Recently, the World Health Organization (WHO) recommended male circumcision as a tool for reducing risks of acquiring HIV/Aids virus. It said circumcised men have about 60 percent-risk free chances of not catching the virus during sexual intercourse.

Recent research has proved that a circumcised surface epithelium of the male organ develops a protective keratin layer, a form of natural condom. Thus, circumcision could reduce the HIV incidence by directly decreasing the susceptibility of uninfected men to HIV/Aids.

Circumcision could also reduce the incidence of HIV by directly decreasing the infectivity of men with HIV, as suggested by the studies of tissue samples collected from macaques infected with the simian immunodeficiency virus (SIV), which showed infected mononuclear cells in the dermis and epidermis of the penile foreskin.

In the past, circumcision has been advocated for many reasons: for religious purposes among the Jews and Muslims; for cultural reasons among several African ethnic groups ;( the Bagisu in Eastern Uganda), for reasons of hygiene in the United States, Canada, and Australia and for therapeutic purposes as the cure for phimosis.

Consequently, circumcision is almost universal in some parts of the world for instance United States and Muslim countries but rare in Europe and South America.

The potential public-health benefits of male circumcision have been greatly discussed in the past 50 years, often in a passionate and emotional manner and therefore relatively few studies have been carried out and those that have often present conflicting results.

Mathematical models of implementing male circumcision in countries with high incident rates suggest marked reductions in HIV incidence in men with subsequent decreased transmission rates to women.

Rwanda’s stand on circumcision

The government recently joined other countries to advocate for male circumcision as a tool to fight against HIV/Aids, but insists on maximum caution as the policy is implemented by Health ministry.

As such, the government says is about to start mass male circumcision as a way of reducing the spread of HIV/Aids and Sexually Transmitted Diseases.

In the interview with the Executive Secretary of the National Commission for HIV/Aids prevention (CNLS), Dr Agnes Binagwaho revealed that circumcision can not prevent someone from contracting the HIV virus but would only reduce on the risks by only 4 out of 10 risks someone had.

"We can not rely on circumcision as a method of preventing HIV/Aids among the masses but we do emphasize that education is needed for people to know how to protect themselves from the disease,” Dr Binagwaho added.

The Health ministry says that Rwanda would adopt male circumcision as one of the preventive measures against the disease.

The State Minister for HIV/Aids and other Epidemic Diseases, Dr Innocent Nyaruhirira recommends that Rwandan men should start going for circumcision at medical centers qualified in medical personnel.

He said that the Health ministry is currently in the process of upgrading and availing relevant equipment in hospitals and health centers to enable the circumcision operation during a press conferences at TRAC headquarters last month.

A document from the ministry states that mass circumcision would kick off with the army, police and students from higher institutions of learning.

Dr Nyaruhirira warned that circumcision does not provide a "green light for promiscuity because it does not guarantee 100% prevention of the virus.”

"Let no one understand that once circumcised, men can go ahead and indulge in unprotected sex, circumcision only protects one from HIV/AIDS by 60 percent. There is a big risk of 40 percent,” he warned.

The Director of the Aids Treatment and Research Center (TRAC) Anita Asiimwe said in an exclusive interview that circumcision had been proved by several researches in Africa as a strategy for reducing HIV/Aids prevalence rate.

"Male circumcision not only protects the man but also the woman. The organisms harbored in the foreskin of an uncircumcised male can easily be passed on to the woman during intercourse and this is the main origin of cervical cancer,” Dr Asiimwe said.

Last year, three groundbreaking studies conducted in Uganda, Kenya and South Africa found that male circumcision reduces a man’s risk of being infected by the human immunodeficiency virus (HIV).

"Male circumcision has been proven to be one of the ways through which Aids transmission can be prevented. Males who are not circumcised are more vulnerable to the virus than those who are circumcised,” she said.

She said that the reason why a circumcised male may not contract Aids mainly lies in the absence of the foreskin. "The foreskin harbors and nurtures many organisms including the Aids virus, which eventually enter the bloodstream.

"The same organisms will not survive on a circumcised male because they are exposed and lack the favorable conditions from which to launch their entry into the body,” Dr Asiimwe added.

For an uncircumcised man, she observed, the foreskin peels away during sexual intercourse, leaving a tender muscle that is quite susceptible to ulceration, hence the easy transmission of the Aids virus if the other partner is positive.

"A circumcised male, due to exposure, is unlikely to get any ulceration during intercourse because his skin is relatively hardened,” she said, adding that male circumcision has more advantages than just the prevention of HIV/Aids and other STDs.

The Minister of Health, Dr Jean Damascene Ntawukuliryayo also in an exclusive interview said male circumcision has many advantages in as far as reducing the susceptibility to infectious diseases in concerned, though it has not yet become a national policy.

"It does not prevent HIV/Aids neither can we say that it’s reliable but scientific research reveals that it reduces the risks of infection,” Ntawukuliryayo said.

"Rwandans should see to it to see that the problem is overcome, they have to change their attitudes and beliefs towards the prevention of HIV/Aids,” Ntawukuliryayo explained. The number of people that were tested positive in 2007 was 9714 out of 162209 who under went blood test, thus making the percentage of 5.9 per cent.

Despite a relatively low HIV prevalence rate of 3 per cent, an estimated 22,000 children under the age of 16 are living with HIV/AIDS and account for nearly 10 per cent of all infections nationwide.

As most of these infections are believed to be parentally acquired, services to prevent mother-to-child transmission (PMTCT) have rapidly scaled up at the national level from 23 sites in 2002 to 234 in 2006.

Nassan Muhutu, 35 a resident of Kayonza Eastern Province, says he supports the program and hastened to add that it would be better if they start from primary schools and then to the general community.

Martin Twahirwa, 29 of Kigali city says that it is to the advantage of all men that they are circumcised, and urged concerned people to cooperate with the Health Ministry to realize its mission.

"As we have supported the indoor residual spraying, I think we should also do the same to the circumcision exercise when it starts,” Twahirwa explains.

Lawmakers Vs circumcision

Members of Parliament recently pledged their support to the government’s decision of mass circumcision. Deputy Ezekias Rwabuhihi, a former Health minister said, "Male circumcision is a practice that we have to embrace. However it must be properly and carefully conducted.”

"If the research on male circumcision is correct as World Health Organization (WHO) said, then we have to give full support to the implementation of this policy,” Senator Aloysia Inyumba said. The WHO has repeatedly called on policymakers to consider using male circumcision to contain the Aids pandemic.

But some countries have been slow on this recommendation, with most of the leaders worried that the mechanism might instead fuel irresponsible sexual behaviors. There are also widespread concerns that low income earners might rush to unsuitable people for circumcision, which might result in far-reaching negative consequences.

Criticisms of circumcision as a defensive measure

The major criticism of most of the studies carried out is the lack of attention given to potential confounding factors, which could be related to both circumcision status and risk of sexually transmitted infections, such as sexual behaviors or differences in hygienic practices, or differential use of specific health facilities.

Therefore, further efforts are still required to quantify male circumcision as a measure of HIV prevention. Some of this can be achieved by using observational designs which better address the limitations discussed above.

Laboratory and primate research might also continue to provide useful information. The safety, expected benefits, feasibility and acceptability of mass circumcision are still questionable, neither public-health interventions nor intervention studies appear to be defensible options.

There should be stronger evidence from observational studies in different settings that show lack of male circumcision as a genuinely independent risk.

However, these epidemiologic, biological, and clinical trial results provide strong evidence that male circumcision significantly lowers the risk of HIV acquisition.

Policy implications of recommending male circumcision to populations in high-risk countries also need to take into consideration cultural norms, religious traditions, national and local laws.

Circumcision therefore may represent one important biological intervention in decreasing the acquisition of HIV, but will need to be carefully integrated into other HIV prevention and sexually transmitted disease control programs prevent subsequent behavioral disinheriting among circumcised men.

Other ways Rwanda is fighting HIV/Aids

In the last few years, Rwandan authorities have shown a high level of determination to mobilize all and sundry, in order to elicit a strong response against AIDS.

A testimony to this determination is the personal involvement of the Head of State and of the First Lady, through their leadership, in the reorganization of the fight against the scourge, both at national and international levels.

The need to reorganize and expand the national response to HIV/AIDS, in conjunction with all actors in AIDS control activities has become a national imperative which the NACC recognizes and has emphasized in the 2002-2006 Strategic Framework.

The establishment of TRAC in the Ministry of Health-(MINISANTE), the Programme Coordinating Units are going through a period of reorganization.

Previously, before the creation of the current the National AIDS Control Commission (NACC) in November 2000, the planning and program coordination duties were carried out by the PNLS, which worked in partnership with both the bilateral and multilateral cooperation and agencies NGOs in the promotion of HIV/AIDS programs throughout the country.

Dr Anita Asiimwe the managing Director of TRAC says that the problem of HIV/Aids is continuously slowing down. By the end of 2006, the number of Rwandans who accessed ARVs exceeded 32812 people; and, this represents 64.3% of all people who were in need of medication in Rwanda, in 2006.

Other methods of preventing HIV/Aids include, education of Development partners

During the last decades, several bilateral cooperation agencies have supported Rwanda’s AIDS control programs.

These are: the USAID, the Belgian Cooperation, the Luxemburg Cooperation, the Swiss Cooperation, the German Cooperation, the British Cooperation, the Italian Cooperation and the Canadian Cooperation among others.

The US Secretary for Health and Human Services (HSS), Mike Leavitt announced recently that the US President’s Emergency Plan for Aids Relief (PEPFAR) would soon begin providing money for male circumcision programs in some African countries in an effort to reduce the spread of HIV.

Rwanda would be one of the beneficiaries of the financial assistance. Pepfar recognizes the accumulation of scientific evidence and normative guidance from the WHO and UNAIDS that supports safe male circumcision for the purpose of HIV prevention.

‘The Emergency Plan will follow the WHO/ UNAIDS recommendations on male circumcision for HIV prevention and each host country government’s policies and cultural norms to support interested countries in introducing the new HIV prevention intervention,’ Leavitt said.

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