News / Africa

Will African Men Line Up for Circumcision if There’s No Doctor?

A Rwandan youth is tested for the AIDS virus before he receives a free male circumcision at the Shingiro Health Center in Musanze. (Courtesy the Global Fund)
A Rwandan youth is tested for the AIDS virus before he receives a free male circumcision at the Shingiro Health Center in Musanze. (Courtesy the Global Fund)
VOA News
An ambitious campaign in 15 high-risk countries in sub-Saharan Africa to foster an AIDS-free generation by circumcising 20 million men and boys by 2016 may depend on a new small inexpensive device that does the job without surgery, pain or hypodermic needles.
 
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The Voluntary Medical Male Circumcision (VMMC) project was launched two years ago by the World Health Organization and UNAIDS to eliminate a major environment for the deadly AIDS virus by surgically removing the foreskin of the male penis.
 
Now that procedure can be done using the PrePex - a $20 pair of plastic rings and a specially designed rubber band that can be applied in remote villages by a nurse with three days of training. The rings painlessly cut off the flow of blood to the foreskin which dies and falls off within a few days.
 
Rwanda’s minister of health announced this week the expansion beyond its field trials in order to reach 700,000 Rwandan males with the PrePex device, possibly the first attempt by an African government to apply the non-surgical technique in rural settings where they are most needed.
 
And Uganda is not far behind.
 
Will PrePex be a game changer?
 
It is uncertain if the non-surgical devices will enable WHO and UNAIDS to meet their goal of 20 million circumcisions, but Dr. Jason Reed is “optimistic” about the impact of PrePex and other non-surgical devices.
 
Trials are showing PrePex involves the least invasive procedure because it doesn’t even require a local anesthetic. Reed said products like PrePex are “potentially easier to provide and hopefully more acceptable to the clients.”
 
Young men volunteer for free surgical circumcision at the Harare Central Hospital Spilhaus Family Planning Centre, May 29, 2012. (Courtesy the Global Fund)Young men volunteer for free surgical circumcision at the Harare Central Hospital Spilhaus Family Planning Centre, May 29, 2012. (Courtesy the Global Fund)
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Young men volunteer for free surgical circumcision at the Harare Central Hospital Spilhaus Family Planning Centre, May 29, 2012. (Courtesy the Global Fund)
Young men volunteer for free surgical circumcision at the Harare Central Hospital Spilhaus Family Planning Centre, May 29, 2012. (Courtesy the Global Fund)
Reed, an epidemiologist and the senior technical advisor at the President’s Emergency Plan for AIDS Relief - the U.S. government agency that is the major funder of the initiative - says the device gives men “an opportunity to stand up and play a role in achieving an AIDS-free generation with a five-minute procedure that offers a lifetime of reduced risk.”
 
But another epidemiologist who has been advising Kenya’s VMMC program in Nyanza Province does not believe PrePex is going to be a game-changer.
 
“PrePex won’t reach that goal,” said Dr. Robert Bailey, a University of Illinois at Chicago epidemiologist. Bailey supervises a VMMC project in Kisumu for the Kenya Ministry of Health. The project has conducted more than 690,000 circumcisions among Kenyans in the predominantly Luo ethic region, where the custom of male circumcision as a coming-of-age ritual was not practiced. Bailey also supervised a demographic study of 425 men who participated in non-surgical procedures using PrePex and another device called the Shang Ring.
 
Counseling needed along with devices
 
PrePex may be appropriate in some areas, Bailey said, particularly where some governments will be encouraged by the lower cost of non-surgical services. But he says the more elaborate surgical procedure is well under way in many countries and moving to non-surgical devices risks wasting valuable resources and possible delays in acquiring the needed training and supplies. “A pharmacy will need to have an inventory of all five sizes of the PrePex rings,” he said.
 
Countries Participating in the Voluntary Medical Male Circumcision ProjectCountries Participating in the Voluntary Medical Male Circumcision Project
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Countries Participating in the Voluntary Medical Male Circumcision Project
Countries Participating in the Voluntary Medical Male Circumcision Project
Any VMMC project that doesn’t include the crucial behavioral counseling, HIV testing and follow-up of the standard surgical program will also not be very effective, Bailey argues. What the men learn in counseling sessions before and after the surgery is essential to lowering the rates of HIV infections, he says.
 
VMMC advocates have long been concerned that circumcised men may acquire a false sense of security from infection and stop using condoms and increase sexual activity with a variety of partners. AIDS experts call it risk compensation. With proper counseling and testing as part of the VMMC procedure, “our studies show there is no risk compensation,” Bailey said.
 
About five million men between the ages of 15 and 49 have been circumcised in the last two years but the VMMC goal is another 15 million to go.  But most prospective patients live far from sterile hospital settings and many are reluctant to undergo the pain of the procedure and a long three-week recovery from the surgery.

Experts say non-surgical devices like the PrePex could make male circumcision more affordable and accessible for African governments - and a lot less painful for African men.

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by: roger desmoulins from: new zealand
December 07, 2013 1:50 PM
"With proper counseling and testing as part of the VMMC procedure, “our studies show there is no risk compensation,” Bailey said."

Dream on, naive American wearer of the white lab coat!
"Proving" the absence of risk compensation would require clinical trials of at least 10 years duration, of which there are none. Risk compensation was discovered by an economist, and is a phenomenon in the realm of social science. It is the sort of human reality that biologists like Bailey are not trained to think about carefully.

If "counseling and testing" suffice to eliminate risk compensation, why bother with circumcision at all??

The belief that Prepex is some sort of silver bullet against HIV in Africa is profoundly naive. Believing that the Africa clinical trials shed light on whether it is a good idea to circumcise a First World baby boy is downright idiotic.

The "circumcise Africa" campaign is predicated on the assumption that the male bits ablated by circumcision do not matter for sexual pleasure and function. This is utterly unproven. For starters, there never has been a survey of the adult North American penis, based on a large random sample of circumcised and intact men, with a view to ascertaining the possible effects of infant circumcision on adult sexual pleasure and functioning. In the absence of such studies, circumcising doctors literally do not know what they are doing.

by: amanda burleigh from: Leeds
December 06, 2013 5:38 PM
Which bright spark started this rolling? There is no evidence to support the statement, that circumcision (a surgical intervention!)reduces HIV infection, on the contrary.
Far better to invest money in education and condoms. Never heard anything so daft in my life!!

by: ml66uk
December 04, 2013 5:33 PM
Rwandan men are *more* likely to have HIV if they've been circumcised:

2.1% of intact Rwandan men have HIV
3.5% of circumcised Rwandan men have HIV

(http://www.measuredhs.com/pubs/pdf/FR183/15Chapter15.pdf)

82% of men and 92% of women aged 15-49 say they've never used a condom.

So how can it make any sense for Rwanda to start a mass circumcision programme?

That's not unusual. From a USAID report:
"There appears no clear pattern of association between male circumcision and HIV prevalence—in 8 of 18 countries with data, HIV prevalence is lower among circumcised men, while in the remaining 10 countries it is higher."
http://www.measuredhs.com/pubs/pdf/CR22/CR22.pdf

It seems highly unrealistic to expect that there will be no risk compensation. The South African National Communication Survey on HIV/AIDS, 2009 found that 15% of adults across age groups "believe that circumcised men do not need to use condoms".
http://www.info.gov.za/issues/hiv/survey_2009.htm

It is unclear if circumcised men are more likely to infect women. The only ever randomized controlled trial into male-to-female transmission showed a 54% higher rate in the group where the men had been circumcised:
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60998-3/abstract

ABC (Abstinence, Being faithful, and especially Condoms) is the way forward. Promoting genital surgery seems likely to cost African lives rather than save them.

Europeans don't circumcise, South Americans don't circumcise, Australians and New Zealanders used to circumcise but stopped, and less than half of North Americans circumcise. Why should Africans circumcise?

Recent news from Botswana
"There is an upsurge of cases of people who got infected with HIV following circumcision."
http://www.gabzfm.com/circumcised-men-still-run-risk-hiv-infection

and from Zimbabwe:
"SOME circumcised men are contracting HIV and Aids after ditching the use of condoms, under a misguided belief that male circumcision (MC) would prevent them from getting infected"
http://www.thestandard.co.zw/2013/11/10/circumcised-men-indulge-risky-sexual-behaviour/
In Response

by: Tom Tobin from: USA
December 05, 2013 9:05 AM
VOA's fixation on circumcision, with an article averaging every 3 days lately, is undermining the credibility of VOA, and the USA. At a time when the value, validity, and legality of circumcision is being questioned worldwide, this is truly peculiar.

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