HIV shedding from male circumcision wounds in HIV-infected men: a prospective cohort study

Background A randomized trial of voluntary medical male circumcision (MC) of HIV--infected men reported increased HIV transmission to female partners among men who resumed sexual intercourse prior to wound healing. We conducted a prospective observational study to assess penile HIV shedding after MC. Methods and Findings HIV shedding was evaluated among 223 HIV--infected men (183 self--reported not receiving antiretroviral therapy [ART], 11 self--reported receiving ART and had a detectable plasma viral load [VL], and 29 self--reported receiving ART and had an undetectable plasma VL [ 50,000 copies/ml than among those with an HIV plasma VL < 400 copies/ml (adjPRR = 10.3, 95% CI = 4.25-24.90, p < 0.001). Detectable HIV shedding was less common in visits from men with healed MC wounds compared to visits from men without healed wounds (adjPRR = 0.12, 95% CI = 0.07-0.23, p < 0.001) and in visits from men on ART with undetectable plasma VL compared to men not on ART (PRR = 0.15, 95% CI = 0.05-0.43, p = 0.001). Among men with detectable penile HIV shedding, the median log10 HIV copies/milliliter of lavage fluid was significantly lower in men with ART--induced undetectable plasma VL (1.93, interquartile range [IQR] = 1.83-2.14) than in men not on ART (2.63, IQR = 2.28-3.22, p < 0.001). Limitations of this observational study include significant differences in baseline covariates, lack of confirmed receipt of ART for individuals who reported ART use, and lack of information on potential ART initiation during follow--up for those who were not on ART at enrollment. Conclusion Penile HIV shedding is significantly reduced after healing of MC wounds. Lower plasma VL is associated with decreased frequency and quantity of HIV shedding from MC wounds. Starting ART prior to MC should be considered to reduce male-to-female HIV transmission risk. Research is needed to assess the time on ART required to decrease shedding, and the acceptability and feasibility of initiating ART at the time of MC.
Introduction Three randomized trials demonstrated that voluntary medical male circumcision, hereafter referred to as male circumcision (MC), significantly decreases heterosexual HIV acquisition in men by 50%-60% [1-3]. MC of HIV-negative [...]