Male circumcision and the path to an AIDS-free generation
Agnes Binagwaho is the Minister of Health of the Republic of Rwanda and recipient of an honorary PhD in sciences from Dartmouth College for her lifetime achievement in treating and preventing AIDS.
We have an opportunity to lay the foundation for an AIDS-free generation, as Secretary of State Hillary Clinton declared on Nov. 8. Unfortunately, we’re trying to dig that foundation with a spoon when we have a shovel at our disposal.
We have the capacity to save nearly 4 million lives in sub-Saharan Africa, the hardest hit region in the world, by scaling up voluntary medical male circumcision — the best tool we have for HIV prevention. But the only method widely approved for funding is the surgical method, which is expensive and impractical for countries lacking physicians and surgical infrastructure.
Rwanda’s national goal is to decrease HIV incidence by 50 percent for boys ages 10 to 19 and 30 percent among men age 20 and older. It would take more than 12 years for Rwanda to achieve its national goal to offer voluntary medical male circumcision to the nation’s male population using formal, surgical procedures. We need to reach 2 million men in two years to benefit from the protective effect of the procedure in order to achieve this as part of a comprehensive, combination HIV prevention strategy.
We have clinically studied and approved PrePex, non-surgical device for voluntary adult male circumcision that requires no injected anesthesia. Over 50 percent of nearly 1,100 Rapid Male Circumcision (RMC) procedures were conducted by low-cadre nurses. Using this device, the out-patient circumcision procedure is safe, fast, bloodless and virtually painless. This device aligns with our national policy change, allowing for task-shifting of circumcision way from surgeons and family physicians to nurses and possibly even community health workers.
What’s more, whereas a surgical circumcision can take as long as 20 minutes per patient, this device reduces procedure time to a total of 1.5 minutes to place the device and 1.5 minutes to remove it, meaning we can circumcise more men faster and without compromising their safety or the device’s effectiveness. In fact, in our comparison study between the device and the surgical method, audited on site by WHO and USAID delegates, we found that this device is in fact safer than the surgical method.
Such simple solutions can be game-changers in the fight against HIV/AIDS. Public health officials set a goal to reach nearly 20 million men ages 15 to 49 by 2015, but in four years, Africa has reached less than 3 percent of its target goal. Research consistently proves that circumcised men reduce their risk of HIV infection by 60 percent. By scaling up circumcision to reach the at-risk population of adult men, we could avert millions of new infections and save billions of dollars in donor funds.
It is time to reinvent the vocabulary for what is possible, and I propose to start talking about RMC, Rapid Male Circumcision, because the device we studied can revolutionize our prevention toolkit in Africa. RMC is not a silver bullet but an extremely powerful tool when promoted in combination with other proven prevention strategies.
We need to be able to use every HIV prevention tool at our disposal, and I call on the international community to effectively support the scale up of Rapid Male Circumcision, through the more efficient non-surgical devices that will make the procedure possible in countries with fewer skilled health-care professionals and surgical infrastructure.
Such scalable solutions provide the clearest path to reaching short-term prevention goals, allowing us to continue efforts toward longer-term efforts to abolish the spread of HIV/AIDS for generations to come.
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