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Background: Randomized controlled trials and observational data have demonstrated that circumcision partially protects men from acquiring HIV and some sexually transmitted infections (STIs) through heterosexual sex. They also suggest that female partners receive some protection, possibly indirectly through lower infection prevalences among men. However, population-level data outside experimental settings is lacking. The HIV Incidence Provincial Surveillance System (HIPSS) is a longitudinal study in Vulindlela and Greater Edendale sub-districts, South Africa, which collected population-level baseline data in 2014 and 2015.
Methods: Female HIPPS participants were aged 15-49 years. Those with at least one past or current male sexual partner who were able to report his circumcision status were analyzed. Participants were assessed for HIV status via double 4th-generation ELISA testing with confirmatory Western Blot; N. gonorrhoeae, C. trachomatis, T vaginalis, and HPV infection with standard testing of self-collected vulvovaginal swabs; T. pallidum, HSV-2 and Hepatitis B with serology; and STI diagnosis history and current STI symptoms with self-report. They were grouped by circumcision status of their most recent partner, stratified into age below or at least equal to 25 years, and compared on presence of STI outcomes by chi-square testing, weighted for selection probability and nonresponse.
Results: 4766 women were included. Women with circumcised partners had similar numbers of lifetime partners (mean 2.45) to those with uncircumcised partners (mean 2.71). In the younger stratum, partner circumcision was negatively associated with HIV (24% vs. 35%, p< 0.01) and HSV-2 (49% vs. 62%, p< 0.01). In the older stratum, partner circumcision was negatively associated with syphilis (1.5% vs. 3.4%, p=0.04) and HSV-2 (83% vs. 86%, p=0.04), but was associated with ever having had an STI (11% vs. 7%, p< 0.01).
Conclusions: Partner circumcision was associated with decreased prevalence of HSV-2 in all female HIPSS participants, decreased prevalence of HIV in younger women, and decreased prevalence of syphilis in older women. Its positive association with self-reported STI history in older participants may derive from differential ascertainment; circumcision typically involves STI screening in men, potentially leading to partner notification. Findings support community-level protection against HIV and some other STIs among women from male circumcision.