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The Association of Female Circumcision With HIV Status and Sexual Behavior in Mali: A Multilevel Analysis

Smolak, Alex PhD

JAIDS Journal of Acquired Immune Deficiency Syndromes: April 15th, 2014 - Volume 65 - Issue 5 - p 597–602
doi: 10.1097/QAI.0000000000000099
Epidemiology and Prevention

Objective: In the regions of Africa where female circumcision (FC) is practiced, it is often regarded as a protective against HIV infection because it is believed to help women resist “illicit” sexual acts. This study examines the association between FC, HIV status, and sexual risk behavior in Mali, while taking into account multilevel factors. The following hypothesis was tested: FC is associated with HIV-positive status but not with decreased sexual behavior.

Design: The sample consists of 13,015 Malian women of reproductive age (15–49 years old). The sample is a nationally representative survey of randomly selected respondents using a stratified multistage sampling strategy. Measures included biospecimens for HIV antibody testing and survey results reporting on number of partners, sexual debut, premarital sex, and sociodemographics.

Methods: Multilevel modeling was used to assess the significance of difference in HIV status and sexual behavior with FC. Multilevel modeling was also used to adjust for age, education, ethnicity, wealth, religion, region, household, and community membership. Multiple imputation with 10 imputations corrected for 10% missing data.

Results: Participants with FC were at 2.100 (P < 0.001; 95% confidence interval: 1.844 to 2.389) higher odds of being HIV positive. Women with FC did not significantly differ from women without FC in number of sexual partners (P = 0.634), age of sexual debut (P = 0.888), or odds of having premarital sex (P = 0.575).

Conclusions: FC is associated with HIV-positive status but not with a decrease in sexual risk behavior. These findings have important implication for FC and HIV prevention.

School of Social Work, Columbia University, New York, NY.

Correspondence to: Alex Smolak, PhD, Global Health Research Center of Central Asia, Columbia University School of Social Work, 1255 Amsterdam Avenue, New York, NY 10027 (e-mail:

Supported partially by a Columbia University Center for the Study of Democracy, Toleration, and Religion fellowship.

Preliminary data were presented at the 2011 Society for Social Work and Research Annual Conference, January 14, 2012, Washington, DC.

The author was supported partially by the Religion and Human Rights Pragmatism project at the Center for the Study of Democracy, Toleration, and Religion at Columbia University.

Received December 20, 2013

Accepted December 20, 2013

© 2014 by Lippincott Williams & Wilkins