Despite improvements in prevention, screening, and treatment, the global burden of sexually transmitted infections (STIs) remains high (1). Worldwide, more than a million people acquire sexually transmitted infections every day, 499 million new cases of treatable STIs (gonorrhea, chlamydia, syphilis, and trichomoniasis) arise each year, and 536 million people are estimated to be living with none curable herpes simplex virus type 2 (HSV-2) (2). In South Africa, the prevalence of STIs in men was 5% for chlamydia and 17% for herpes simplex virus type 2 between October 2016 and January 2017 (3). A home-based prevalence survey conducted in rural KwaZulu Natal, South Africa, among young man and women aged between 15–24 years old found a weighted prevalence of treatable STIs; 1.8% for gonorrhea, 0% and 0.4% for active syphilis, 0.6% and 4.6% for trichomoniasis (3). There is a need to both promote and evaluate existing interventions to improve the effectiveness of prevention of STIs.
STIs have varying consequences on sexual and reproductive health. Syphilis in pregnancy leads to an estimated 305 000 adult and new-born deaths and leaves 215 000 babies at high risk of losing their life from prematurity, low birth weight or congenital disease each year in the world (2). Gonorrhea and chlamydia are risk factors for infertility, and untreated genital infection may be the cause of up to 85% of sterility of women seeking infertility treatment (2). As a result of an understanding of the persistent problem f STIs, as well as the effects on health, the World Health Organization (WHO) Global Health Sector strategy on STI 2016–2021 (4) has outlined the goals and targets for global STIs prevention and control. Among these targets is to collect information on STI prevalence and incidence across representative populations (4). In South Africa, the government is promoting voluntary male circumcision and condom use (6) and has sentinel surveillance in place across the nine provinces (5). However, the burden of STIs remains high and this may require combining the biological and behavioral interventions.
Male circumcision is one of the oldest and most common surgical procedures worldwide and is accepted for many reasons including religious, cultural, social and medical (7). Circumcision decreases the entry of pathogens through abrasions in the thinly keratinized inner mucosal surface of the foreskin and eliminates the moist environment under the foreskin, which may favor pathogen persistence and reproduction (4). From an efficacy point of view, there is conclusive evidence that male circumcision reduces the risk of HIV and STI infection risk is conclusive. Three randomized controlled trials (RCTs), a meta-analysis of the 3 RCTs, and several cohort studies have shown consistent benefits and the WHO now recommends voluntary medical male circumcision (VMMC) as one of the key HIV and STI prevention strategies (9). The first RCT was conducted in Johannesburg, South Africa, from October 25, 2005, including 3274 uncircumcised men of 18–24 years old, reported that male circumcision reduced risk of HIV infection by60% (8). The same authors found a 58% reduction in risk of incident Trichomonas vaginalis in women with circumcised partners, compared to those with uncircumcised partners, in a prospective study conducted in Kenya (10). Another RCT found that male circumcision decreased Trichomonas vaginalis infection among men (OR 0.49, p = 0.030, AOR 0.41, p = 0.030 (11) among men aged 18–24 years, in Orange farm in South Africa. A systematic review of 57 observational studies also found that females were at a decreased risk of STIs when their male partners were medically circumcised (12). Another systematic review and meta-analysis of global data from April 2019 of 62 observational studies including 119248 men who have sex with men (MSM) found that circumcision was associated with 23% reduced odds of HIV infection among MSM (OR 0.77, 955 CI 0.67–0.89) (13). In controlled settings and the general population, male circumcision is effective in reducing the risk of STIs in both men and women.
Although data from clinical trials and several observational studies show the efficacy of VMMC in reducing the risk of STDs, several questions remain unanswered. This may have an unintended effect in that circumcised men expose themselves more, in the belief that they will not get STIs (19). Behavioral risk compensation is not limited to men only as women may change their behavior in the belief that VMMC protects them. In one study in South Africa, women who were aware of the benefits believed that VMMC reduced the need to worry about HIV and were less likely to use condoms with circumcised men (20). STIs tend to be diagnosed late in women and commercial sex workers may act as reservoirs of infection and increase the risk of incident cases and re-infection (21). Further, resumption of sexual activity before 6 weeks post circumcision wound healing period increases the risk of STIs (19). How these factors affect the risk of STIs in a setting where high-risk sexual activity is prevalent such as migrant mining communities found in certain parts of South Africa is not known (22). Further, many traditional communities practice circumcision as a rite of passage to manhood (23). Available data suggest that traditional circumcision may increase the risk of STI through a lack of health education, incomplete skin removal and higher risk sexual behaviors such as multiple partners and lower condom use (23). More research is needed to investigate how all these factors affect the efficacy of interventions for the reduction of STI risk, such as male circumcision.
This study compares the prevalence of STIs between men who are circumcised and those who are not, in an observational setting, where high-risk sexual behaviors are prevalent. Further, we compared the prevalence of STIs between males who were traditionally circumcised and those medically circumcised. Lastly, we assessed the effect of circumcision on the risk of STIs, after adjusting for established risk factors for STIs.