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Kebaabetswe et al obviously believe the conventional wisdom that heterosexual sex is the major vector for the transmission/reception of HIV, and that male circumcision is an effective deterrent to infection.1 Based on that belief, they have constructed an elaborate and impressive study of the acceptability of circumcision as a prophylactic measure in Botswana. Furthermore, they argue for a programme of neonatal circumcision in Botswana in the hope of reducing the HIV infection rate 15 years later.1
It has been believed since about 1988 that heterosexual coitus accounts for 90% of the HIV infection in Africa.2,3 Many studies do argue that circumcision can reduce the transmission of HIV through heterosexual coitus. The quality of these studies has been criticised for their methodological flaws, including their failure to control for numerous confounding factors.4,5
Gray et al found that transmission by coitus “is unlikely to account for the explosive HIV-1 epidemic in sub-Saharan Africa.”6 It now appears that these studies have not accounted for the largest confounding factor of all—iatrogenic transmission of HIV. Earlier this year the International Journal of STD & AIDS published a trilogy of articles.3,7,8 These articles strongly argue that unsafe healthcare practices, especially non-sterile injections, not heterosexual intercourse, are the principal vectors by which HIV is transmitted. A programme of mass circumcision would be ineffective against iatrogenic transmission …