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Urethrocutaneous fistulas after voluntary medical male circumcision for HIV prevention-15 African Countries, 2015-2019. 2021
Todd Lucas, and
Jonas Z Hines, and
Julia Samuelson, and
Timothy Hargreave, and
Stephanie M Davis, and
Ian Fellows, and
Amber Prainito, and
D Heather Watts, and
Valerian Kiggundu, and
Anne G Thomas, and
Onkemetse Conrad Ntsuape, and
Kunle Dare, and
Elijah Odoyo-June, and
Leonard Soo, and
Likabelo Toti-Mokoteli, and
Robert Manda, and
Martin Kapito, and
Wezi Msungama, and
James Odek, and
Jotamo Come, and
Marcos Canda, and
Nuno Gaspar, and
Aupokolo Mekondjo, and
Brigitte Zemburuka, and
Collen Bonnecwe, and
Peter Vranken, and
Susan Mmbando, and
Daimon Simbeye, and
Fredrick Rwegerera, and
Nafuna Wamai, and
Shelia Kyobutungi, and
James Exnobert Zulu, and
Omega Chituwo, and
Sinokuthemba Xaba, and
John Mandisarisa, and
Carlos Toledo
Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, GA, USA. tlucas@cdc.gov.
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.
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