DEMOGRAPHIC

AND

HEALTH

SURVEYS

DHS WORKING PAPERS

2016 No. 125

Tiisetso Makatjane

Thandie Hlabana

Emmanuel Letete

August 2016

This document was produced for review by the United States Agency for

International Development.

Male Circumcision and HIV in Lesotho: 

Is the Relationship Real or Spurious? 

Analysis of the 2009 Demographic and Health Survey

Male Circumcision and HIV in Lesotho: 

Is the Relationship Real or Spurious? 

Analysis of the 2009 Demographic and Health Survey

Tiisetso Makatjane1

Thandie Hlabana2

Emmanuel M. Letete3

ICF International 

Rockville, Maryland, USA 

August 2016 

1

 Department of Statistics and Demography 

2

 Department of Sociology, Anthropology and Social Work 

3

 Department of Economics 

All three are based at the National University of Lesotho 

Corresponding author: T. J. Makatjane, Department of Statistics and Demography, National University 

of Lesotho; E-mail: tj.makatjane@nul.ls or tjmakatjane@gmail.com 
Acknowledgments 

We would like to extend our heartfelt gratitude to ICF International and USAID for considering 

us for this opportunity and for funding us to be part of the 2016 DHS Fellows program. We are 

greatly indebted to our facilitators Dr. Wenjuan Wang, Dr. Shireen Assaf, Dr. Elizabeth 

Nansubuga, Simona Simona, and Damian Damian for their guidance and patience during this 

process. Our reviewer, Joy Fishel at ICF, is appreciated for valuable insights about this work. We 

are also grateful to our DHS Program co-fellows for their support, feedback, and humor. This has 

been an opportunity for growth, and we see ourselves as ambassadors of The DHS Program in 

Lesotho and beyond. We also want to extend our gratitude to our institution, the National 

University of Lesotho, Faculty of Social Sciences, for affording us the opportunity to participate 

in the 2016 DHS Fellows Program. 

Editor: Bryant Robey 

Document Production: Natalie La Roche 

The DHS Working Papers series is a prepublication series of papers reporting on research in 

progress that is based on Demographic and Health Surveys (DHS) data. This research is carried 

out with support provided by the United States Agency for International Development (USAID) 

through The DHS Program (#AIDOAA-C-13-00095). The views expressed are those of the 

authors and do not necessarily reflect the views of USAID or the United States Government. 

The DHS Program assists countries worldwide in the collection and use of data to monitor and 

evaluate population, health, and nutrition programs. For additional information about The DHS 

Program, contact DHS Program, ICF International, 530 Gaither Road, Suite 500, Rockville, MD 

20850, USA. Phone: +1 301-407-6500; Fax: +1 301-407-6501; Email: reports@dhsprogram.com; 

Internet: www.dhsprogram.com. 

Recommended citation: 

Makatjane, T. J., T. Hlabana, and E. M. Letete. 2016. Male Circumcision and HIV in Lesotho: Is 

the Relationship Real or Spurious? Analysis of the 2009 Demographic and Health Survey. DHS 

Working Papers No. 125. Rockville, Maryland, USA: ICF International. 
iii 

Abstract 

Background. Lesotho has the second highest prevalence of HIV in the world, estimated at 23%. 

Compelling evidence from ecological studies, as well as from randomized clinical trials in Africa, 

suggests that male circumcision reduces the risk of heterosexually-acquired HIV infection in men. 

However, results from DHS surveys in Lesotho present contradictory evidence of high HIV 

prevalence among circumcised men (21%) compared with uncircumcised men (16%). The 

objective of this study is to analyze the relationship between HIV and male circumcision in 

Lesotho. In particular, the study seeks to assess whether it makes a difference if one is medically 

or traditionally circumcised, and if the differences in risky sexual behaviors could explain the 

contradictory evidence in Lesotho. 

Data and Methods. The study used data from the 2009 Lesotho Demographic and Health Survey 

(LDHS). A weighted sample of 2,283 sexually active males age 15-59 was used for this analysis. 

Descriptive univariate, bivariate, and logistic regression analyses were used. 

Results. Although 57% of sexually active men in Lesotho are circumcised, HIV infection is high 

among all men. When controlling for background and risky sexual behaviors, the study found that 

medically circumcised men had significantly lower odds of HIV infection than uncircumcised 

men. However, the odds of HIV infection among traditionally circumcised men were similar to 

those of uncircumcised men. When comparing the odds of HIV infection among circumcised men 

only, the study found that traditionally circumcised men had significantly higher odds of being 

HIV-positive compared with medically circumcised men. 

Conclusion and Recommendations. The previously reported, apparent non-existence of 

protection offered by male circumcision occurs because traditional circumcision and medical 

circumcision were treated like the same procedure. However, medical circumcision provides the 

expected protection that traditional circumcision does not. There is need to engage with 

gatekeepers of initiation schools to ensure that traditional circumcision is as effective as medical 

circumcision. It is equally important that Lesotho continues to emphasize the importance of 

avoiding risky sexual behaviors if the war against the AIDS epidemic is to be won. Further research 

is needed to understand why HIV prevalence for medically and traditionally circumcised men in 

Lesotho is dissimilar to what prevails in other settings. 

Keywords: HIV, Medical Circumcision, Traditional Circumcision, Risky Behaviors 

1 

1. Introduction 

Lesotho has the second highest prevalence of HIV in the world, estimated at 23% (Ministry of 

Health Lesotho 2015). HIV infections in Lesotho are found within the general population, and 

heterosexual contact has been identified as the main mode of transmission (Ministry of Health 

Lesotho 2015). Indeed, prevention of new HIV infections is one of the biggest hopes in the fight 

against the HIV pandemic. While the ABCs (Abstinence, Be Faithful, and Correct Condom Use) 

have long been promoted as preventive strategies in Lesotho, the high HIV prevalence rate 

reflects the country’s challenge in combating HIV infections. 

In 2012 Lesotho launched voluntary male medical circumcision as an additional preventive 

strategy (Ministry of Health Lesotho 2015). It is noteworthy that the launch was not supported 

by local evidence, since both the 2004 and 2009 Lesotho Demographic and Health Surveys 

(LDHS) provided evidence that HIV prevalence was higher among circumcised men, suggesting 

no protection was offered by circumcision. For example, in 2009 HIV prevalence among 

circumcised men was 21% compared with 16% among uncircumcised men (Ministry of Health 

and Social Welfare (MOHSW) [Lesotho] and ICF Macro 2009). Rather, the notion that voluntary 

male medical circumcision should be rolled out as a public health intervention to protect against 

the transmission of HIV and other sexually transmitted infections was promoted by the World 

Health Organization (WHO) starting in 2007 based on evidence from ecological and randomized 

trail studies done in other countries in sub-Saharan Africa (WHO/UNAIDS 2007). 

It is important to highlight the relationship between HIV and circumcision as an area of contested 

research. Epidemiological evidence from ecological studies in sub-Saharan African countries with 

heterosexually driven epidemics have shown that populations with a relatively high prevalence of 

male circumcision have relatively low HIV prevalence (Siegfried et al. 2002; Moses et al. 1990). 

Specifically, these findings have been used to explain the difference in HIV prevalence between 

Eastern and Southern African countries, which have high HIV prevalence but low male 

circumcision rates, compared with West African countries with low HIV prevalence and high 

circumcision rates. Furthermore, within-country research also has supported the inverse 

relationship between male circumcision and HIV prevalence. For example, in Western Kenya 

uncircumcised men had four times higher odds of being HIV positive compared with circumcised 

men (Auvert et al. 2005; Marum et al. 2004). A recent study (MacLaren et al. 2015) found that in 

regions of Papua New Guinea where male circumcision is ritually practiced, HIV seroprevalence 

was considerably lower than in areas where it is not practiced. Cameron and colleagues (1989) 

suggested a greater than eight-fold increased risk of HIV-1 infection for uncircumcised men. In a 

systematic review of literature on the relationship between HIV and male circumcision in subSaharan Africa, Weiss, Quigley, and Hayes (2000) concluded that male circumcision is associated 

with significantly reduced risk of HIV infection among men, especially men at high risk of 

infection. These findings are supported by the biological theory that the entry of HIV into host 
2 

cells is facilitated by CD4 and other HIV co-receptors present on the Langerhans’ cells of the 

foreskin (Hussain and Lehner 1995). 

The ecological studies that suggested the negative relationship between HIV and male 

circumcision prompted development of randomized controlled studies to test the efficacy of 

medical male circumcision. These randomized controlled trials (RCTs), conducted in South 

Africa, Kenya, and Uganda, indicated that medical circumcision reduces the risk of HIV 

acquisition by more than 60% among heterosexual men (Auvert et al. 2005; Bailey et al. 2007; 

Gray et al. 2007; Siegfried et al. 2005). Based on this evidence, Williams and colleagues (2006) 

estimated, using a simulation model, that increased coverage of male circumcision among men in 

Southern Africa could avert as many as 2 million HIV infections and 300,000 deaths over a 10-

year period. This was further supported by Kahn, Marseille, and Auvert (2006), who suggested 

that the protective value of circumcision would be cost-saving. Therefore, these studies presented 

compelling evidence of a protective benefit of male circumcision against the spread of HIV. 

Despite the evidence from ecological studies and RCTs of a protective effect of circumcision, 

some national surveys have failed to support this effect consistently in sub-Saharan Africa. For 

example, Garenne (2008) argued that data from 13 African DHS surveys did not support a 

protective effect. Using DHS data from 18 countries, Mishra and Assche (2009) also showed that 

circumcision status was not correlated with lower HIV prevalence rate in 10 countries, including 

Lesotho. An HIV survey in South Africa also showed no relationship between male circumcision 

and HIV status (Connolly et al. 2008). It was only in pooled DHS data that the protective effect of 

circumcision once again emerged, with the odds of having HIV four times higher for 

uncircumcised men than circumcised men, and the effect was more pronounced once sexual 

behavior and other co-variates were included in the regression analysis (Gebremedhin 2010). In 

fact, some authors, such as Warren (2010), argue that the protective effect of male circumcision 

may occur mainly because circumcision is associated with safer sexual behavior and hence lower 

rates of HIV infection, as was the case in Botswana and Swaziland, though not in Lesotho. 

Circumcision has also been found to facilitate condom use, thereby increasing the efficacy of male 

circumcision (Kebaabetswe et al. 2003; Bailey et al. 2007). Talbott (2007) posited that male 

circumcision is not significantly associated with lower HIV prevalence once commercial sexworker patterns are controlled for. These contradictory findings on the effect of male circumcision 

on HIV infection suggest that male circumcision alone is not sufficient in explaining HIV 

prevalence in sub-Saharan Africa. 

Risk compensation theory can also be used to explain the contradictory effect of male 

circumcision. According to the theory, people adjust their behavior based on their perceived level 

of risk. Thus as the perceived risk of HIV is reduced, a person may adopt riskier sexual behaviors 

(Eaton and Kalichman 2007). For example, some studies have shown that men who are 

circumcised tend to think they are protected against or immune to HIV infection (Westercamp et 

al. 2012; Green et al. 2008). Using Uganda DHS data, Kibira and colleagues (2014) found that 
3 

circumcised men were more likely to engage in risky sexual behaviors. Consequently, risky sexual 

behaviors may undermine the effects of male circumcision. Nevertheless, Chikutsa, Ncube, and 

Mutsau (2014) found that in Zimbabwe it was uncircumcised men who were more likely to practice 

risky sexual behaviors. These mixed results have prompted further questions on the relationship 

between HIV and circumcision. 

Notwithstanding available research on the subject, a number of studies on the relationship between 

male circumcision and HIV fail to address questions associated with circumcision within 

traditional contexts. First, they do not differentiate between traditional and medical circumcision, 

which is likely to mediate outcomes within the circumcision and HIV literature. The sociocultural 

factors surrounding circumcision are important in unearthing the myth behind differences in HIV 

protective efficacy between traditional and medical male circumcision. For instance, MacLaren 

and colleagues (2015) have shown that the HIV protective effect of male circumcision is not 

limited to medical procedures, as other traditional foreskin cuttings showed similar results in Papua 

New Guinea. Second, it is important to understand whether traditionally circumcised men have 

different sexual behaviors compared with medically circumcised men, which might offset the 

protective effect of circumcision in specific settings. These issues have become more pressing in 

the context of Lesotho, where traditional circumcision has remained a common practice that 

defines manhood even today, and yet HIV prevalence remains among the highest in the region. 

Thus, the peculiarity of the situation in Lesotho calls for more scientific interrogation that might 

help explain the relationship between circumcision and HIV. 

5 

2. Background 

Circumcision in Lesotho is embedded within Sesotho culture. Historically, male circumcision has 

been part of an “initiation” process known as “lebollo,” culturally practiced as a rite of passage 

from adolescence into adulthood (Gayle et al. 2007). Initiation became part of life in Lesotho 

culture after the settlement of the Sotho tribe in the Caledon River Valley and Maluti Mountain 

(Warren 2010). Initiation schools were attended by boys and girls who had reached puberty, and 

were held in secret locations. Although the curriculum of traditional initiation schools is unclear, 

Ashton (1952) asserted that in Lesotho this type of school has always been associated with virility. 

Nevertheless, discussion of initiation remains taboo in the Sesotho culture; as such, information 

on initiation school practices is based on anecdotal evidence. This evidence only suggests that 

traditional male circumcision is performed in different ways, and that it may be incomplete by 

biomedical standards, with perhaps only a small incision cut into the foreskin (Corno and de 

Walque 2007). Thus, biomedical concerns about safety have contributed to the marginalization of 

traditional male circumcision. In addition, the timing of traditional male circumcision often takes 

place after sexual debut, and this is a concern because of its effect on HIV prevention. In Lesotho, 

age at circumcision was reported to be between 16 and 20 (Ministry of Health and Social Welfare 

Government of Lesotho 2008). 

Nonetheless, traditional male circumcision remains a common practice even today in Lesotho and 

continues to carry a symbolic meaning of manhood in the Sesotho culture (Skolnik et al. 2014). It 

appears that young men circumcised under traditional circumcision far out-number those 

circumcised in the health care system (Warren 2010). It is estimated that about 10,000 initiates are 

circumcised each year by traditional “healers and elders” compared with between 4,000 and 5,000 

men circumcised in the formal health sector (National AIDS Commission 2009). Targeting 

traditional male circumcision would be a better strategy on the basis of large numbers, not to 

mention that traditional male circumcision is mainly voluntary. It is important to engage with 

traditional practitioners in order to effectively roll out voluntary male medical circumcision as a 

public health intervention. However, historical beliefs and practices around traditional male 

circumcision will affect the take-up of voluntary male medical circumcision, public health 

messaging, and broader HIV prevention strategies. 

2.1. Conceptual Framework 

This paper is based on the conceptual framework illustrated in Figure 1. The framework identifies 

HIV status as the outcome variable. Based on previous research referenced above, there is a direct 

link between HIV status and circumcision status. However, the framework identifies this link to 

be weak (denoted by broken lines in Figure 1) given the unique context of Lesotho in which men 

who are circumcised present higher HIV prevalence compared with uncircumcised men (Ministry 

of Health and Social Welfare (MOHSW) [Lesotho] and ICF Macro 2009). The framework divides 

circumcision status into three categories: traditional circumcision, medical circumcision, and no 
6 

circumcision. It assumes that individuals within these three categories might exhibit different 

sexual behaviors and come from different socioeconomic backgrounds. In particular, traditional 

circumcision is a “rite of passage” into manhood and not necessarily intended as protection against 

HIV/AIDS. Manhood in this case is associated with family formation and sexual activity, whereas 

medical circumcision is associated with protection against HIV and other sexually transmitted 

infections (STIs). Therefore, conceptualization of circumcision between these two groups is 

different, with different implications for sexual behaviors. 

In Lesotho, HIV is mainly transmitted through heterosexual intercourse (Ministry of Health 

Lesotho 2015). To account for this, the framework posits that risky sexual behaviors mediate the 

relationship between circumcision and HIV status. For example, Kibira and colleagues (2014) 

found that in Uganda circumcised men were more likely to engage in risky sexual behaviors, while 

Chikutsa, Ncube, and Mutsau (2014) had contradictory results in their study of Zimbabwe. In our 

study, risky sexual behaviors are defined as number of lifetime sexual partners, age at first sex, 

non-use of condom at last sex, and relationship with last sex partner. Moreover, risky sexual 

behaviors could be influenced by other factors such as HIV comprehensive knowledge, STI 

experience in the past 12 months, and exposure to alcohol consumption. The conceptual 

framework assumes that men who have comprehensive HIV knowledge would behave differently 

from those without this knowledge. For instance, some research has found that men with 

comprehensive HIV knowledge are less likely to engage in unprotected sexual intercourse (Wang 

and Alva 2012). In the same manner, prior experience of bacterial and viral STIs is associated with 

risk of acquisition and transmission of HIV infection (Ward and Rönn 2010). Individuals who 

consume alcohol are likely to make risky sexual decisions while under the influence of alcohol—

for example, engaging in sexual intercourse without using a condom (Kalichman et al. 2007). 

Similarly, individuals who have ever tested for HIV/AIDS have different attitudes and sexual 

behavior compared with those who have never tested (Kalichman and Simbayi 2003). Moreover, 

Lurie and colleagues (2003) showed that in South Africa migrant men were twice as likely to be 

HIV-infected as nonimmigrant men. Thus in mobile societies like Lesotho, migration is an 

important independent risk factor for HIV infection. 
7 

Figure 1: Conceptual framework 

2.2. Research Questions 

The main research question of the study is why do circumcised men in Lesotho have higher HIV 

prevalence than uncircumcised men? 

Specifically: 

• Does it make a difference if one is medically or traditionally circumcised? 

• Do differences in risky behavior provide the answer? 

Socioeconomic 

characteristics

• Age 

• Residence (rural or urban) 

• Ecological zone 

• Region 

• Wealth status 

• Marital status 

• Education level 

Risky Sexual Behavioral Factors 

• Number of lifetime sexual partners 

• Condom use at last sex 

• Age at first sex 

• Sex before circumcision 

• Relationship with last sex partner 

• Exposure to STIs

Other Risk Factors 

• Alcohol consumption 

• Migration 

HIV/AIDS status 

HIV/AIDS Knowledge & 

Behaviour 

• HIV/AIDS knowledge 

• Ever tested for HIV 

Circumcision Status 

• Traditional MC 

• Medical MC 

• Not circumcised 

9 

3. Data and Methods 

3.1. Data 

The study used data from the Lesotho 2009 Demographic and Health Survey for the analysis. This 

was a nationally representative sample. The survey used a stratified, two-stage cluster sampling 

strategy. At the first stage, clusters were selected from the 2006 Lesotho Population and Housing 

Census list of enumeration areas (EAs), with probability proportional to size. At the second stage, 

a complete listing of households within selected clusters was done. From the household listing, 

systematic sampling was used to select 10,000 households (Ministry of Health and Social Welfare 

(MOHSW) [Lesotho] and ICF Macro 2009). The survey collected information on 

sociodemographic characteristics (age, marital status, highest educational level, survey region, 

residence, ecological zone, and work status), sexual behavior, and self-reported circumcision 

status. Based on household assets, a wealth index variable was generated. HIV status information 

was obtained from blood samples collected during interviews from consenting respondents. 

In all, 3,317 records were available from the data file for men. Of the total, 3,075 men performed 

an HIV test. Since the study included variables linked to risky behavior, only men who had been 

sexually active in the past 12 months were included in the study. Excluding respondents who were 

not sexually active in the past 12 months and those with missing information on variables of 

interest reduced the sample size to 2,283. There were 1,432 circumcised men (118 medically 

circumcised and 1,314 traditionally circumcised) and 851 not circumcised. Based on these figures 

the weighted distribution of the sample is 58% circumcised men (51% traditional and 6% medical) 

and 42% uncircumcised. 

3.2. Key Variables and Measurements 

HIV status was the main outcome variable in this research. The variable was based on blood 

samples collected from respondents consenting to HIV testing. The variable was categorized into 

HIV negative and HIV positive. Circumcision status was also a key variable, since the study was 

interested in the relationship between circumcision and HIV. Based on two questions, “Are you 

circumcised (self-report)” and “where circumcision was performed,” the variable was categorized 

into medical male circumcision, traditional male circumcision, and uncircumcised. 

Factors related to risky sexual behavior were another set of variables of interest. Included in this 

group was total number of lifetime sexual partners, age at first sex, age at circumcision, 

relationship with the last sex partner, condom use at last sexual intercourse, and exposure to STIs. 

Other risky behavior factors included alcohol consumption, categorized into never drank alcohol, 

never got drunk, and ever got drunk. 

Testing for HIV was categorized into never tested for HIV and ever tested for HIV. Comprehensive 

HIV knowledge was a computed variable. According to the 2009 DHS report for Lesotho, 

respondents had to know the correct answers to three questions about protection against AIDS and 

two questions about local myths. The myth questions were coded as 1 for correct responses and 0 
10 

for incorrect responses. An HIV knowledge variable was computed by adding the responses of the 

5 variables. The knowledge variable was categorized into “Yes” for respondents with a score of 5, 

indicating comprehensive HIV knowledge, and “No” for those with a score of less than 5, 

indicating lack of comprehensive HIV knowledge. Being away from home for more than one 

month was used as a proxy for migration. The variable was categorized as away for less than one 

month, away for more than one month, and not away, meaning the individual had never left home. 

Background or control variables included region/district, residence, ecological zone (lowlands and 

highlands), age (15-24, 25-34, 34-44, and 45-59), marital status (never married and ever married), 

educational level (no education, primary, and secondary and above) and wealth index (poor, 

middle, and rich). 

3.3. Statistical Methods 

At the univariate level, the distribution of background/control variables was presented using 

circumcision status as the unit of comparison. 

At the bivariate level, a comparison of risky behaviors by circumcision status was presented, as 

well as a comparison of HIV status by circumcision status. Chi square tests were used to test for 

presence of statistically significant associations. 

At the multivariate level, four regression models were run on the association between HIV 

prevalence and circumcision status: 

Model 1: circumcision status 

Model 2: circumcision status and risky behaviors 

Model 3: circumcision status and background characteristics 

Model 4: circumcision status, risky behaviors, and background characteristics 

To fully answer the research question “Does it make a difference if one is medically or traditionally 

circumcised?” two comparisons were made. In the first comparison, uncircumcised men were the 

reference category and compared with medically circumcised men and traditionally circumcised 

men. This comparison included all men in the survey sample. A second comparison was made 

among circumcised men only, with medical circumcision as the reference category. 

To account for the survey sampling methodology, the analysis took into consideration the sample 

stratification design and sampling weights. Permission to use the data was obtained from ICF 

International. 
11 

4. Results 

4.1. Background Characteristics 

Table 1 shows the characteristics of the study population by circumcision status. Overall, nearly 

three-fourths of respondents (72%) live in rural areas, and 14% of respondents have no education. 

Sixty percent live in the lowlands, and the largest proportions are age 15-24 (37%) and age 25-34 

(31%). Ever-married respondents are in the majority (58%), and 43% of respondents reside in rich 

households. Over two-thirds of the men (69%) are currently working. 

Comparing respondents by circumcision status, 74% of medically circumcised men reside in urban 

areas; in contrast, 87% of traditionally circumcised men and 59% of uncircumcised men reside in 

rural areas. Medically circumcised men and uncircumcised men are comparatively well educated84% and 56%, respectively, have completed secondary education or better compared with only 

16% of traditionally circumcised men. Most medically circumcised men (84%) and uncircumcised 

men (74%) live in the lowlands compared with less than half of traditionally circumcised men 

(46%). Uncircumcised men and traditionally circumcised men show a younger age distribution 

than medically circumcised men, who are concentrated between ages 25-34 and 35-44. Almost 

half of uncircumcised men (49%) have never been married compared with 32% of medically 

circumcised men and 38% and traditionally circumcised men. Eighty-six percent of medically 

circumcised men and 60% of uncircumcised men reside in rich households, while 50% of 

traditionally circumcised men reside in poor households. There are only marginal differences in 

work status among respondents by circumcision status. 

Table 1. Characteristics of the study population by circumcision status 

Variable Labels 

Circumcision Status 

Medical 

Circumcision 

Traditional 

Circumcision 

Not 

Circumcised Total

Residence urban 74.4 13.1 41.1 28.5

rural 25.6 86.9 58.9 71.5

Education 

no education 2.1 22.7 4.5 13.8

primary 14.4 61.2 39.9 49.4

secondary+ 83.5 16.1 55.5 36.7

Zone lowlands 83.9 46.1 73.6 59.9

high lands 16.1 53.9 26.4 40.1

Age 

15-24 20.8 35.6 40.9 37.0

25-34 35.0 30.9 29.4 30.6

35-44 26.2 18.1 14.1 16.9

45-59 18.0 15.3 15.6 15.6

Marital status never married 31.7 38.0 49.2 42.3

ever married 68.3 62.0 50.8 57.7

Wealth index 

poor 6.8 49.6 21.5 35.2

middle 6.8 25.6 18.4 21.4

rich 86.4 24.8 60.1 43.3

Respondent currently 

working? 

no 23.7 29.2 34.7 31.2

yes 76.3 70.8 65.3 68.8

N (weighted) 135 1163 947 
12 

4.2. Risky Behaviors 

As Table 2 shows, the majority of Basotho men (56%) experience sex for the first time between 

the ages of 15 and 19, while more than half (54%) report four or more lifetime sexual partners. For 

almost all respondents (94%), the last sexual partner was the usual partner, and the majority (53%) 

did not use a condom at last sex. Half of the respondents have never tested for HIV, and almost all 

respondents (96%) did not experience an STI in the past 12 months. Close to three-fourths of 

respondents (73%) lack comprehensive HIV knowledge, while 52% say they have never been 

drunk. More than half of men have been away from home for at least once, but only 9% have been 

away for more than one month. 

There are differences in migration by circumcision status. Among medically circumcised men, 

one-third (34%) have never been away from home compared with 46% of traditionally circumcised 

men and 42% of uncircumcised men. There are no substantial differences between respondents by 

circumcision status with respect to age at first sex, STIs, drunkenness, number of lifetime sexual 

partners, and relationship with last sex partner. However, traditionally circumcised men are less 

likely to have ever tested for AIDS or to have used a condom at last sex compared with medically 

circumcised men and uncircumcised men. Fifty-nine percent of medically circumcised men and 

57% of uncircumcised men used a condom at last sex compared with only 37% of traditionally 

circumcised men. Only 41% of traditionally circumcised men have ever tested for AIDS compared 

with 50% of uncircumcised men and 65% of medically circumcised men. 

Among circumcised men overall, close to two-thirds (63%) were circumcised between ages 15 

and 19, while only 10% were circumcised before age 15. Among traditionally circumcised men, 

however, two-thirds (67%) were circumcised between ages 15 and 19. In contrast, among 

medically circumcised men, about half (47%) were circumcised at age 20 or older. 
13 

Table 2. Risky behaviors by circumcision status 

Variable Labels 

Circumcision Status Chisquare p 

value 

Medical 

Circumcision 

Traditional 

Circumcision 

Not 

Circumcised Total 

Age at circumcision 

< 15 25.6 7.6 na 9.5 

0.000 15-19 27.6 66.8 na 62.7 

20+ 46.8 25.6 na 27.8 

not circumcised na na na na 

Age at first sex 

< 15 15.3 12.4 16.6 14.3 

0.221 15-19 52.1 56.5 56.9 56.4 

20+ 27.7 26.6 23.1 25.2 

don’t know 4.9 4.5 3.4 4.0 

Number of lifetime 

sexual partners 

1 8.8 9.4 11.2 10.1 

0.145 2-3 20.4 30.1 31.8 30.2 

4+ 61.4 55.3 51.8 54.2 

don’t know 9.3 5.2 5.3 5.5 

Relationship with the 

last sex partner 

usual partner 94.6 94.3 94.2 94.3 0.987 casual acquaintance 5.4 5.7 5.8 5.7 

Was condom used 

during last sex? 

no 40.8 63.1 42.8 53.3 0.000 yes 59.2 36.9 57.2 46.7 

Ever tested for AIDS? 

no 35.5 54.6 46.5 50.0 

0.000 yes 64.5 40.8 49.6 45.9 

does not know about 

AIDS 

0.0 4.6 (3.9) 4.0 

Had STIs in the past 

12 months? 

no 96.1 96.1 95 95.7 0.606 yes 3.9 3.9 5 4.3 

Comprehensive HIV 

knowledge? 

no 45.6 85.6 61.9 73.3 0.000 yes 54.4 14.4 38.1 26.7 

Ever got drunk? 

no 16.2 11.8 12.5 12.3 

yes 50.5 46.8 48.4 47.7 0.557 

never drank 33.4 41.4 39.1 40.0 

Away from home 

not away 33.8 46.3 41.8 43.6 

0.021 

away for less than a 

month 

49.7 46.4 48.2 47.4 

away for more than a 

month 

16.5 7.3 1.0 9.0 

N (weighted) 135 1163 947 

4.3. HIV Prevalence and Risky Behavior 

Of the risky behavior variables, including circumcision status, suggested to be associated with HIV 

prevalence by the conceptual framework, only six are significantly associated with HIV 

prevalence. As Table 3 shows, age at first sex, number of lifetime sexual partners, ever tested for 

AIDS, STIs experience in the past 12 months, drunkenness experience, and being away from home 

are significantly associated with HIV prevalence (p<0.05). Circumcision status, age at 

circumcision, relationship with the last sex partner, condom use during the last sex, and 

comprehensive HIV knowledge are not significantly associated with HIV prevalence. 
14 

According to Table 3, HIV prevalence increases with increasing age at first sex and with increasing 

number of lifetime sexual partners. Table 3 further shows that respondents who have either ever 

tested for HIV or experienced STIs in the past 12 months have the highest HIV prevalence. 

Respondents who have experienced drunkenness or been away from home for more than a month 

have the highest prevalence among their groups. 

Table 3. HIV prevalence by circumcision status and risky behaviors 

Variable Labels 

HIV 

Prevalence N 

Chi-square 

p value 

Circumcision status 

medical circumcision 15.1 141 

traditional circumcision 21.9 1,217 0.260 

not circumcised 20.7 981 

Age at first sex 

< 15 10.5 335 

0.000 15-19 19.7 1,320 

20+ 27.4 590 

don’t know 36.8 94 

Age at circumcision 

< 15 21.8 129 

0.144 15-19 19.0 852 

20+ 26.1 377 

not circumcised 20.7 981 

Number of lifetime sexual 

partners 

1 13.5 237 

0.000 2-3 16.5 706 

4+ 23.8 1,268 

don’t know 32.0 128 

Relationship with the last sex 

partner 

usual partner 20.6 2,205 0.121 casual acquaintance 27.7 134 

Was condom used at last sex? no 20.0 1,246 0.335 yes 22.1 1,093 

Ever tested for HIV/AIDS? 

no 16.3 1,170 

yes 26.7 1,074 0.000 

does not know about AIDS 13.9 94 

Had STIs in the past 12 

months? 

no 19.9 2,238 0.000 yes 45.3 101 

Comprehensive HIV 

knowledge? 

no 20.9 1,713 0.858 yes 21.3 625 

Away from home 

not away 20.2 1,020 

away for less than 1 month 20.0 1,108 0.015 

away for more than a month 30.2 211 

Ever got drunk? 

no 22.4 289 

yes 23.9 1,116 0.006 

never drank 17.1 935 

4.4. Factors Associated with HIV Prevalence 

At the univariate level there are differences in the distribution of respondents based on 

circumcision status. There are also differences in risky behavior based on circumcision status. 

According to our conceptual framework, the relationship between circumcision and HIV could be 

operating through risky behaviors. Bivariate analysis shows six variables to be significantly 
15 

associated with HIV prevalence. To establish the existence of the relationship suggested by the 

chi-square statistics in Table 3, and to answer the research question of the study (Are differences 

in risky behaviors the answer?), multivariate analysis was conducted. Four models were run 

regressing circumcision status and HIV status, as indicated in the statistical methods. 

Table 4a presents the results of this analysis. According to Model 1 there is no statistically 

significant association between circumcision status and HIV prevalence in Lesotho. Controlling 

for risky behaviors in Model 2, however, the odds of being HIV positive are 0.5 for medically 

circumcised men and 1.1 for traditionally circumcised men relative to uncircumcised men, but the 

odds are not statistically significant. After controlling for background characteristics in Model 3, 

medically circumcised men have significantly lower odds of being HIV-positive compared with 

uncircumcised men (AOR =0.4; 95% CI: 0.2 - 0.8), while there is no statistical difference between 

traditionally circumcised men and uncircumcised men. When controlling for both risky behavior 

and background characteristics in Model 4, medically circumcised men continue to have 

significantly lower odds of being HIV-positive relative to uncircumcised men (AOR = 0.4; 95% 

CI: 0.2 - 0.8). The results of Models 3 and 4 are similar, suggesting that risky behaviors have no 

effect, since the odds do not change between controlling for background characteristics alone and 

controlling for both background and risky behaviors. 

Table 4a. The odds that a circumcised man Is HIV positive, for all sexually active men in the last 12 

months 

Circumcision Status Model 1 Model 2 Model 3 Model 4 

Medical circumcision 0.7 0.5 0.4** 0.4** 

Traditional circumcision 1.0 1.1 1.1 1.1 

Not circumcised (RC) 1 1 1 1 

Controls 

Risky behaviors √ √

Background characteristics √ √

No. of Observations 2283 2283 2283 2283 

*** p<0.001, ** p<0.01, * p<0.05 

Note: The complete results for each model are in Appendix 1 

To fully answer the question “whether it makes a difference if one is medically or traditionally 

circumcised,” modeling similar to that in Table 4a is repeated, but this time among circumcised 

men only rather than all men who were sexually active in the last 12 months. Table 4b presents 

the results of this modeling. According to Model 1 in Table 4b, there is no association between 

HIV status and circumcision. In contrast to Model 2 in Table 4a, Model 2 in Table 4b shows that 

after controlling for risky behavior, traditionally circumcised men have significantly higher odds 

(AOR = 2.1; 95% CI: 1.1 - 3.9) of being HIV-positive compared with medically circumcised men. 

Controlling for background characteristics brings a change in the odds, but after controlling for 

both background characteristics and risky behaviors, the odds are similar to those found after 
16 

controlling for background characteristics alone. The odds that a traditionally circumcised man is 

HIV-positive increases from 2.1 in Model 2, when risk behaviors alone are controlled for, to 2.9 

(95% CI: 1.4 – 6.0) in Model 3, when background characteristics are controlled for. As was the 

case in Table 4a, controlling for both risky behavior and background characteristics does not bring 

a change in the odds, as indicated in Model 4 of Table 4b. 

Table 4b. The odds that a traditionally circumcised man Is HIV positive, for circumcised sexually 

active men in the last 12 months 

Type of Circumcision Model 1 Model 2 Model 3 Model 4 

Medical circumcision 1 1 1 1 

Traditional circumcision 1.6 (0.9–2.8) 2.1* (1.1–3.9) 2.9** (1.4–6.0) 2.9** (1.4-6.1) 

Controls 

Risky behaviors √ √

Background characteristics √ √

No. of Observations 1432 1432 1432 1432 

*** p<0.001, ** p<0.01, * p<0.05 

Note: The Complete results for each model are in Appendix 2 

For Model 2 in both Tables 4a and 4b, age at first sex, STI experience, number of lifetime sexual 

partners, and experience of testing for HIV are important factors significantly associated with HIV 

status, as shown in Appendix 1 and Appendix 2. Drunkenness experience and migration are only 

significant when comparing uncircumcised men with circumcised men. In both scenarios age, 

marital status, and region are significant factors after controlling for background characteristics 

only as well as after controlling for both background characteristics and risky behaviors. When 

controlling for both risky behaviors and background characteristics, however, only condom use at 

last sex and STI experience are significantly associated with HIV status. Both are associated with 

increased odds of HIV infection. 
17 

5. Discussion 

The distribution of the study sample was such that 58% of the study population reported being 

circumcised (52% traditional and 6% medical). In terms of background characteristics, among 

uncircumcised men and medically circumcised men the majority resided in lowlands, urban areas, 

and in rich households relative to traditionally circumcised men. Traditionally circumcised men 

were less schooled compared with either uncircumcised or medically circumcised men. Thus, 

traditionally circumcised men tend to have a lower socioeconomic status compared with other men 

in the study population. 

All men demonstrated similar risky behavior practices irrespective of their circumcision status, 

except in a few cases. There were no significant differences among Basotho men by circumcision 

status in the number of lifetime sexual partners, relationship with the last sex partner, age at first 

sex, experience of STIs, and alcohol consumption. However, uncircumcised men and medically 

circumcised men had a higher percentage using a condom at last sex, as well as having ever tested 

for HIV relative to traditionally circumcised men. Medically circumcised men had higher 

comprehensive HIV knowledge (54%) than traditionally circumcised men (14%) and 

uncircumcised (38%) men. Among medically circumcised men, a higher percentage were 

circumcised at age 20 or older (44%), while among traditionally circumcised men the majority 

(68%) were circumcised between the ages of 15 and 19. 

Risky sexual behaviors were associated with HIV status-age at first sex, number of lifetime sexual 

partners, ever tested for AIDS, experience of STIs, and drunkenness. There was no direct 

association between circumcision status and HIV status, but after controlling for risky behaviors 

in a sample restricted to only circumcised men, traditionally circumcised men had significantly 

higher odds of being HIV-positive compared with medically circumcised men. The odds increased 

when controlling for background characteristics, but no increase was observed after controlling 

for both background characteristics and risky behaviors. Medically circumcised men had 

significantly lower odds of being HIV positive relative to uncircumcised men only after controlling 

for background characteristics for all men in the sample. Thus, in Lesotho traditional circumcision 

does not seem to offer the same protection from HIV. This is contrary to reports on traditional 

circumcision in Papua New Guinea (MacLaren et al., 2015). However, medical circumcision in 

Lesotho provides protection, as shown by randomized control trials (Auvert et al. 2005; Bailey et 

al. 2007; Gray et al. 2007; Siegfried et al. 2005). 

19 

6. Conclusion 

The study set out to understand the relationship between male circumcision and HIV prevalence 

in Lesotho. The apparent nonexistence of the protection offered by medical circumcision found in 

previous studies is due to treating traditional circumcision and medical circumcision the same 

versus treating them separately. In our study, medical circumcision provides protection against 

HIV, but traditional circumcision does not. When modeling among circumcised men only, medical 

circumcision protects against HIV relative to traditional circumcision. While medical circumcision 

provides expected protection when comparing this group with either traditionally circumcised or 

uncircumcised men, risky behaviors-particularly condom use at last sex and STI experience in the 

past 12 months—are only important when comparing medical and traditional circumcision. This 

finding is supported by Skolnik and colleagues (2014), who found that 73% of voluntary medical 

circumcision clients in Lesotho highlighted protection against HIV as their main reason for 

circumcision, suggesting that medically circumcised men are conscious of HIV infection, while 

the motivation for traditional circumcision is manhood (Ashton 1952). It is noteworthy, though, 

that since this is a cross-sectional study we cannot know if the medical circumcision is what 

protected the men from HIV or whether they went for medical circumcision because they were 

more aware of protection offered by medical circumcision against HIV. 

Coburn, Okano, and Blower (2013) had also attempted to separate traditional circumcision and 

medical circumcision in testing for the efficacy of circumcision in HIV prevention in Lesotho. 

They used data from the 2009 DHS and found partially significant evidence (p=0.053) of the effect 

of circumcision on HIV after controlling for background characteristics and risky behaviors. These 

findings differ from those of the present study. These differences may be due to differences in the 

group of respondents included in the analysis. While their study analyzed all men in the sample, 

the current study included only men who were sexually active in the past 12 months. Moreover, 

our study went further to look at the efficacy differences among the circumcised men. This 

approach was particularly insightful in providing strong evidence of the efficacy of medical 

circumcision. 

The importance attached to traditional circumcision could lead to false self-reporting of 

circumcision status, thus confounding the association between circumcision and HIV. For 

instance, Thomas and colleagues (2011) in a study in Lesotho found that physical examinations 

revealed that 23% of military male applicants who reported themselves as circumcised showed no 

evidence of circumcision. This suggests that self-reporting of circumcision could confound the 

results of the present study. Moreover, only 28% of men who reported traditional circumcision 

could be classified as fully circumcised (Thomas et al. 2011), suggesting that not all traditional 

circumcision should be ruled out in protecting against HIV. Along similar lines, Maclaren and 

collegues (2013) found that, partial or not, circumcision protected against HIV infection in Papua 

New Guinea. 
20 

What remains in question is (1) why sexual risk behavior makes no difference once background 

characteristics are controlled for and (2) why background characteristics make a difference even 

when sexual risk behaviors are controlled for. While the present analysis does not provide a clue, 

it is probable that, because medical circumcision is currently low (6%), men in this group are a 

special self-selecting group with lower HIV risk for some reason that is better reflected by 

background characteristics than by risky behaviors. Also, if voluntary medical circumcision is 

publicized as a means to reduce risk of HIV acquisition for men, perhaps men who already know 

they are HIV-positive would be highly unlikely to get the procedure. In fact “compulsory” HIV 

testing has been highlighted as one of the concerns hindering voluntary medical circumcision 

uptake in Lesotho (Skolnik et al. 2014). 

It is equally plausible that our study did not properly capture risk behavior (and thus did not truly 

control for increased exposure to HIV), either due to reporting issues, or not asking the right 

questions. For example, we lacked comprehensive data on coital frequency with various partners 

and comprehensive measures for condom use. Also, while we had reasonable measures of the 

number of sexual partners, we did not have a good way of measuring the likelihood that someone’s 

partners were HIV-positive. In a population with high prevalence of HIV, like Lesotho, this could 

make a big difference. For example, living in a high-prevalence area and selecting sexual partners 

from a high-prevalence area would increase the risk of HIV acquisition per partner. 

Recommendations 

Based on the results of the study, the following recommendations are put forward: 

• There is need to engage with gatekeepers of traditional circumcision to ensure that their 

practice of circumcision is as effective as medical circumcision. 

• The current voluntary medical male circumcision targeting uncircumcised men should be 

expanded to include traditionally circumcised men. To avoid resistance among traditionally 

circumcised men, health professionals who have undergone traditional circumcision should be 

used in performing the procedure for correcting circumcision among traditionally circumcised 

men. 

• Health professionals who have undergone traditional circumcision should be used to transfer 

medical circumcision skills to those who perform traditional circumcision. 

• It is equally important that Lesotho emphasize risky behaviors if the war against the AIDS 

epidemic is to be won. HIV prevalence among medically circumcised men in Lesotho is very 

high by any standards, despite the protective effect of circumcision. Without behavior change, 

the effect of circumcision will not bring HIV prevalence to levels observed elsewhere among 

medically circumcised men. 
21 

• Further research is needed to understand why HIV prevalence for medically and traditionally 

circumcised men in Lesotho is not similar to what prevails in other settings. 

Limitations of the Study 

The study is based on cross-sectional survey data, and thus causality cannot be inferred. Although 

DHS data are nationally representative, subdividing circumcised men into medical and traditional 

groups might have introduced problems of precision, because the proportion of medically 

circumcised men is quite low. 

23 

References 

Ashton, H. 1952. The Basuto. Oxford University Press: London. 

Auvert, B., D. Taljaard, E. Lagarde, J. Sobngwi-Tambekou, R. Sitta, and A. Puren. 2005. 

“Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV 

Infection Risk: the ANRS 1265 Trial.” PLoS Medicine 2(11):1112-22. 

Bailey, R., S. Moses, C. B. Parker, K. Agot, I. Maclean, J. N. Krieger, C. F. Williams, R.T. 

Campbell, and J.O. Ndinya-Achola. 2007. “Male Circumcision for HIV Prevention in 

Young Men in Kisumu, Kenya: A Randomised Controlled Trial.” The Lancet 369:643-

656. 

Cameron, D., L. D’Costa, G. Maitha, M. Cheang, P. Piot, J. Simonsen, A. Ronald, et al. 1989. 

“Female To Male Transmission of Human Immunodeficiency Virus Type 1: Risk Factors 

for Sero Conversion in Men.” The Lancet 334(8660):403-407. 

Chikutsa, A., A. Ncube, and S. Mutsau. 2014. “Male Circumcision and Risky Sexual Behavior in 

Zimbabwe: Evidence from the 2010-11 Zimbabwe Demographic and Health 

Survey.”African Population Studies 28(2):1057-1071. 

Coburn, B., J. Okano, and S. Blower. 2013. “Current Drivers and Geographic Patterns of HIV in 

Lesotho: Implications for Treatment and Prevention in Sub-Saharan Africa.” BMC 

Medicine 11: 224.

Connolly, C., L. Simbayi, R. Shanmugam, and A. Nqeketo. 2008. “Male Circumcision and Its 

Relationship to HIV Infection in South Africa: Results of a National Survey in 2002.” 

South African Medical Journal = Suid-Afrikaanse Tydskrif Vir Geneeskunde 98(10):789-

94. 

Corno, L., and D. de Walque. 2007. “The Determinants of HIV Infection and Related Sexual 

Behaviors : Evidence from Lesotho.” Policy Research Working Papers, World Bank 

Group. 

Eaton, L., and S. Kalichman. 2007. “Risk Compensation in HIV Prevention: Implications for 

Vaccines, Microbicides, and Other Biomedical HIV Prevention Technologies.” Current 

HIV/AIDS Reports 4(4):165-172. 

Garenne, M. 2008. “Long-Term Population Effect of Male Circumcision in Generalised HIV 

Epidemics in Sub-Saharan Africa.” African Journal of AIDS Research 7(1):1-8. 

Gayle, M., L. Bollinger, T. Pandit-Rajani, R. Nkambula, and J. Stover. 2007. “Costing Male 

Circumcision in Swaziland and Implications for the Cost Effectiveness of Circumcision as 

an HIV Intervention.” Swaziland Mbabane. USAID/Health Policy Initiative, Task Order 

1, USA. 

Gebremedhin, S. 2010. “Assessment of the Protective Effect of Male Circumcision from HIV 

Infection and Sexually Transmitted Diseases: Evidence from 18 Demographic and Health 

Surveys in Sub-Saharan Africa.” East African Journal of Public Health 7 (4):295-299. 
24 

Gray, R., G. Kigozi, D. Serwadda, F. Makumbi, S. Watya, F. Nalugoda, N. Kiwanuka, et al. 2007. 

“Male Circumcision for HIV Prevention in Men in Rakai, Uganda: A Randomised Trial.” 

The Lancet 369 (9562): 657-666. 

Green, L., R. McAllister, K. Peterson, and J. Travis. 2008. “Male Circumcision Is Not the HIV 

‘Vaccine’ We Have Been Waiting For!” Future HIV Therapy 2(3):193-199. 

Hussain, L., and T. Lehner. 1995. “Comparative Investigation of Langerhans’ Cells and Potential 

Receptors for HIV in Oral, Genitourinary and Rectal Epithelia.” Immunology 85(3):475-

484. 

Kahn, J., E. Marseille, and B. Auvert. 2006. “Cost-Effectiveness of Male Circumcision for HIV 

Prevention in a South African Setting.” PLoS Med 3(12):e517. 

Kalichman, S., and L. Simbayi. 2003. “HIV Testing Attitudes, AIDS Stigma, and Voluntary HIV 

Counselling and Testing in a Black Township in Cape Town, South Africa.” Sexually 

Transmitted Infections 79(6):442-447. 

Kalichman, S., L. Simbayi, M. Kaufman, D. Cain, and S. Jooste. 2007. “Alcohol Use and Sexual 

Risks for HIV/AIDS in Sub-Saharan Africa: Systematic Review of Empirical Findings.” 

Prevention Science 8(2):141-151. 

Kebaabetswe, P., S. Lockman, S. Mogwe, R. Mandevu, I. Thior, M. Essex, and R. Shapiro. 2003. 

“Male Circumcision: An Acceptable Strategy for HIV Prevention in Botswana.” Sexually 

Transmitted Infections 79(3):214-219. 

Kibira, S., E. Nansubuga, N. Tumwesigye, L. Atuyambe, and F. Makumbi. 2014. “Differences in 

Risky Sexual Behaviors and HIV Prevalence of Circumcised and Uncircumcised Men in 

Uganda: Evidence from a 2011 Cross-Sectional National Survey.” Reproductive Health

11:25. 

Lesotho National AIDS Commission. 2009. HIV Prevention Response and Analysis of Modes of 

HIV Transmission Studies. Government Printers, Maseru 100: Lesotho. 

Lurie, M., B. Williams, K. Zuma, D. Mkaya-Mwamburi, G. Garnett, A. Sturm, M. Sweat, J. 

Gittelsohn, and S. Abdool Karim. 2003. “The Impact of Migration on HIV-1 Transmission 

in South Africa A Study of Migrant and Nonmigrant Men and Their Partners.” Sexually 

Transmitted Diseases 30(2):149-156.

MacLaren, D., W. McBride, G. Kelly, R. Muller, R. Tommbe, J. Kaldor, and A. Vallely. 2015. 

“HIV Prevalence Is Strongly Associated with Geographical Variations in Male 

Circumcision and Foreskin Cutting in Papua New Guinea: An Ecological Study.” Sexually 

Transmitted Infections 91(7):502-505. 

MacLaren, D., R. Tommbe, T. Mafile, C. Manineng, F. Fregonese, M. Redman-Maclaren, M. 

Wood, et al. 2013. “Foreskin Cutting Beliefs and Practices and the Acceptability of Male 

Circumcision for HIV Prevention in Papua New Guinea.” BMC Public Health 13:818.

Marum, L., J. Muttunga, F. Munene, and B. Cheluget. 2004. “HIV Prevalence and Associated 

Factors.” Kenya Demographic and Health Survey, 217-232. Maryland: Calverton, Macro 

International Maryland. 
25 

Ministry of Health and Social Welfare (MOHSW) [Lesotho] and ICF Macro. 2009. Lesotho 

Demographic and Health Survey of 2009. Maryland: Calverton, Macro International 

Maryland. 

Ministry of Health and Social Welfare Government of Lesotho. 2008. Male Circumcision in 

Lesotho: Situation Analysis Report. Human Resource Research Council (HSRC), Cape 

Town, South Africa. 

Ministry of Health Lesotho. 2015. Global AIDS Response Progress Report 2015 Lesotho Country 

Report, Follow-Up to the 2011 Political Declaration on HIV/AIDS: Intensifying Efforts to 

Eliminate HIV/AIDS.” Government of Lesotho, Maseru 100, Lesotho. 

Mishra, V., and S. Bignami-Van Assche. 2009. Concurrent Sexual Partnerships and HIV 

Infection : Evidence from National Population-Based Surveys. DHS Working Paper No.62. 

Calvaton. Maryland: Macro International Inc. 

Moses, S., J. Bradley, N. Nagelkerke, A. Ronald, J. Ndinya-Achola, and F. Plummer. 1990. 

“Geographical Patterns of Male Circumcision Practices in Africa: Association with HIV 

Seroprevalence.” International Journal of Epidemiology 19:693-697. 

Quigley M., R. Hayes, and H. Weiss. 2000. “Male Circumcision and Risk of HIV Infection in SubSaharan Africa: A Systematic Review and Meta-Analysis.” AIDS 14:2361-2670. 

Siegfried, N., M. Muller, J. Deeks, J. Volmink, M. Egger, N. Low, S. Walker, and P. Williamson. 

2005. “HIV and Male Circumcision—a Systematic Review with Assessment of the Quality 

of Studies.” The Lancet Infectious Diseases 5(3):165-173. 

Siegfried, N., M. Muller, J. Deeks, and J. Volmink. 2002. “Male Circumcision for Prevention of 

Heterosexual Acquisition of HIV in Men.” Cochrane Database of Systematic Reviews 5: 

1-27. 

Skolnik, L., S. Tsui, T. Adamu Ashengo, V. Kikaya, and M. Lukobo-Durrell. 2014. “A CrossSectional Study Describing Motivations and Barriers to Voluntary Medical Male 

Circumcision in Lesotho.” BMC Public Health 14 (1): 1119. 

Talbott, J. 2007. “Size Matters : The Number of Prostitutes and the Global HIV/AIDS Pandemic.” 

PLoS ONE 2 (6). 

Thomas, A, B. Tran, M. Cranston, M. Brown, R. Kumar, and M. Tlelai. 2011. “Voluntary Medical 

Male Circumcision : A Cross-Sectional Study Comparing Circumcision Self-Report and 

Physical Examination Findings in Lesotho.” PLoS ONE 6(11):1-6. 

Wang, W., and S. Alva. 2012. HIV-Related Knowledge and Behavior in Eight High HIV 

Prevalence Countries in Sub-Saharan Africa. DHS Analytical Studies, No.29. Calverton, 

Maryland, USA: ICF International. 

Ward, H., and M. Rönn. 2010. The Contribution of STIs to the Sexual Transmission of HIV.” 

Current Opinion in HIV and AIDS 5 (4): 305-310. 

Warren, K. 2010. HIV and Male Circumcision in Swaziland, Botswana and Lesotho: An 

Econometric Analysis. CSSR Working Paper no 273. Centre for Social Science Research, 

University of Cape Town. 
26 

Westercamp, M., K. Agot, J. Ndinya-Achola, and R. Bailey. 2012. “Circumcision Preference 

among Women and Uncircumcised Men Prior to Scale-up of Male Circumcision for HIV 

Prevention in Kisumu, Kenya.” AIDS Care 24(2):157-166. 

WHO/UNAIDS. 2007. “New Data on Male Circumcision and HIV Prevention: Policy and 

Programme Implications.” Geneva: World Health Organization. 

Williams, B., J. Lloyd-Smith, E. Gouws, C. Hankins, W. Getz, J. Hargrove, I. De Zoysa, C. Dye, 

and B. Auvert. 2006. “The Potential Impact of Male Circumcision on HIV in Sub-Saharan 

Africa.” PLoS Medicine 3 (7): e262. 
27 

Appendix I: 

Modeling Circumcision Status and HIV Status 
28 

Model 1. Circumcision status and HIV: No controls 

Variables Labels Odds (95% CI) 

Circumcision status 

medical circumcision 0.7 (0.4 - 1.2) 

traditional circumcision 1.1 (0.8 - 1.4) 

not circumcised 1.0 

Constant 0.3*** 

Observations 2,283 

*** p<0.001, ** p<0.01, * p<0.05 

Model 2. Circumcision status and HIV: Controlling for risky sexual behaviors 

Variables Labels Odds (95% CI) 

Circumcision status 

medical circumcision 0.5 (0.3 - 1.0) 

traditional circumcision 1.1 (0.9 - 1.5) 

not circumcised 1.0 

Age at first sex 

< 15 1.0 

15-19 2.2** (1.3 - 3.5) 

20+ 3.8*** (2.3 - 6.2) 

don’t know 5.0*** (2.5 - 10.1) 

Was condom used at last sex? yes 1.2 (1.0 - 1.6) 

no 1.0 

Relationship with last sex partner usual partner 1.0 

casual acquaintance 1.4 (0.8 - 2.3) 

Had STIs in the past 12 months? no 1.0 

yes 2.9*** (1.8 - 4.5) 

Number of lifetime sexual partners 

1 1.0 

2-3 1.3 (0.7 - 2.2) 

4+ 2.0** (1.2 - 3.2) 

don’t know 2.7** (1.4 - 5.2) 

Comprehensive HIV knowledge? no 1.0 

yes 1.0 (0.7 - 1.3) 

Ever tested for HIV/AIDS? 

no 1.0 

yes 1.6** (1.2 - 2.1) 

does not know about AIDS 1.0 (0.5 - 1.7) 

Ever got drunk 

no 1.0 

yes 1.3 (0.8 - 1.9) 

never drank 1.4* (1.1 - 1.8) 

Away from home? 

away for less than 1 month 0.9 (0.7 - 1.2) 

away for more than a month 1.6* (1.0 - 2.4) 

not away 1.0 

Constant 0.0*** 

Observations 2,283 

*** p<0.001, ** p<0.01, * p<0.05 
29 

Model 3. Circumcision status and HIV: Controlling for background characteristics 

Variables Labels Odds (95% CI) 

Circumcision status 

medical circumcision 0.4** (0.2 - 0.8) 

traditional circumcision 1.2 (0.9 - 1.6) 

not circumcised 1.0 

15-24 1.0 

Age 

25-34 6.1*** (3.8 - 9.9) 

35-44 8.8*** (5.1 - 15.1) 

45-59 4.4*** (2.5 - 7.9) 

Wealth index 

poor 1.0 

middle 1.5* (1.0 - 2.1) 

rich 1.4 (0.9 - 2.0) 

Education 

no education 1.0 

primary 1.0 (0.7 - 1.4) 

secondary+ 1.2 (0.7 - 1.8) 

Marital status never married 1.0 

ever married 1.8** (1.2 - 2.7) 

Rural urban residence urban 1.0 

rural 0.9 (0.6 - 1.4) 

Ecological zone lowlands 1.0 

highlands 1.0 (0.7 - 1.6) 

District 

Botha-Bothe 1.0 

Leribe 2.3* (1.2 - 4.4) 

Berea 2.0* (1.1 - 3.8) 

Maseru 2.3* (1.2 - 4.3) 

Mafeteng 2.4* (1.2 - 4.7) 

Mohale’s Hoek 2.2* (1.1 - 4.4) 

Quthing 1.9 (0.9 - 3.9) 

Qacha’s-Nek 1.8 (0.9 - 3.8) 

Mokhotlong 1.6 (0.8 - 3.3) 

Thaba-Tseka 1.9 (1.0 - 3.9) 

Constant 0.0*** 

Observations 2,283 

*** p<0.001, ** p<0.01, * p<0.05 
30 

Model 4. Circumcision status and HIV: Controlling for risky sexual behaviors and background 

characteristics 

Variables Labels Odds (95% CI) 

Circumcision status 

medical circumcision 0.4** (0.2 - 0.8)

traditional circumcision 1.2 (0.8 - 1.6)

not circumcised 1.0 

Age 

15-24 1.0 

25-34 5.3*** (3.2 - 8.7)

35-44 7.6*** (4.3 - 13.4)

45-59 3.8*** (2.0 - 7.1)

Wealth index 

poor 1.0 

middle 1.4 (1.0 - 2.0)

rich 1.2 (0.8 - 1.8)

Education 

no education 1.0 

primary 1.0 (0.7 - 1.4)

secondary+ 1.1 (0.7 - 1.7)

Marital status never married 1.0 

ever married 2.0*** (1.3 - 3.0)

Rural urban residence urban 1.0 

rural 1.0 (0.7 - 1.5)

Ecological zone lowlands 1.0 

highlands 1.1 (0.7 - 1.7)

District 

Botha-Bothe 

Leribe 2.4** (1.3 - 4.6)

Berea 1.9 (1.0 - 3.6)

Maseru 2.0* (1.1 - 3.9)

Mafeteng 2.4* (1.2 - 4.8)

Mohale’s Hoek 2.1* (1.0 - 4.2)

Quthing 1.7 (0.8 - 3.5)

Qacha’s-Nek 1.7 (0.8 - 3.6)

Mokhotlong 1.5 (0.7 - 3.1)

Thaba-Tseka 1.9 (0.9 - 4.0)

Age at first sex 

< 15 1.0 

15-19 1.4 (0.8 - 2.3)

20+ 1.4 (0.8 - 2.5)

don’t know 2.1 (1.0 - 4.4)

Was condom used at the last sex? no 1.0 

yes 1.7*** (1.3 - 2.3)

Relationship with last sex partner usual partner 1.0 

casual acquaintance 1.6 (0.9 - 3.0)

Had STIs in the past 12 months? no 1.0 

yes 2.5*** (1.6 - 4.1)

Number of lifetime sexual partners 

1 1.0 

2-3 1.0 (0.5 - 1.8)

4+ 1.3 (0.7 - 2.3)

don’t know 1.5 (0.7 - 3.1)

Comprehensive HIV knowledge? no 1.0 

yes 0.9 (0.7 - 1.3)

Ever tested for HIV/AIDS? 

no 1.0 

yes 1.3 (0.9 - 1.7)

does not know about AIDS 1.2 (0.7 - 2.2)

Ever got drunk? 

no 1.0 

yes 1.2 (0.8 - 1.9)

never drank 1.0 (0.6 - 1.5)

Away from home? 

away for less than 1 month 1.0 (0.7 - 1.3)

away for more than a month 1.4 (0.9 - 2.1)

not away 1.0 

Constant 0.0*** 

Observations 2,283 

*** p<0.001, ** p<0.01, * p<0.05 
31 

Appendix II: 

Modeling Circumcision Status Based on Where Circumcision 

Was Performed (Circumcised Men Only) 
32 

Model 1. Circumcision status and HIV: No controls 

Variables Labels Odds (95% CI) 

Circumcision status medical circumcision 1.0 

traditional circumcision 1.6 (0.9 - 2.8) 

Constant 0.2*** 

Observations 1,432 

*** p<0.001, ** p<0.01, * p<0.05 

Model 2. Circumcision status and HIV: Controlling for risky sexual behaviors 

Variables Labels Odds (95% CI) 

Circumcision status medical circumcision 1.0 

traditional circumcision 2.1* (1.1 - 3.9) 

Age at first sex 

<15 1.0 

15-19 1.7 (1.0 - 3.0) 

20+ 2.4** (1.3 - 4.4) 

don’t know 4.2*** (1.9 - 9.3) 

Was condom used during the last 

sex? 

no 1.0 

yes 1.2 (0.9 - 1.7) 

Relationship with last sex partner usual partner 1.0 

casual acquaintance 1.1 (0.6 - 2.2) 

Had STIs in the past 12 months? no 1.0 

yes 2.4** (1.3 - 4.6) 

Number of lifetime sexual partners 

1 1.0 

2-3 1.7 (0.8 - 3.7) 

4+ 2.8** (1.3 - 5.7) 

don’t know 4.1** (1.6 - 11.0) 

Comprehensive HIV knowledge? no 1.0 

yes 0.9 (0.6 - 1.3) 

Ever tested for HIV/AIDS? 

no 1.0 

yes 1.8*** (1.3 - 2.4) 

does not know about AIDS 1.1 (0.5 - 2.2) 

Ever got drunk? 

no 1.0 

yes 0.8 (0.5 - 1.3) 

never drank 0.6 (0.4 - 1.0) 

Away from home? 

away for less than 1 month 1.0 (0.7 - 1.3) 

away for more than a month 1.6 (1.0 - 2.6) 

not away 1.0 

Constant 0.0*** 

Observations 1,432 

*** p<0.001, ** p<0.01, * p<0.05 
33 

Model 3. Circumcision status and HIV: Controlling for background characteristics 

Variables Labels Odds (95% CI) 

Type of circumcision medical circumcision 1.0 

traditional circumcision 2.9** (1.4 - 6.0) 

Age 

15-24 1.0 

25-34 6.5*** (3.6 - 11.8) 

35-44 9.7*** (5.2 - 18.0) 

45-59 4.6*** (2.3 - 8.9) 

Wealth index 

poor 1.0 

middle 1.3 (0.9 - 2.0) 

rich 1.2 (0.7 - 2.0) 

Education 

no education 1.0 

primary 0.9 (0.6 - 1.4) 

secondary+ 1.2 (0.7 - 2.1) 

Marital status never married 1.0 

ever married 1.9* (1.1 - 3.1) 

Rural urban residence urban 1.0 

rural 0.9 (0.5 - 1.5) 

Ecological zone lowlands 

highlands 1.2 (0.7 - 2.0) 

District 

Botha-Bothe 1.0 

Leribe 2.3* (1.1 - 4.9) 

Berea 2.0 (1.0 - 4.0) 

Maseru 1.9 (0.8 - 4.2) 

Mafeteng 2.2* (1.1 - 4.8) 

Mohale’s Hoek 1.9 (0.9 - 4.0) 

Quthing 1.4 (0.6 - 3.1) 

Qacha’s-Nek 1.3 (0.6 - 2.9) 

Mokhotlong 1.5 (0.7 - 3.1) 

Thaba-Tseka 1.7 (0.8 - 3.6) 

Constant 0.0*** 

Observations 1,432 

*** p<0.001, ** p<0.01, * p<0.05 
34 

Model 4. Circumcision status and HIV: Controlling for risky sexual behaviors and background 

characteristics 

Variables Labels Odds (95% CI) 

Circumcision status medical circumcision 1.0 

traditional circumcision 2.9** (1.4 - 6.1)

Age 

15-24 1.0 

25-34 6.0*** (3.2 - 11.1)

35-44 8.9*** (4.4 - 18.0)

45-59 4.5*** (2.1 - 9.3)

Wealth index 

poor 1.0 

middle 1.2 (0.8 - 1.8)

rich 1.0 (0.6 - 1.8)

Education 

no education 1.0 

primary 0.9 (0.6 - 1.3)

secondary+ 1.1 (0.6 - 1.9)

Marital status never married 1.0 

ever married 2.1** (1.3 - 3.4)

Rural urban residence urban 1.0 

rural 1.0 (0.6 - 1.8)

Ecological zone lowlands 1.0 

highlands 1.2 (0.7 - 2.1)

District 

Botha-Bothe 1.0 

Leribe 2.5* (1.2 - 5.4)

Berea 1.9 (0.9 - 4.1)

Maseru 1.7 (0.8 - 4.0)

Mafeteng 2.3* (1.0 - 4.9)

Mohale’s Hoek 1.7 (0.8 - 3.7)

Quthing 1.3 (0.6 - 2.8)

Qacha’s-Nek 1.2 (0.5 - 2.8)

Mokhotlong 1.3 (0.6 - 3.0)

Thaba-Tseka 1.6 (0.7 - 3.7)

Age at first sex 

<15 1.0 

15-19 1.0 (0.5 - 1.9)

20+ 0.9 (0.4 - 1.8)

don’t know 1.7 (0.7 - 4.3)

Was condom used during last sex? no 1.0 

yes 1.6** (1.1 - 2.2)

Relationship with last sex partner usual partner 1.0 

casual acquaintance 1.2 (0.6 - 2.7)

Had STIs in the past 12 months? no 1.0 

yes 2.8** (1.4 - 5.3)

Number of lifetime sexual partners 

1 1.0 

2-3 1.4 (0.6 - 3.2)

4+ 2.0 (1.0 - 4.2)

don’t know 2.8 (1.0 - 7.7)

Comprehensive HIV knowledge? no 1.0 

yes 0.8 (0.5 - 1.3)

Ever tested for HIV/AIDS? 

no 1.0 

yes 1.4 (1.0 - 1.9)

does not know about AIDS 1.4 (0.6 - 2.9)

Ever got drunk? 

no 1.0 

yes 0.9 (0.6 - 1.5) never drank 0.8 (0.5 - 1.4)

Away from home? 

away for less than 1 month 1.0 (0.7 - 1.4)

away for more than a month 1.6 (1.0 - 2.7)

not away 1.0 

Constant 0.0*** 

Observations 1,432 

*** p<0.001, ** p<0.01, * p<0.05