In the late 1980s, an ecological association between high rates of male circumcision and low human immunodeficiency virus (HIV) prevalence in Africa was noted from epidemiologic, geographic, and ethnographic data.1 A meta-analysis of epidemiological studies published prior to 2000 suggested a statistically significant protective association between circumcision and HIV infection among African heterosexual men.2 A causal relationship between HIV risk reduction and male circumcision seemed likely; there was biological plausibility and consistency between studies. The studies, however, did not confirm that circumcision predated HIV risk reduction or that confounding factors might not explain the association.
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