Wound Healing and Resumption of Heterosexual intercourse Following Voluntary Medical Circumcision of Adult Males in Kisumu City, Kenya

Abstract

Although male circumcision reduces men’s risk of acquiring HIV heterosexually, the procedure may increase HIV transmission if sex is resumed before the wound is fully healed. World Health Organization therefore recommends 42 days post-circumcision sexual abstinence to allow for complete healing. Unfortunately, the exact time to complete healing and its determinants are not fully understood and some men are reported to engage in sex before completing 42 days of abstinence. This study evaluated post-circumcision wound healing and its predictors in order to determine whether the 42-day post-circumcision sexual abstinence recommended by WHO is optimal. Compliance with guidance on abstinence and condom use at resumption of sex were also assessed. The effect of circumcision on penile viral shedding among HIV-positive men was examined to gauge the risk of HIV transmission following circumcision of HIV-positive men. Methods A total of 215 HIV-negative and 108 HIV-positive men were circumcised by the forceps guided method and their post-circumcision wounds assessed for healing at weekly intervals for seven weeks and at 12 weeks. The wound was certified healed if dry with edges completely apposed all round and no gaps, disruptions, scabs or stitch sinuses. Each participant was asked at every follow-up visit if he had engaged in sex since circumcision and whether he used a condom at the first sex following surgery. Reported intercourse was recorded in terms of the number of post-operative days that had elapsed before it occurred; and classified as early sex if it occurred before 42 days. Plasma and penile lavage samples for viral shedding studies were collected from HIV-positive men before circumcision and at each follow-up visit. Results Cumulative proportions of men healed were 64.7% at week 4, 83.1% at week 5, and 94.1% at week 6. There was no difference in the hazard of healing between 108 HIV-positive and 108 age-matched HIV-negative men (HR 0.91 95%CI 0.70-1.20). Post-operative infection was associated with delayed healing in both HIV-positive and HIV-negative men (HR 0.48 95%CI 0.23-1.00). Overall 37.7% (120/318) of men reported sex before 42 days and 18.8% (60/319) reported sex before complete healing. Only 7% of the men had unprotected sex before complete wound healing. Risk factors for sex before healing included being married or having two or more sex partners in the past one year and consistent alcohol consumption Circumcision of HIV-positive men was followed by a significant rise in penile HIV viral shedding, which declined to undetectable levels by 6 weeks after surgery (MANOVA; p<0.0001). In 96.6% of HIV-positive men there was no viral shedding after certification of wound healing. Conclusions and recommendations Given that 94.0 % of men are healed within 42 days after circumcision regardless of their HIV status and there is virtually no viral shedding after healing, the WHO guidance of 6 weeks sexual abstinence after circumcision should be maintained and applied to HIVnegative and HIV-positive men. Because 5.9% of the men remained unhealed at 42-days post-circumcision, condom use at resumption of sex should be emphasized for all men. Postcircumcision wounds should however be examined on the 7th post-surgery day to exclude post-operative infection and tight sutures which are both associated with longer time to healing. Adherence to the 42-day abstinence period and condom use at every sexual intercourse within three months following circumcision should minimize the risk of HIV spread in the immediate post-circumcision healing period.