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Conceived and designed the experiments: GK SW DS N. Kiwanuka FWM NS RHG MJW. Performed the experiments: GK RM N. Kighoma FN JN GKN RMG MA TL. Analyzed the data: GK RM FM N. Kiwanuka FWM RHG MJW. Wrote the paper: GK RM N. Kighoma SW DS FN N. Kiwanuka FWM GKN MA AT FM RMG NS RHG MJW. Managed study quality assurance and Quality control: GNK.
Medical male circumcision (MC) of HIV-infected men may increase plasma HIV viral load and place female partners at risk of infection. We assessed the effect of MC on plasma HIV viral load in HIV-infected men in Rakai, Uganda.
195 consenting HIV-positive, HAART naïve men aged 12 and above provided blood for plasma HIV viral load testing before surgery and weekly for six weeks and at 2 and 3 months post surgery. Data were also collected on baseline social demographic characteristics and CD4 counts. Change in log10 plasma viral load between baseline and follow-up visits was estimated using paired t tests and multivariate generalized estimating equation (GEE).
Of the 195 men, 129 had a CD4 count ≧350 and 66 had CD4 <350 cells/mm3. Men with CD4 counts <350 had higher baseline mean log10 plasma viral load than those with CD4 counts ≧350 cells/mm3 (4.715 vs 4.217 cps/mL, respectively, p = 0.0005). Compared to baseline, there was no statistically significant increase in post-MC HIV plasma viral loads irrespective of CD4. Multivariate analysis showed that higher baseline log10 plasma viral load was significantly associated with reduction in mean log10 plasma viral load following MC (coef. = −0.134, p<0.001).
We observed no increase in plasma HIV viral load following MC in HIV-infected, HAART naïve men.
Three trials of male circumcision (MC) show that MC reduces male HIV acquisition by 50–60%
To determine whether MC of HIV+ men affected plasma HIV viral load, we assessed the effect of MC surgery on plasma HIV viral load during the immediate post- MC period among HAART naive HIV-infected men with CD4+ T cell counts <350 and ≧350 cells/mm3.
The study was reviewed and approved by the Higher Degrees, Research and Ethics Committee (HDREC) of the Makerere University, School of Public Health (MUSPH), by the Scientific and Ethics Committee (SEC) of the Ugandan Virus Research Institute (UVRI), by Western Institutional review Board (WIRB) in the US, and by the Uganda National Council of Science and Technology (UNCST).
We conducted a prospective cohort study in Rakai district, Uganda between 2009 and 2011. All uncircumcised HIV-infected men aged 12 and above who requested free MC services and had no contraindication to surgery were invited to participate in the study and asked to provide written informed assent if minor or consent if adult. Parents or guardians provided written informed consent for minors aged less than 18 years. All HIV-infected men were referred for HIV care. Referral notes were given to clients to take to an HIV care clinic of their choice for further counseling and consideration for HAART.
All HIV-infected men who consented to participate in the study (n = 332) were enrolled. A random sample of HIV-negative men who came for the free MC service were concurrently enrolled in a parallel study of MC wound healing to avoid stigmatization of the HIV-positive participants.
Men were offered free individual voluntary counseling and testing (VCT), though acceptance of VCT was not a prerequisite for free MC. On the day of surgery men were provided with education on HIV prevention and MC through group sessions. Information was provided on risks and benefits of MC, on the surgical procedure, wound care and the need to abstain from intercourse until complete wound healing was certified. Men were then clinically assessed for contraindications to surgery by trained medical or clinical officers. Participants without contraindications were asked to consent to participation in the study.
Data were collected at baseline and follow-up visits by trained male interviewers using structured questionnaires. Information collected included socio-demographic, health and behavioral characteristics, symptoms of surgery related complications, resumption of sex, and condom use. Blood for HIV testing, plasma viral load and CD4 count determination was collected prior to surgery. 96% of the surgeries were conducted by trained clinical officers and 4% by medical officers using the dorsal slit method as described in the WHO Manual for Male Circumcision Under Local Anaesthesia
All participants were followed weekly for six weeks and then at 2 and 3 months post-surgery. At these visits, venous blood was collected for plasma viral load determination, and data collected on surgery related moderate or severe adverse events and wound healing status.
HIV status was determined by two enzyme immunoassays (EIAs); Vironostika HIV-1/2 Plus O (Organon Teknika, Charlotte, NC, USA) and Murex HIV-1.2.0 (Murex Biotech Limited, Dartford, UK), which were run in series. Samples were first tested using Murex Biotech EIA assay which is more sensitive, and then by the Vironostika HIV-1/2 test which is more specific. Samples discordant on the two EIA tests and those that were in the gray zone on Vironostika HIV-1/2 were subjected to Western blot (WB) confirmation (HIV-1 Western Blot; Bio-Merieux-Vitek) or by PCR in cases where WB result were indeterminate. Determination of CD4+ T cell counts used a three-color FACSCaliber (Becton Dickenson, New Jersey, USA). Plasma HIV-1 RNA viral loads were determined by a reverse-transcriptase–polymerase-chain-reaction (RT-PCR) assay (AMPLICOR HIV-1 MONITOR version 1.5 Roche Molecular Systems, Branchburg, N.J.). All tests were done at the Rakai Health Sciences Laboratory in Kalisizo.
Men who were on Highly active antiretroviral therapy (HAART) were excluded from this analysis because therapy suppresses viremia which could obscure the effects of MC. Participants' characteristics were assessed at baseline stratified by CD4 counts ≧350 cells/mm3 and below 350 cells/mm3. Baseline behavioral and social demographic characteristics were compared using Chi-square tests.
Plasma HIV Viral load was log10 transformed. Equality of means of log10 plasma viral load for the two CD4 groups and by HIV care status was tested using two sample t-test.
Mean change in log10 plasma viral load and 95% confidence intervals were estimated by follow up visit and plotted to examine change in plasma viral load relative to the pre-MC enrollment levels. Within-individual changes in plasma viral load relative to pre-surgical levels were assessed using paired t test. Population-averaged (marginal) multivariate regression models with generalized estimating equations (GEE) estimates of robust variance were used to estimate adjusted changes in plasma viral load. A sensitivity analysis was performed in a subgroup of 111 men who had complete data on plasma viral load from week 1 to week 8 postoperatively. Analyses were performed using Stata version 12.0 (College Station, Texas).
All men | Subsample with complete data at all visits 1–8 | |||||||||
Baseline Characteristic | HIV+ (CD4≥350) | HIV+ (CD4<350) | P-Value | HIV+ (CD4≥350) | HIV + (CD4<350) | P-Value | ||||
No. | % | No. | %. | No. | % | No. | % | |||
<30 | 57 | 44.2 | 21 | 31.8 | 25 | 36.8 | 11 | 30.6 | ||
30–39 | 47 | 36.4 | 34 | 51.5 | 26 | 38.2 | 24 | 55.8 | ||
40+ | 25 | 19.4 | 11 | 16.7 | 17 | 25.0 | 8 | 18.6 | ||
Married | 96 | 74.4 | 49 | 74.2 | 51 | 75.0 | 35 | 81.4 | ||
Not married | 33 | 25.6 | 17 | 25.8 | 17 | 25.0 | 8 | 18.6 | ||
None or Primary | 93 | 72.1 | 49 | 74.2 | 47 | 69.1 | 35 | 81.4 | ||
Secondary education or more | 36 | 27.9 | 17 | 25.8 | 21 | 30.9 | 8 | 18.6 | ||
Agriculture | 51 | 39.5 | 24 | 36.4 | 32 | 47.1 | 18 | 41.9 | ||
Paid Employment | 33 | 25.6 | 23 | 34.9 | 13 | 19.1 | 13 | 30.2 | ||
Other forms of Employment | 45 | 34.9 | 19 | 28.8 | 23 | 33.8 | 12 | 27.9 | ||
0 or 1 | 52 | 40.3 | 20 | 30.3 | 30 | 44.1 | 14 | 32.6 | ||
2 or more | 77 | 59.7 | 46 | 69.7 | 38 | 55.9 | 29 | 67.4 | ||
No Condom use | 53 | 41.1 | 29 | 43.9 | 25 | 51.0 | 21 | 58.3 | ||
Sometimes | 36 | 27.9 | 20 | 30.3 | 15 | 30.6 | 14 | 38.9 | ||
Always | 13 | 10.1 | 04 | 6.1 | 9 | 18.4 | 1 | 2.8 | ||
No Alcohol use | 34 | 26.4 | 18 | 27.3 | 20 | 29.4 | 11 | 25.6 | ||
Sometimes | 87 | 67.4 | 45 | 68.2 | 44 | 64.7 | 31 | 72.1 | ||
Often | 08 | 6.2 | 03 | 4.6 | 4 | 5.9 | 1 | 2.33 | ||
HIV+ men Not in HIV Care | 99 | 76.7 | 54 | 81.8 | 55 | 80.9 | 34 | 79.1 | ||
In care on Septrin | 30 | 23.3 | 12 | 18.2 | 13 | 19.1 | 20.9 |
In the 195 men, the enrollment mean log10 plasma viral load for men with CD4<350 cells/mm3 was 4.715 cps/mL which was significantly higher than for men with CD4≧350 cells/mm3, 4.217 cps/mL, p = 0.0005 (mean difference = 0.498 [95% CI: 0.222, 0.774]). Similar differences were observed in the subsample with complete follow up visits (p = 0.0013).
Group | Visit | Number of observations | Baseline mean log10 viral load (cps/mL) of men seen at each visit | Follow up visit mean log10 viral load(cps/mL) | Mean within individual difference in viral load (Baseline – follow up)(95%CI) | p-value |
CD4> = 350 | Day 1 | 111 | 4.241 | 4.188 | 0.053 (−0.012, 0.117) | 0.109 |
Week 1 | 117 | 4.210 | 4.080 | 0.130 (0.044, 0.216) | 0.003 | |
Week 2 | 103 | 4.226 | 4.124 | 0.102 (−0.008, 0.211) | 0.069 | |
Week 3 | 104 | 4.185 | 4.098 | 0.087 (−0.017, 0.192) | 0.103 | |
Week 4 | 106 | 4.204 | 4.103 | 0.101 (−0.003, 0.205) | 0.057 | |
Week 5 | 106 | 4.227 | 4.135 | 0.092 (−0.019, 0.203) | 0.104 | |
Week 6 | 100 | 4.220 | 4.180 | 0.040 (−0.052, 0.132) | 0.390 | |
Week 8 | 107 | 4.263 | 4.149 | 0.114 (0.005, 0.224) | 0.041 | |
Week 12 | 109 | 4.206 | 4.137 | 0.069 (−0.066, 0.203) | 0.314 | |
CD4<350 | Day 1 | 61 | 4.689 | 4.682 | 0.007 (−0.062, 0.077) | 0.839 |
Week 1 | 65 | 4.723 | 4.695 | 0.028 (−0.088, 0.143) | 0.634 | |
Week 2 | 60 | 4.720 | 4.615 | 0.105 (0.052, 0.262) | 0.187 | |
Week 3 | 57 | 4.686 | 4.536 | 0.150 (0.026, 0.274) | 0.018 | |
Week 4 | 61 | 4.745 | 4.610 | 0.135 (−0.023, 0.293) | 0.092 | |
Week 5 | 56 | 4.771 | 4.591 | 0.178 (0.0107, 0.349) | 0.038 | |
Week 6 | 55 | 4.786 | 4.690 | 0.096 (−0.083, 0.275) | 0.286 | |
Week 8 | 58 | 4.749 | 4.638 | 0.111 (−0.099, 0.320) | 0.294 | |
Week 12 | 48 | 4.579 | 4.319 | 0.260 (−0.000, 0.520) | 0.050 |
We observed similar trends in the subsample with complete scheduled follow up visits.
Multivariate analysis (GEE) showed that higher baseline log10 plasma viral load was significantly associated with reductions in mean log10 plasma viral load (coef. = −0.134, p<0.001). A similar finding was observed with the subsample of men with complete follow up (p<0.001).
Our findings show that MC is not associated with an increase in plasma viral load post-operatively, irrespective of baseline CD4 count. Men consistently had higher mean log10 plasma viral loads before surgery compared to all post- surgery visits, irrespective of initial CD4, though the differences were borderline or not statistically significant.
This finding differs from our prior study of HIV+ men with CD4 counts >350 cells/mm3 that suggested an increase in plasma viral load at week 4 post-surgery
The strengths of the current study were the frequent weekly observations and the inclusion of HIV+ men with lower CD4 counts <350. We also excluded men on HAART since the effects of therapy could mask viral load changes following MC. The findings are internally consistent. As expected, the mean log10 plasma viral load among men with CD4<350 cells/mm3 was higher than men with CD4≧350 cells/mm3, but enrollment CD4 count was not associated with significant changes in mean log10 plasma viral load postoperatively. Limitations of this study include small sample size, especially for HIV+ men with CD4 counts <350 which limited our ability to compare them to those with CD4 counts >350. Nevertheless, the study had >80% power to detect a difference or change in viral load among all HIV positive men combined (
Other limitations to this study include the fact that though we knew HAART status at enrollment and referred participants for care, we did not establish HAART initiation status during the 12 weeks of follow up visits. Initiation of HAART could lead to a reduction in viral load especially among men with high viral load. However, this is a short time window and would only potentially affect men with CD4<350 cells/mm3. Also the sample of men with CD4<350 cells/mm3 was small due to exclusion of men on HAART.
We observed no increase in plasma HIV viral load following MC in HIV-infected men not on HAART. MC programs should continue providing services to HIV-positive men who request them and counsel them to abstain from sex until the wound is completely healed and to use condoms after they resume intercourse in order to minimize the risk of transmitting HIV to their sexual partners.