Kamanzi Alex is one of thousands of Rwanda men who have finally decided to have the cut – get circumcised. He has come for his second and last immunization jab against tetanus prior the procedure at Rwamagana hospital.

Kamanzi has always loved night life and as a bachelor, he admits that he has lived a reckless life of alcohol and women. One day he discovered that his female partner was actually married and her husband was battling with HIV/AIDS.

A few weeks after the discovery, he passed away and was buried during a silent ceremony attended by a few friends and family in a cemetery in Nyamirambo.

This event brought him face to face with the fact that he had compromised his health and he later decided to go for HIV test which, thankfully, turned out to be negative. What he now needed was protection.

"I had always toyed with the idea to get circumcised for personal hygiene’s sake but always worried about the high hospital costs and the idea of being hospitalized for weeks. Now it was my life at stake and still I feared the knife” says Kamanzi.

Kamanzi like many men out there thought that if you are unlucky, there are chances that they may die during the surgical operation or lose their ‘manhood’ permanently.

He explains that what encouraged him to get circumcised is an article published by researchers saying circumcision is a good preventive measure against HIV/AIDS.

"The fact that it prevents HIV infection by 60% got me thinking that I had to get the cut though some issues still remained a challenge like the cost implication and obviously the pain” says Kamanzi.

Kamanzi also found out about a new surgical-free circumcision procedure that makes the process easier than ever had arrived in Rwanda.

"I really got excited hearing that men across the country are flocking to health centers to get circumcised, and what has go me excited about getting circumcised is the new Prepex method that is non-surgical” says Kamanzi as he eagerly awaits his turn.

What is non-surgical circumcision (PrePex)

An Israeli company pioneered a device called PrePex that is making mass circumcision easier than ever. PrePex has proved practical for low-resource settings and large-scale rollout.

According to Dr Bantura Leonard the Clinical Team Leader at Aids Healthcare Foundation (AHF) that partners with Rwanda Biomedical Center (RBC) in fighting HIV, PrePex circumcision only requires two immunizations against tetanus and a clean environment, usually conducted by a trained nurse, and takes approximately five minutes.

The device is comprised of three rings: the placement ring, inner ring, and elastic ring. (I propose to add a picture here- I attached a few to the email).

The procedure is comprised of the following steps: the client’s penis is sized to select the appropriate device size, the operator disinfects and marks the foreskin where the device should be placed, the elastic band is loaded onto the placement ring, the placement ring is slid over the penis, the inner ring is placed inside of the foreskin and adjusted to the circumcision marking line, and finally the elastic ring is rolled from the placement ring into the inner ring pressing the foreskin tightly.

"The procedure does not involve cutting live tissue, injected anesthesia or sutures. After the PrePex ring is placed, the client continues to wear his clothes as usual and embarks on his normal life. The ring is removed seven days after its placement when the foreskin is necrotic. The dead tissue is removed with scissors, and any local wound from the device removal is treated” explains Dr Bantura.

The client is also instructed to return for any urgent issues, regardless of the weekly follow-up visit schedule.

The makers of PrePex boast that a man "can resume work and do all daily activities shortly after the procedure”, with the device "designed to be placed, worn, and removed with minimal disruption”, although they should abstain from sex for six weeks afterwards.

The procedure takes only five minutes to apply, and has very good cosmetic results eventually. Alon Gilboa, Director of HIV Prevention Programs at PrePex, described it as "a very simple procedure that any nurse can conduct in any setting, rural, urban or campaign.”

How it all begun in Rwanda

The vast majority of all new HIV infections occur in sub-Saharan Africa and 70% are due to heterosexual intercourse.

In this region, poverty, among other factors, limits access to HIV prevention and treatment.

In Rwanda, 3% of adults are infected with HIV, and only 13% of Rwandan men were circumcised in 2010. In 2009, the Rwanda Ministry of Health set the target of 2 million adult male circumcisions by the end of 2012.

According to Col Dr JP Bitega head of Commandant of Rwanda Military Hospital (RMH), for Rwanda to have massive circumcision, it necessitated a faster and easier procedure thus opting for non-surgical circumcision.

"We started a study in 2011 on non-surgical circumcision because surgical circumcision was not ideal for mass intervention in adult men in Rwanda due to limited resources and few equipped health facilities and physicians” explained Col Dr Bitega one of the pioneers of the non- surgical circumcision in Rwanda.

According to Col Dr Bitega, the first study was done on ten people and the motive was to make sure that the technology was working and after that we had to be perfect with the basics of like how much pressure to be exerted on the ring and how many days before removal.

"With only 1 physician per 16,000 inhabitants, the Rwandan government considered alternatives to surgical MC thus opting for PrePex, a quick, non-surgical procedure that does not require highly qualified staff or a sterile environment. With three clinical trials in Rwanda, the procedure was pre-qualified in March 2012 by the WHO” he explained.

Non-surgical circumcision involves a plastic device called PrePex comprising two rings and an elastic band that cuts off blood supply to the foreskin, which shrivels and is removed with the band after a week.

"For us it was a game changer, after seeing and proving that the technology worked, we started training nurses to do procedures in non- surgical circumcision "PrePex” and within four days, they were conversant with the operation. The trained nurses were then tasked to train other nurses thus taking over the circumcision operation from the few doctors available” says Bitega

In November 2013, Rwanda became the first country in the world to launch a national drive to "non-surgically” circumcise 700,000 men in a bid to cut rates of HIV infection. Around 210,000 people are living with HIV in this East African country.

According to Col Dr Bitega, being the first country to roll out a massive campaign on non-surgical circumcision and the fact that no other country in the region reached such a successful progress of scale up PrePex with providing tetanus vaccines in such a short period of time was a success story for Rwanda.

"Rwanda became a center of Excellency and we started sharing or transferring our expert knowledge with other countries like Uganda, Kenya, South Africa, Lesotho, Botswana, Zambia, and Tanzania. Around that, many staff from Rwanda Military Hospital flew to these countries to help start and teach "PrePex” the non-surgical circumcision” he explains

Other implementing partners

Rwanda has been successful in implementing PrePex as a non-surgical MC procedure, a strategy to supplement surgical MC to achieve the Ministry of Health target of two million adult male circumcisions by 2012.

However, the number of men circumcised in the first two years period at RMH was small compared to the two million targeted men; as of 2014,

PrePex was only implemented at RMH health facilities in Rwanda and during army weeks and RMH outreach activities.

Given these promising results, and that the procedure can be performed in a non-sterile environment with a non-physician with very few adverse events, it strongly encouraged the scale up of PrePex MC at all district hospitals in Rwanda.

Today Rwanda biomedical center (RBC), Rwanda Military Hospital (RMH), Aids Healthcare Foundation (AHF), JHPIEGO, PIH, DCI District hospital and health centers partner to carry out non- surgical circumcisions PrePex in Rwanda.

According to Dr. Niyonzima Japhet the person responsible for non-surgical circumcision department at RBC, the Government has done a lot in training staff, mobilizing and educating the masses about the importance of circumcision through radios, TVs, campaigns and community education.

"We do routine male circumcision service provision of non-surgical (PrePex) and surgical male circumcision methods in all Government hospitals and in 150 health facilities and also do circumcision campaigns country wide. We have moved from 15% in 2010 up to 30% in 2015 of male circumcised and the national target of Mc is 66% by 2018 as the demand has increased. We are optimistic that the target will be reached” Dr. Niyonzima explained.

Peer pressure

There is surprisingly little opposition to adult circumcision in Rwanda. Western opponents to male circumcision argue that removal of the foreskin dramatically decreases sensations of pleasure for men, but Rwandan men appear very happy with their circumcisions, and if they are not, they are certainly not speaking up about it.

Health officials say that some of the only men unwilling to part with their foreskins are older, married men who do not see any reason to change their ways.

"Specifically older men may feel that it is taking part of their dignity yet they are also among those targeted to prevent HIV transmission,” explains Dr Bienvenue Niyongabo, a medical officer at AHF.

"It’s really changing,” says Dr. Niyongabo,” says Dr. Placidie, "Looking at the demand we have today, people are really beginning to understanding how important circumcision is in HIV and also STI prevention” he adds.

The program is really a success and today over 10,000 men received 2 tetanus vaccination jabs before undergoing PrePex every month across the country.

The government is continuing to run campaigns on non-surgical circumcision and to scale up the practice to all heath centers in the country so that all men seeking to get circumcised with PrePex will be able to reach a clinic easily.