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RWANDA: Cutting Edge HIV/AIDS Prevention Presents Challenges

Aimable Twahirwa

KIGALI, Feb 21 2008 (IPS) - Certain medical workers in Rwanda have expressed concern about the country’s campaign to promote male circumcision as a means of curbing the spread of HIV. They fear that in a country with low levels of knowledge about sexual health, people could mistakenly believe the procedure offers complete protection against the virus.

An epidemiologist based in the capital, Kigali, said there was a risk of “a bloodbath in the country once circumcision is taken as an anti-AIDS measure.”

Cyriaque Twagirumukiza, a general practitioner in the city, is also apprehensive: “Most of the difficulties relate to convincing men that circumcision does not exclude…the use of condoms during sex.”

The campaign got underway this month amidst figures showing that HIV prevalence is on the rise in this Central African nation – from three to 3.6 percent during the past year, according to government.

A number of studies have indicated that circumcision – which involves the removal of part or all of the foreskin from the penis – substantially reduces a man’s risk of contracting HIV during penile-vaginal intercourse.

Trials sponsored by the National Institutes of Health in the United States and the Canadian Institute of Health Research in Kenya and Uganda have shown a 53 percent and 51 percent decline in risk, respectively. Similar findings were made during a study funded by the French National Agency for Research on AIDS that was carried out in South Africa; results of this research, published in 2005, indicated a minimum 60 percent reduction in infection.

The inner, mucous membrane of the foreskin is said to have a greater number of cells that are targets for the HI-virus – notably Langerhans cells – than the external surface of the skin, making it more vulnerable to infection than other penile tissue. (Langerhans cells are immune system cells located in the skin.)

In addition, the warm, humid area between the foreskin and penis head is seen as a favourable environment for HIV, which may also be able to penetrate the foreskin because of other factors.

Noting that circumcision cannot provide a complete safeguard against HIV, health workers emphasise the need for other protective measures.

“It is…critical to ensure that clear and correct information on the continuing need for other HIV prevention measures is also provided,” say the World Health Organisation (WHO) and Joint United Nations Programme on HIV/AIDS (UNAIDS) in a March 2007 document, ‘New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications’.

“Communities, and particularly men opting for the procedure and their partners, require careful and balanced information and education materials that underline that male circumcision is not a ‘magic bullet’ for HIV prevention but is complementary to other ways of reducing risk of HIV infection.”

Innocent Nyaruhirira, secretary of state in charge of fighting AIDS and other diseases, acknowledges that “more time is needed to sensitise all people” about the potential benefits of circumcision.

Nonetheless, government is pushing ahead with the initiative, notably as concerns new-borns, and groups such as students and soldiers, although there are no published figures as yet for the number of people circumcised since the start of the campaign.

In the surgical waiting room at the University Hospital Centre of Butare, in the south of Rwanda, queues can be seen every Thursday as various groups of people – the overwhelming majority of them teenagers – wait their turn with a doctor to be circumcised.

The health ministry has also started to provide medical equipment for circumcision to all health centres in the country.

According to the WHO and UNAIDS, “Integrated approaches to deliver male circumcision services with other essential HIV and sexual health services are most likely to be sustainable in the longer term.”

“However, vertical, stand-alone programmes that provide the recommended minimum package of services may be useful in the short term to expand access to safe male circumcision services and to train providers in standardized procedures, especially where demand is high and health systems are weak.”

At present, Rwandan parents normally circumcise their new-borns for social, cultural or religious reasons – although more than 80 percent of the population is Christian, and does not have circumcision as a religious requirement (most Muslim and Jewish men are circumcised).

For Yvonne Umubyeyi, who took her two-year-old son for a consultation on circumcision, having the procedure carried out is a matter of good hygiene: “The intention is not to protect my son against AIDS in the future,” she told IPS.

Some claim that circumcision is said to reduce instances of urinary tract infections and cancer of the penis, among other diseases. However, others dispute this view.

“The current consensus of most experts is that circumcision should not be recommended as a prevention strategy for penile cancer,” notes the American Cancer Society on its website.

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