Circumcision Rollout in Four African Countries Fails to Curb Self-Reported STIs

Voluntary medical male circumcision has been a cornerstone of HIV prevention in eastern and southern Africa since 2007, when the World Health Organization recommended it for countries with high HIV burden and low circumcision prevalence. A new analysis of national survey data from Malawi, Rwanda, Zambia and Zimbabwe suggests that the programme's benefits may not extend to sexually transmitted infections more broadly, at least as they are reported by men themselves. Researchers examined Demographic and Health Surveys conducted before national scale-up of circumcision services, between 2004 and 2006, and after scale-up, between 2015 and 2020.

Their study population comprised sexually active adolescent boys and men aged 15 to 49 years. An infection was defined as a self-reported STI diagnosis or symptoms of a genital sore, ulcer or discharge in the previous 12 months, a measure that captures symptomatic disease rather than laboratory-confirmed infection. The pooled analysis included 41,094 respondents.

Circumcision coverage rose significantly over the study period in all four countries except Zimbabwe, where prevalence was 11.9 percent before scale-up and 12.8 percent afterwards, a difference that was not statistically significant. Despite the expansion of surgical services, the proportion of men reporting an STI or compatible symptoms increased from 5.3 percent before scale-up to 8.2 percent afterwards. At the population level, the odds of self-reported STIs were 52 percent higher after circumcision scale-up than before, with an adjusted odds ratio of 1.52 and a 95 percent confidence interval of 1.33 to 1.74.

The individual-level picture was strikingly different. When men who reported being circumcised were compared with men who did not, after adjustment for potential confounders, there was no association between circumcision status and self-reported STIs, with an adjusted odds ratio of 1.03 and a confidence interval spanning 0.92 to 1.17. In other words, circumcised men were not more or less likely than uncircumcised men to report an infection.

The divergence between these two findings is the study's central puzzle. A population-level rise in reported STIs coinciding with programme scale-up does not demonstrate that circumcision caused the increase, and the authors are careful not to make that claim. The results contrast with randomised trial evidence showing that medical circumcision reduces HIV acquisition in men, the basis for the WHO recommendation, and with some studies suggesting partial protection against other STIs.

The authors note that while VMMC protects against HIV and some STIs, there is limited evidence for a protective population-level association between programme scale-up and self-reported STIs in the region. The study has further limitations inherent to its design. Zimbabwe's negligible change in coverage also limits what that country contributes to the before-and-after comparison.

The practical message of the analysis concerns service design rather than the fate of circumcision programmes. STI rates remain high, particularly among young men, and the authors argue that the findings underscore the need for comprehensive, male-oriented sexual health strategies. They suggest that reducing barriers to care and integrating circumcision services into person-centred sexual health provision for men could help close persistent gaps in STI prevention, so that a programme originally built around HIV also addresses the broader burden of sexually transmitted infections.

Subject of Research: Population-level association between voluntary medical male circumcision scale-up and self-reported sexually transmitted infections among men in four African countries

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

Article References: Vanhamel, J., Smekens, T., Ameyan, W., Choko, A., Mavhu, W., Phiri, M. M., & Hensen, B. (2026). Examining the association between male circumcision and the prevalence of self-reported sexually transmitted infections among adolescent boys and men (15–49 years old) in Malawi, Rwanda, Zambia and Zimbabwe. BMC Public Health. https://doi.org/10.1186/s12889-026-29699-7

Image Credits: AI Generated

DOI: 10.1186/s12889-026-29699-7

Keywords: male circumcision, VMMC, sexually transmitted infections, HIV prevention, Malawi, Rwanda, Zambia, Zimbabwe, Demographic and Health Surveys, public health, men's sexual health, sub-Saharan Africa