Male circumcision associated with reduced syphilis transmission

1. Circumcised African men were 42 percent less likely to contract syphilis than uncircumcised men.

2. The female partners of circumcised men were nearly 60 percent less likely to get syphilis than partners of uncircumcised men.

Evidence Rating Level: 1 (Excellent)      

Study Rundown: Multiple randomized controlled trials have shown that male circumcision offers at least a 60 percent protection against HIV-1 in heterosexual males.  The data is so convincing that the World Health Organization recommends male circumcision as a high priority HIV prevention strategy in areas with large HIV/AIDS burdens, like sub-Saharan Africa. Male circumcision has also been linked with prevention of other sexually transmitted infections (STIs), like human papillomavirus (HPV) and herpes type 2 (HSV-2), as well as HIV and STIs in female partners. Several studies have looked at the effect of male circumcision on syphilis acquisition, but none have looked at its benefit in HIV positive males or women. The greatest burden of syphilis, a bacterial STI, lies in sub-Saharan Africa and Asia, where rates of circumcision are low. Syphilis, if untreated, can lead to irreversible neurologic and cardiovascular damage and if acquired during pregnancy, adverse birth outcomes like stillbirths, neonatal deaths, and birth defects. In this study, the largest of its kind, researchers looked at the association between male circumcision and the incidence of syphilis in heterosexual couples in Kenya and Uganda and found that male circumcision was associated with a 42 percent reduction in syphilis incidence. The benefit of male circumcision extended to their female partners—partners of circumcised men were 59 percent less likely overall to get syphilis than partners of uncircumcised men.

Strengths of this study include large, prospective design and evaluation of couples, allowing for examination of transmission from the affected partner to the previously unaffected partner. One limitation is that syphilis was only tested annually. African, heterosexual and HIV-discordant couples may not have the same prevalence of syphilis or patterns of sexual behavior as other populations. Replicated findings in a more diverse population that include singles and homosexual couples and singles would solidify findings.

Click to read the study in The Lancet Global Health

Click to read an accompanying editorial in The Lancet Global Health

Relevant Reading: Male circumcision and risk of syphilis, chancroid, and genital herpes

In-Depth [prospective cohort study]: Researchers followed 4716 HIV-1 discordant heterosexual couples in Kenya and Uganda enrolled in a randomized safety and efficacy trial of pre-exposure prophylaxis for HIV-1. At enrollment, 53 percent of HIV-positive and 32 percent of HIV-negative men were circumcised. Male circumcision and syphilis status in both men and women were assessed annually for a median of 2.75 years.

Male circumcision was associated with a 42 percent reduction in syphilis incidence in men overall (aHR=0.58, 95% CI-0.37-0.91), with a 62 percent reduction in HIV-positive males (aHR-0.38, 95% CI=0.18-0.81) and a non-significant reduction in HIV-negative males. In women, male partner circumcision was associated with a 59 percent reduction in syphilis incidence overall (aHR=0.41, 95% CI=0.25-0.69), with a 75% reduction in HIV-negative women (aHR=0.25, 95% CI=0.08-0.76) and a 48% reduction in HIV-positive women (aHR=0.52, 95% CI=0.27-0.97).

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