Todd Lucas1, Jonas Z Hines2, Julia Samuelson3, Timothy Hargreave4, Stephanie M Davis2, Ian Fellows5, Amber Prainito6, D Heather Watts6, Valerian Kiggundu7, Anne G Thomas8, Onkemetse Conrad Ntsuape9, Kunle Dare10, Elijah Odoyo-June11, Leonard Soo12, Likabelo Toti-Mokoteli13, Robert Manda14, Martin Kapito15, Wezi Msungama16, James Odek17, Jotamo Come18, Marcos Canda19, Nuno Gaspar20, Aupokolo Mekondjo21, Brigitte Zemburuka22, Collen Bonnecwe23, Peter Vranken24, Susan Mmbando25, Daimon Simbeye26, Fredrick Rwegerera27, Nafuna Wamai28, Shelia Kyobutungi29, James Exnobert Zulu30, Omega Chituwo31, Sinokuthemba Xaba32, John Mandisarisa33, Carlos Toledo2. 1. Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, GA, USA. tlucas@cdc.gov. 2. Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, GA, USA. 3. Global HIV, Hepatitis, and STIs Programmes, World Health Organization, Geneva, Switzerland. 4. Department of Surgery, Edinburgh University, Scotland, UK. 5. Fellows Statistics, Contractor, Centers for Disease Control and Prevention, San Diego, CA, USA. 6. U.S. Office of the Global HIV/AIDS Coordinator, Washington, DC, USA. 7. Office of HIV/AIDS, U.S. Agency for International Development, Washington, DC, USA. 8. Department of Defense, Defense Health Agency, San Diego, CA, USA. 9. Ministry of Health and Wellness, Gaborone, Botswana. 10. Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Gaborone, Botswana. 11. Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Nairobi, Kenya. 12. U.S. Agency for International Development, Nairobi, Kenya. 13. Ministry of Health, Maseru, Lesotho. 14. U.S. Agency for International Development, Maseru, Lesotho. 15. Ministry of Health, Lilongwe, Malawi. 16. Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Lilongwe, Malawi. 17. U.S. Agency for International Development, Lilongwe, Malawi. 18. Ministry of Health, Maputo, Mozambique. 19. Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Maputo, Mozambique. 20. U.S. Agency for International Development, Maputo, Mozambique. 21. Ministry of Health and Social Services, Windhoek, Namibia. 22. Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Windhoek, Namibia. 23. National Department of Health, Pretoria, South Africa. 24. Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Pretoria, South Africa. 25. Ministry of Health, Dar es Salaam, Tanzania. 26. Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Dar es Salaam, Tanzania. 27. U.S. Agency for International Development, Dar es Salaam, Tanzania. 28. Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Kampala, Uganda. 29. U.S. Agency for International Development, Kampala, Uganda. 30. Ministry of Health, Lusaka, Zambia. 31. Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Lusaka, Zambia. 32. Ministry of Health and Child Care, Harare, Zimbabwe. 33. Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Harare, Zimbabwe.
Abstract
BACKGROUND: Voluntary medical male circumcision (VMMC) is an HIV prevention strategy recommended to partially protect men from heterosexually acquired HIV. From 2015 to 2019, the President's Emergency Plan for AIDS Relief (PEPFAR) has supported approximately 14.9 million VMMCs in 15 African countries. Urethrocutaneous fistulas, abnormal openings between the urethra and penile skin through which urine can escape, are rare, severe adverse events (AEs) that can occur with VMMC. This analysis describes fistula cases, identifies possible risks and mechanisms of injury, and offers mitigation actions. METHODS: Demographic and clinical program data were reviewed from all reported fistula cases during 2015 to 2019, descriptive analyses were performed, and an odds ratio was calculated by patient age group. RESULTS: In total, 41 fistula cases were reported. Median patient age for fistula cases was 11 years and 40/41 (98%) occurred in patients aged < 15 years. Fistulas were more often reported among patients < 15 compared to ≥ 15 years old (0.61 vs. 0.01 fistulas per 100,000 VMMCs, odds ratio 50.9 (95% confidence interval [CI] = 8.6-2060.0)). Median time from VMMC surgery to appearance of fistula was 20 days (interquartile range (IQR) 14-27). CONCLUSIONS: Urethral fistulas were significantly more common in patients under age 15 years. Thinner tissue overlying the urethra in immature genitalia may predispose boys to injury. The delay between procedure and symptom onset of 2-3 weeks indicates partial thickness injury or suture violation of the urethral wall as more likely mechanisms of injury than intra-operative urethral transection. This analysis helped to inform PEPFAR's recent decision to change VMMC eligibility policy in 2020, raising the minimum age to 15 years.
BACKGROUND: Voluntary medical male circumcision (VMMC) is an HIV prevention strategy recommended to partially protect men from heterosexually acquired HIV. From 2015 to 2019, the President's Emergency Plan for AIDS Relief (PEPFAR) has supported approximately 14.9 million VMMCs in 15 African countries. Urethrocutaneous fistulas, abnormal openings between the urethra and penile skin through which urine can escape, are rare, severe adverse events (AEs) that can occur with VMMC. This analysis describes fistula cases, identifies possible risks and mechanisms of injury, and offers mitigation actions. METHODS: Demographic and clinical program data were reviewed from all reported fistula cases during 2015 to 2019, descriptive analyses were performed, and an odds ratio was calculated by patient age group. RESULTS: In total, 41 fistula cases were reported. Median patient age for fistula cases was 11 years and 40/41 (98%) occurred in patients aged < 15 years. Fistulas were more often reported among patients < 15 compared to ≥ 15 years old (0.61 vs. 0.01 fistulas per 100,000 VMMCs, odds ratio 50.9 (95% confidence interval [CI] = 8.6-2060.0)). Median time from VMMC surgery to appearance of fistula was 20 days (interquartile range (IQR) 14-27). CONCLUSIONS: Urethral fistulas were significantly more common in patients under age 15 years. Thinner tissue overlying the urethra in immature genitalia may predispose boys to injury. The delay between procedure and symptom onset of 2-3 weeks indicates partial thickness injury or suture violation of the urethral wall as more likely mechanisms of injury than intra-operative urethral transection. This analysis helped to inform PEPFAR's recent decision to change VMMC eligibility policy in 2020, raising the minimum age to 15 years.
Entities:
Keywords:
Fistula; HIV; Intraoperative complications; Male circumcision
Authors: Ronald H Gray; Godfrey Kigozi; David Serwadda; Frederick Makumbi; Stephen Watya; Fred Nalugoda; Noah Kiwanuka; Lawrence H Moulton; Mohammad A Chaudhary; Michael Z Chen; Nelson K Sewankambo; Fred Wabwire-Mangen; Melanie C Bacon; Carolyn F M Williams; Pius Opendi; Steven J Reynolds; Oliver Laeyendecker; Thomas C Quinn; Maria J Wawer Journal: Lancet Date: 2007-02-24 Impact factor: 79.321
Authors: Robert C Bailey; Stephen Moses; Corette B Parker; Kawango Agot; Ian Maclean; John N Krieger; Carolyn F M Williams; Richard T Campbell; Jeckoniah O Ndinya-Achola Journal: Lancet Date: 2007-02-24 Impact factor: 79.321