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.
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.”
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.
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.