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The Do-it-Yourself circumcision

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Rwanda pioneers revolutionary product in fight against HIV

In many cultures and religions across the world, including Islam and Judaism, male circumcision, the act of removing a male’s foreskin with a sharp blade, is viewed as an essential rite of passage, done just days after a boy is born. It is a festive event, for everyone except the young boy, of course.

A man and child lie inside a circumucision theatre at Bisate health centre in northern Rwanda.A man and child lie inside a circumucision theatre at Bisate health centre in northern Rwanda.Nevertheless, however painful the event is for a child of seven or eight days, it becomes infinitely more difficult to go through the procedure as a young man. Although anesthesia helps limit the pain, the recovery can still be an unpleasant process. If the procedure is conducted without medication and without the proper medical supervision, as is the case in many rural villages, circumcision can be extremely painful.

But a new device pioneered through the Rwandan government and made available to the public earlier this year, has changed the face of circumcision both inside and outside the country. The product is called the PrePex and is safe, simple to use, requires little training and can be used both outside a clinical environment and without anesthetic.

A special elastic mechanism is simply fitted and trapped around the male’s foreskin and after one week the foreskin is dried up and can be easily removed. The patient doesn’t bleed and the recovery period takes a matter of hours instead of days or weeks.

“The PrePex device is a game-changing innovation,” said Steven Kaplan, a urologist New York’s Cornell University and co-investigator of a current PrePex study in a press release. “The evidence from the study is very compelling – a non-surgical technique with no local anaesthesia will make this technology accessible and scalable.”

Before the PrePex was officially launched, the Rwandan Ministry of Health tested its capability and effectiveness by circumcising forty men with the device. In addition to being approved by Rwanda’s Ministries of Defense and Health in 2010, PrePex has also been approved by the European Union. The World Health Organization, citing the need for more data that illustrates the device’s “efficacy, safety and accountability,” has not yet endorsed the product.

A surgeon carries out circumcision at Bisate health centre in Rwanda.A surgeon carries out circumcision at Bisate health centre in Rwanda.But in Rwanda, the PrePex is already having an impact. “The implications of a device like this are broad - we can arrive at a university and circumcise 1,000 students in days, in a regular classroom, by trained nurses,” explains Jean Paul Bitega, a surgeon who headed the research team that was testing the device.

“In Africa, where we lack medical infrastructure, we feel it is the best way to go,” explained Agnes Binagwaho, permanent secretary in Rwanda’s Ministry of Health. “You don’t need a sterile environment, you don’t need anesthetic, you don’t need to use an operating theatre.”

Rwanda’s development of the PrePex is part of a larger effort to reduce the prevalence of HIV in the country, which currently stands at three percent.

In 2005 a study conducted in South Africa and Kenya revealed that circumcised men were 60 percent less likely then non circumcised men to contract HIV if they had unprotected sex with an infected partner. In Rwanda only 15 percent of the male population is currently circumcised but the country’s HIV prevention strategy includes a plan to circumcise two million men by the end of 2012.

The government’s investment in this campaign has led hospitals and clinics to record an unprecedented rise in the number of people seeking circumcision. At Polyclinique la Medicale, a clinic in Kigali City, on average 20 men arrive for circumcision everyday.  “When we, started we could circumcise 15, but now the number has gone up, especially during holidays,” says Octave Uwizeyimana, a medical practitioner.

The Rwandan government, and President Paul Kagame in particular, have been lauded for their efforts: “President Kagame is a visionary and a highly respected world leader,” said Michel Sidibé, Executive Director of UNAIDS. “He has been pivotal in turning Rwanda’s AIDS epidemic around. The experience and leadership he will bring to the High Level Meeting discussions in June will be instrumental in bringing AIDS out of isolation and greater country ownership.”

Benon is one recent circumcision patient. At 29 years of age, the decision to be circumcised was not an easy one. “It was not a simple decision,” he says.  “Initially, we quarreled over it, but later I thought about the advantages of being circumcised, but I finally accepted.”

Before his surgery at Kanombe Military Hospital, Benon had a lot of questions: How long will it take to heal?  Will I be able to wear trousers and go to work?  Will there be much pain in the following days?

However, for the majority of people living in rural areas the cost of the procedure alone, estimated at Rwf25,000 at Kanombe, forces them to contemplate even more uncertainty; these individuals must often undergo circumcision without anesthesia or the proper professionals.

Despite attempts by Rwandan authorities to discourage circumcisions in settings that don’t meet the country’s health standards, individuals, most notably from Muslim families, still attempt the procedure in precarious environments.

“We have had men coming here to be re-circumcised after being badly circumcised at a mosque,” says Uwizeyimana.

The healing period, he adds, which requires the patient to wash their wound with warm salty water and with clean cotton, can also vary depending on the resources and facilities available.

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