Wound Healing and Resumption of Sexual Activity Following Medical Male Circumcision

Three randomized controlled trials in South Africa, Kenya, and Uganda showed that medical male circumcision reduces the risk of HIV-acquisition by 60%. Following these trials, the World Health Organization recommended that voluntary medical male circumcision be offered as a comprehensive, multi-faceted HIV-prevention strategy in countries with low male circumcision rates and high HIV prevalence. Part of the WHO recommendation for VMMC is that men abstain from sexual activity for six-weeks following circumcision to allow for complete healing. This post-circumcision abstinence period has yet to be tested for circumcision or in the context of men's sexual behavior. A prospective cohort of 323 HIV-negative and HIV-positive men seeking voluntary medical male circumcision was recruited, circumcised, and followed weekly for seven weeks and again at twelve weeks. Their wounds were examined and photographed to document healing and a behavioral questionnaire was administered to document self-reported timing of resumption of sex. By six-weeks follow-up, 94% of men were fully healed. There was no difference in healing time by HIV-serostatus. Overall, 38% of men resumed sex before six-weeks of follow-up. However, only 18% of the cohort resumed sex before complete healing. HIV-positive men saw an increase in mean CD4+ cells from baseline to two weeks of follow-up, and showed a spike in mean post-operative penile viral shedding that was attenuated by week 4. Photography was tested as an alternative method of wound progression diagnosis, with mixed results. The WHO recommended post-circumcision abstinence period of six-weeks should be maintained. Factors associated with a reduction in the protective effect of circumcision are likely not significant in this study population. Eighteen percent of men resumed sex before complete healing and 93% of men reported condom use at sexual re-initiation. This reduces the likelihood of HIV-acquisition by seronegative men undergoing circumcision in the early post-operative period. Shedding of virus from the incision site and spikes in viral load return to baseline levels by the fourth week following surgery, which means seronegative partners of HIV-positive men are not at increased risk. Coupled with the low rate of sex before healing and high rate of condom use, sex in the early post-oper