Examining the association between male circumcision and the prevalence of self-reported sexually transmitted infections among adolescent boys and men (15-49 old) in Malawi, Rwanda, Zambia and Zimbabwe

In 2007, the World Health Organization recommended voluntary medical male circumcision (VMMC) as an effective HIV prevention strategy in countries with a high HIV burden and low prevalence of male circumcision. While there is some evidence that VMMC lowers the risk of other sexually transmitted infections (STIs), its population-level impact beyond HIV remains uncertain. This study aimed to examine population and individual level associations between male circumcision (scale-up) and self-reported STIs (defined as a self-reported STI diagnosis or symptoms of a genital soar, ulcer, or discharge, in the past 12 months) among sexually active adolescent boys and men aged 15-49. We analysed nationally representative data from Demographic and Health Surveys conducted before (2004-2006) and after (2015-2020) VMMC scale-up in Malawi, Rwanda, Zambia, and Zimbabwe using a multilevel logistic regression approach adjusted for potential confounders. Our analysis included 41,094 respondents; circumcision coverage increased over time in all countries except Zimbabwe (11.9% before vs. 12.8% after VMMC scale-up; p=0.821). STI prevalence also increased, from 5.3% (95% CI 4.8-5.8) before to 8.2% (95% CI 7.7-8.7; p<0.001) after VMMC scale-up, with variations in the relative increase across countries. At population level, we found a higher odds of self-reported STIs after compared to before VMMC scale-up (aOR 1.52; 95% CI 1.33-1.74; p<0.001). We found no association between circumcision status and self-reported STIs at individual-level (aOR 1.03; 95% CI 0.92-1.17; p=0.55). These findings suggest that while VMMC protects against HIV and some STIs, its impact on reducing the STI burden at population level in Eastern and Southern Africa is limited. As STI rates remain high, especially among young men, our results underscore the need for comprehensive, male-oriented sexual health strategies. Reducing service delivery barriers, combined with integrating VMMC into person-centred sexual health services for men, may help address persistent gaps in STI prevention.