There was however no significant association found between peak HIV prevalence and circumcision prevalence globally. Of note, the sub Saharan African region has the second highest percentage of countries where more than 80% of men are circumcised in the world with the highest prevalence of HIV. Even in the countries of Western Africa with close to universal circumcision [22] [27], HIV prevalence rates are considerably higher than the low HIV prevalence world regions [21]. This patterning of the relationship between circumcision and HIV prevalence globally is possibly explained by the existence of some other factor that is driving the higher HIV prevalence rates in sub Saharan Africa and that circumcision is then moderating this effect. This explanation is strengthened by the fact that exactly the same relationship between circumcision and HIV prevalence exists in South Africa’s ethnic groups. There is no correlation between HIV and circumcision prevalence by ethnic group when all 12 of South Africa’s major ethnic groups are included in the analysis [28]. There is however a strong correlation when the analysis is restricted to the black ethnic groups. The non-black ethnic groups (white, colored, Indian) have both the lowest circumcision and HIV prevalence rates. As is the case with the global relationship, it appears that something else is driving the higher HIV prevalence within the high HIV prevalence groups and circumcision modifies this effect.
What might this driver be?