Below I have cut and paste the research presentation "Female Circumcision and HIV Infection in Tanzania:
for Better or for Worse?" by Rebecca Y. Stallings, from Missouri State University.
The research was conducted to try and gather data to validate the hypothesis by K.E. Kun that female circumcision caused an elevated risk for HIV infection.
Note the political/medical discussions of that time, that epidemic levels of HIV infections in Africa were being blamed on lack of circumcision in males, and a positive incidence of circumcision in females. A bit of opposing logic here. Cut genitals on one gender, the females, will increase the likelihood of HIV infection, versus uncut genitals in the male gender, being the cause of
increased likelihood of HIV infections in men? Logical?
The question needs to be posed, as to how much the culture of the American researchers influences such logic? Americans support and practice male circumcision, but abhor the practice of female circumcision. Could this have influenced such an a priori hypotheses?
The results of the research showed that female circumcision reduced HIV infections by a significant margin, and the researchers were not happy, as per following "The surprising and perplexing significant inverse association between reported female circumcision and HIV seropositivity remained highly statistically significant in the final logistic regression model, despite the presence of other significant potential confounders, namely, geographic zone, household wealth index, woman´s age, lifetime sex partners, and current/past union status". Rather than be happy for the women that they were protected from HIV they were palpably disappointed.
Further Findings "The couples analysis also suggests a protective effect, real or not, of female
circumcision" "The surprising and perplexing significant inverse association between reported female circumcision and HIV seropositivity has not been explained by other variables available and examined in these analyses"
This next statement is telling for their lack of curiosity or unwillingness to speculate, as seems to be so common with male circumcision research. "As no biological mechanism seems plausible, we conclude that it is due to irreducible confounding". If American researchers are willing to speculate or hypothesise that male genitals have virus entry points, why isn't it permissable to speculate that female genitals have viral entry points also? Cultural bias?
Female Circumcision and
HIV Infection in Tanzania:
for Better or for Worse?
Rebecca Y. Stallings,
χ
2
Statisticus Consultoris, USA and
Emilian Karugendo,
National Bureau of Statistics,
Tanzania
Data Source
This analysis and its findings are
derived from the 2003-04 Tanzania
HIV/AIDS Indicator Survey (the THIS),
which is currently available for public
use. The first author received
permission from the National Bureau of
Statistics in Tanzania to conduct this
work prior to the official release of the
data set to the public.
Introduction
Female circumcision, also referred to
as female genital cutting (FGC) and
female genital mutilation (FGM), is
most prevalent in Africa. The practice
has been linked to obstetrical and
gynecological problems in addition to
mental and physical trauma that may
result from the more severe forms of
the procedure and has hence been
widely condemned for both ethical and
health reasons by the World Health
Organization and other entities
involved with Human Rights.
(continued)
WHO has defined 4 types of circumcision:
I. Clitoridectomy
II. Excision (cutting of both the clitoris and
part or all of the labia minora)
III. Infibulation (cutting of all external
genitalia with stitching of the vaginal
opening)
IV. Other less radical forms including
pricking and piercing
It has been estimated that 80-85% of female
circumcision is either type I or II.
K.E.Kun proposed 4 hypothetical
mechanisms by which female
circumcision could result in an
elevated risk of HIV infection
(ref. K.E.Kun, 1997, Intl J Gynecology
and Obstetrics)
I.
Female circumcision
Infection/scarring
Partial/complete occlusion of the vagina
Greater risk of inflammation/bleeding during
intercourse
Disruption of the genital epithelium/exposure
to blood/penile abrasions which have been
reported to enhance risk of HIV infection
II.
Female circumcision
Painful/difficult vaginal penetration
Increased practice of anal
intercourse, which has been
shown to enhance the efficiency
of HIV transmission
III.
Female circumcision
Higher incidence of obstructed
labor and tearing
Hemorrhage
Higher risk of blood transfusion;
blood supply may not be optimally
screened for HIV
IV.
Use of unsterilized instruments to
perform the female circumcision
procedure
Exposure to blood contaminated by
the virus
(continued)
While WHO and the International Federation
of Gynecology and Obstetrics publicly
postulated that female circumcision might be
a risk factor for HIV infection as long ago as
1992, very little research has been published
to date examining this relationship.
In light of the alarming spread of HIV among
females in a number of African countries
where female circumcision continues to be
practiced, the dearth of work on this question
is somewhat perplexing.
Prior Studies
3 published studies were identified which
looked at the association between female
circumcision and HIV infection;
All 3 studies were conducted in the
Kilimanjaro region of Tanzania
•S.E.Msuya et al, 2002, Tropical Medicine
and Intl Health
0.64 [95% CI = 0.26<RR<1.57]; N=379
•S.H.Kapiga et al, 2002, JAIDS
1.29 [95% CI =0.88<RR<1.90];N=312
•E.Klouman et al, 2005, Tropical Medicine
and Intl Health
1.19 [95% CI=0.45<RR<3.16];N=392
Tanzania HIV/AIDS Indicator Survey
• All protocols were reviewed and given ethical
clearance by the National Institute for Medical
Research (NIMR)
• A nationally representative probability sample
of households was selected, excluding
Zanzibar, which had recently been similarly
surveyed
• Data collection took place from December
2003-March 2004 and was conducted by
trained interviewers, all of whom were nurses
from the Ministry of Health
(continued)
• Participants aged 15-49 were
interviewed and asked to give informed
consent for the collection of capillary
blood by finger-prick for HIV testing
• All participants were offered free VCT at
their closest center regardless of their
consent
• For participants consenting to the
procedure, a set of unique barcoded
labels was used to provide an
anonymous link
(Continued)
• HIV testing was conducted at the
national reference laboratory at
Muhimbili University College of Health
Sciences
• Cleaned questionnaire data was
anonymously linked to results from the
HIV testing using the barcodes after the
destruction of the end pages of the
questionnaires
Response Rates
Households selected: 6901
…interviewed 6499
…response rate 98.5%
Eligible women 7154
…interviewed 6863
…response rate 95.9%
…interview & HIV test result 6061
…response rate for both 84.7%
Distribution of reported female
circumcision
• The highest reported rates of female
circumcision were found in the Northern
regions of Tanzania bordering Kenya, and in
the regions directly south of those, ranging
from 20% in Iringa to 73% in Manyara. These
adjacent regions hence form a central belt
from North to South.
• Other than in the capital city of Dar es
Salaam (7%), the rate did not exceed 3%
elsewhere in the country
• Ethnicity was not collected but may explain
the regional clustering wrt female
circumcision rates.
Age at time of circumcison, type of
procedure, and practitioner
• Age at time of circumcision, type of procedure,
and practitioner were not collected in the 2003-
04 THIS, but were included in the 1996 DHS
• 74% of women in 1996 who self-reported
having been circumcised said that the
procedure was performed by a “circumcision
practitioner” (91% in Lake zone)
• Doctors or trained nurses/midwives were most
frequently reported by women in the Northern
Highlands (6.9%)
• The next 2 slides show distributions of age and
type by zone
Age at circumcision by zone
0
10
20
30
40
50
60
70
0-5 yrs 6-10 yrs 11-15 yrs 16+ yrs miss/dk
Coastal N Highlands Lake Central S Highlands
Type of procedure by zone
0
10
20
30
40
50
60
70
80
90
clitoridectomy
excision
infibulation
Coastal N Highlands Lake Central S Highlands
Distribution of female HIV infection
• HIV infection among women aged 15-44
ranged from 2.0-15.2% by region
• Among the 10 (of 21) regions with the highest
reported female circumcision rates (>=20%),
only 4 were among the 10 regions with the
highest female HIV infection rates
• The regions with female HIV infection rates
>10% were Mbeya, Iringa, Dar es Salaam,
and Pwani
Potential confounders available and
examined
Demographic characteristics
•Region
• Household wealth index
•Age
• Educational attainment
• Occupation
• Time in current residence
• Religion
(continued)
Marriage and sexual activity
• Age at sexual debut
• Age when began cohabiting
• Currently married or living with partner
• Number of wives of husband/partner
• Lifetime sex partners
• Sex partners in last 12 months
• Use of alcohol during recent sexual liasons
• Ability to say “no” to having sex with recent
partners
(continued)
Symptoms of sexually transmitted
diseases
• Genital sore or ulcer in last 12 months
• Bad smelling abnormal discharge in last
12 months
Potential exposure to contaminated blood
• Any injection in last 12 months
• Any blood transfusion in last 12 months
Methods
•The χ
2
test of association was used to
examine the bivariate relationships between
potential HIV risk factors with both
circumcision and HIV serostatus
• Logistic regression was used to reduce the
model to those factors remaining statistically
significantly associated with HIV serostatus
and to adjust circumcision status for those
factors
• All analyses were performed using the latest
version of the Statistical Analysis System
(SAS)
Results
The crude relative risk of HIV
infection among women reporting
to have been circumcised versus
not circumcised was
0.51 [95% CI =0.38<RR<0.70]
The power (1 – ß) to detect this
difference is 99%
Logistic Regression Models
• Each variable that was statistically significant in the
simple bivariate analyses was added to a separate
simple logistic regression model to predict HIV
serostatus, together with circumcision status
• Additional logistic models were run which
combined those variables which remained
significant in their individual models, together with
circumcision status
• Models were further restricted to include only those
women who had ever been sexually active
• A final model was selected in which all variables
remain statistically significant
Final Logistic Regression Model
n=5284 ever sexually active women
(continued on following slides)
0.880.410.60Circumsized
3.771.282.20Genital ulcer
in last 12
mos
UL 95% CILL 95% CIOR estimateEffect
(continued)
UL 95% CILL 95% CIOR estimateEffect
Regional
zone
1.00Central (ref).
2.250.721.27Northern
highlands
2.070.691.19Coastal
1.590.480.87Southern
5.091.632.88Southern
highlands
1.730.560.99Lake
(continued)
UL 95% CILL 95% CIOR estimateEffect
6.152.784.135th
(highest)
4.862.253.314th
2.761.211.833rd
2.050.861.332nd
1.001st
(lowest)
HH wealth
index
quintile
(continued)
UL 95% CILL 95% CIOR estimateEffect
3.250.811.6245-49
4.891.402.6240-44
5.121.562.8235-39
7.202.304.0730-34
4.561.462.5825-29
3.631.172.0620-24
1.0015-19 (ref.)
Age (years)
(continued)
UL 95% CILL 95% CIOR estimateEffect
6.871.763.476-10
4.892.173.265
5.282.233.434
3.591.802.543
3.081.642.252
1.001 (ref.)
Lifetime sex
partners
(continued)
UL 95% CILL 95% CIOR estimateEffect
5.212.003.23In 2+ prior
unions
4.812.653.57In 1 prior
union
2.501.331.82In 2+
union
2.241.041.53Never in
union
1.00In 1st
union (ref.)
Union
status
Discussion
• The surprising and perplexing significant
inverse association between reported female
circumcision and HIV seropositivity remained
highly statistically significant in the final
logistic regression model, despite the
presence of other significant potential
confounders, namely, geographic zone,
household wealth index, woman´s age,
lifetime sex partners, and current/past union
status
• Some additional analyses were undertaken
using those women for whom a male partner
was interviewed and could be linked (n=2305)
Couples analysis (male x female)
UL 95% CILL 95% CIRR estimate
that both
partners are
+ for the
factor
Factor
examined
19.96.911.7Genital
ulcer
9.03.35.4Abnormal
discharge
10.35.07.1Circum-
cised
15.88.511.6HIV
positive
Muslim women are more likely
than other women to be married
to a partner of the same religion
90.5 82 75.2 68.4
0
20
40
60
80
100
Muslim Catholic Protestant None
Percent of women married to partner of
same religion
Relative Risk of HIV infection for the
Female Partner by circumcision status
UL 95% CILL 95% CIRR estimateComparison
made
1.420.660.97Male circ
vs neither
0.960.310.55Both circ
vs neither
0.970.330.56Both circ
vs male
only
Discussion continued
• The couples analysis also suggests a
protective effect, real or not, of female
circumcision
• There are several important risk factors which
were not collected in the 2003-04 THIS which
might be explanatory confounders of this
perplexing conundrum, including ethnic
group, age at time of circumcision and type of
circumcision
• In 6 of the 10 regions with the highest female
circumcision rates, the HIV seroprevalence
among males is <5%, and is <3% in 3 of
them. In such cases, a lower transmission
risk may be an explanatory confounder.
Conclusions
• The surprising and perplexing
significant inverse association between
reported female circumcision and HIV
seropositivity has not been explained by
other variables available and examined
in these analyses
• As no biological mechanism seems
plausible, we conclude that it is due to
irreducible confounding
• Anthropological insights on female
circumcision as practiced in Tanzania
may shed light on this conundrum
Recommendations
• Similar analyses are needed
from other countries to
determine if this association
holds elsewhere.
• It is an understatement to say
that further research is
warranted.
Thank you for your attention !
This research doesn't cite any other publications.
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This study compares the residential outcomes of affluent black and affluent white households using data from the 1990 and 2000 censuses and pooled data from the 2005–2009 American Community Survey. Results indicate that affluent black households are highly segregated from their white economic peers. Furthermore, affluent black households live in neighborhoods of lower average quality compared... [Show full abstract]
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Female Circumcision and HIV Infection in... (PDF Download Available). Available from: https://www.researchgate.net/publication/265824402_Female_Circumcision_and_HIV_Infection_in_Tanzania_for_Better_or_for_Worse [accessed Jun 05 2018].
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