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 (WHO) recommended that voluntary medical male circumcision (VMMC) be offered as a comprehensive, multifaceted HIV-prevention strategy in countries with low male circumcision (MC) rates and high HIV prevalence. Part of the WHO recommendation for VMMC is that men abstain from sexual activity for six weeks following circumcision. However, this post-circumcision abstinence period was arbitrarily selected as the hypothesized time it takes for a wound to heal by primary intention following surgery and was not tested for circumcision or in the context of men's sexual behavior.;This dissertation tests the WHO-recommended six-week abstinence period by monitoring postcircumcision wound healing and timing of resumption of sexual activity in more than 300 adult men from Kisumu, Kenya---an area with high HIV-prevalence and traditionally low MC rates. To test whether healing rates and sexual behavior differed by HIV-status, we recruited 108 HIV-positive men aged 18 to 35 years who were voluntarily seeking VMMC services and age-matched these men to HIV-negative counterparts. We additionally recruited a serial sample of 107 HIV-negative men presenting, unprompted, at our clinic for VMMC services for a total study population of 323 men.;Men were circumcised according to Kenya Ministry of Health (MOH) guidelines using the forceps-guided method and followed weekly for seven weeks and again at 12 weeks. At each visit the men had their wounds inspected for healing and photographed for documentation. They were also administered a questionnaire designed to track the postoperative behavior as it related to both healing and sexual activity. Using these data, we sought to answer four main research questions: (1), what is the rate at which men heal following VMMC and is there a difference in healing time by HIV-serostatus; (2) what is the duration of self-reported postoperative abstinence and is this related to the rate of wound Healing; (3) are there changes to the pathophysiology of HIV-positive men following VMMC; and (4), can photography be used for remote assessment of post-circumcision wounds.;The results of these inquiries are presented in the chapters to follow. In summary, the WHOrecommended post-circumcision abstinence period is adequate as 94% of our population healed within six weeks of follow-up; there is no difference in healing time by HIV-serostatus. While more than a third (38%) of our population engaged in sex before six weeks of follow-up, only 18% of our population did so before wound healing was complete. We documented a rise in CD4+ counts from baseline to two weeks of follow-up in HIV-positive men, and penile viral shedding and plasma viral load had initial spikes that were attenuated well before healing was complete, which means that HIV-negative partners of HIVpositive men are not at increased risk of obtaining HIV in the immediate postoperative period if postcircumcision guidelines are followed. Finally, we showed that photography may be a useful tool for remote assessment of post-circumcision wounds in regions with limited access to qualified healthcare personnel.