Background
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.