Military to lead the way in male circumcision

Early in 2008, the Rwandan Ministry of Health declared its intention to include circumcision scientifically proven to reduce a man's risk of contracting the virus from an infected sexual partner by as much as 60 percent in its HIV prevention programmes. The voluntary circumcision programme is expected to start in August. "We will use the military as role models for the rest of the population they are adult enough to give consent, and if young men see that soldiers are willing to suffer the pain of circumcision, they will also get the courage to do it," said Dr Agnes Binagwaho, executive secretary of Rwanda's national AIDS commission (CNLS). "After the military we will concentrate on students and, finally, on the general population eventually we hope to move on to circumcising new-born babies, as long as research proves that it is advantageous and cost-effective to do so." Unlike many other cultures in the region, Rwandan men and boys are not circumcised as a rite of passage, so it is unclear exactly how many men are circumcised but the number is presumed to be low.

Research is underway to determine the percentage of men eligible for circumcision. Rwanda's Centre for Infectious Disease Control and Prevention, known as TRAC PLUS, is to conduct a 'knowledge, attitude and practice' survey in the army to determine the level of awareness-raising needed, followed by a similar survey among the general population ahead of national rollout of the programme in 2009. "The survey will ask questions like whether or not they know what circumcision is, whether they can name its advantages or disadvantages, whether they will continue to use condoms following circumcision, and so on. After that, CNLS will be responsible for information, education and communicating the message of circumcision to the public," said Elvanie Nyankesha, HIV prevention coordinator of TRAC PLUS. "Our national public awareness campaign is due to start in July [2008] and will make it clear that circumcision cannot replace any of our existing prevention strategies education, abstinence, faithfulness to a single sexual partner and correct and consistent use of condoms," Binagwaho told IRIN/PlusNews. "People must be made aware that although circumcision is beneficial, there is still a 40 percent risk of HIV transmission, so they must know that it must be used in conjunction with another HIV prevention method, such as condom use," she said.

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HIV prevalence in the RDF is estimated at between two and three percent - slightly lower than the national average of three percent. Intense prevention activities have been carried out since the mid-1990s, and barracks and military hospitals are plastered with billboards and posters urging soldiers to use condoms and be tested for HIV. "We recently interviewed 70 men at one of the army's VCT [voluntary counselling and testing] centres and, surprisingly, it turned out that 55 of them had already been circumcised either for hygiene reasons, to prevent other diseases or because they believed it would improve their sexual performance," said Dr Charles Murego, director of medical services in the Ministry of Defence. The circumcision campaign is to be rolled out gradually over a long period, because the 35,000-strong RDF could not afford to have hundreds of men incapacitated at the same time: "We will circumcise, say, 50 soldiers per week it would be too dangerous to carry out mass circumcision in the army." The RDF will also encourage former rebels undergoing disarmament, demobilisation and reintegration to undergo circumcision as they prepare to re-enter civilian society. "We need to train medical staff doctors, nurses and clinical officers at our military hospitals, get the necessary equipment and then start the procedures," Murego told IRIN/PlusNews. The RDF has three military hospitals around the country. Rwanda has more than nine million people, but only one doctor for every 50,000 people and one nurse for every 3,900 people, so increasing the number of medical staff able to perform the procedure is vital to the success of the programme. Nyankesha said doctors who had recently received training in Zambia would start training local practitioners at district level. The circumcision programme will be funded by, among others, WHO and the UN Children's Fund, and carried out according to United Nations World Health Organisation (WHO) guidelines.