeficiency virus type 1 (HIV-1) acquisition in a number of studies, but questions remain as to whether confounding by behavioral practices explains these results. The objective of the present study was to model per–sex act probabilities of female-to-male HIV-1 transmission (i.e., infectivity) for circumcised and uncircumcised men, by use of detailed accounts of sexual behavior in a population with multiple partnerships. Methods. Data were collected as part of a prospective cohort study of HIV-1 acquisition among 745 Kenyan truck drivers. Sexual behavior with wives, casual partners, and prostitutes was recorded at quarterly follow-up visits. Published HIV-1 seroprevalence estimates among Kenyan women were used to model HIV-1 per–sex act transmission probabilities. Results. The overall probability of HIV-1 acquisition per sex act was 0.0063 (95 % confidence interval, 0.0035– 0.0091). Female-to-male infectivity was significantly higher for uncircumcised men than for circumcised men (0.0128 vs. 0.0051;). The effect of circumcision was robust in subgroup analyses and across a wide rangePp.04 of HIV-1 prevalence estimates for sex partners. Conclusions. After accounting for sexual behavior, we found that uncircumcised men were at a 12-fold increased risk of acquiring HIV-1 per sex act, compared with circumcised men. Moreover, female-to-male infectivit