The world in mad rush for male circumcision but . . .

Getting the most of it. Now that three studies have shown that circumcising adult heterosexual men is one of the most effective “vaccines” against Aids—reducing the chances of infection by 60 per cent or more—public health experts are struggling to find ways to make the process faster, cheaper and safer.

Uganda marks its 50th anniversary as an independent country in 2012 but excessive celebrations could prove contentious or even divisive. The day of the assembly-line circumcision is drawing closer.

Now that three studies have shown that circumcising adult heterosexual men is one of the most effective “vaccines” against Aids—reducing the chances of infection by 60 per cent or more—public health experts are struggling to find ways to make the process faster, cheaper and safer.

The goal is to circumcise 20 million African men by 2015, but only about 600,000 have had the operation thus far. Even a skilled surgeon takes about 15 minutes, most African countries are desperately short of surgeons, and there is no Mohels Without Borders.
So donors are pinning their hopes on several devices now being tested to speed things up.

Dr Stefano Bertozzi, director of HIV for the Bill and Melinda Gates Foundation, said it had its eyes on two, named PrePex and the Shang Ring, and was supporting efforts by the World Health Organisation to evaluate them.

Circumcision is believed to protect heterosexual men because the foreskin has many Langerhans cells, which pick up viruses and “present” them to the immune system—which HIV attacks.

PrePex, invented in 2009 by four Israelis after one of them, a urologist, heard an appeal for doctors to do circumcisions in Africa, was approved by the Food and Drug Administration three weeks ago. WHO will make a decision on it soon, said Mitchell Warren, an Aids-prevention expert who closely follows the process.

From the initial safety studies done so far, PrePex is clearly faster, less painful and more bloodless than any of its current rivals. And it relies on the simplest and least-threatening technology—a rubber band.

The band compresses the foreskin against a plastic ring slipped inside it; the foreskin dies within hours for lack of blood and, after a week, falls off or can be clipped off “like a fingernail,” said Tzameret Fuerst, the company’s chief executive officer, who compared the process to the stump of an umbilical cord’s shriveling up and dropping off a few days after it is clamped.

It is done with topical anesthetic cream, and there is usually no bleeding. And PrePex can be put in place and removed by nurses with about three days’ training.
The rings come in five sizes, A through E, Ms Fuerst said, “and you won’t believe how high-tech the rubber band is.” Each size must apply just enough pressure to cut off blood flow without being tight enough to cause pain.

Complication rate
The WHO, Mr Warren said, is also evaluating the Shang Ring, a plastic two-ring clamp developed in China to treat conditions in which the foreskin becomes so tight that it cuts off urination.

However, it requires cutting off the excess foreskin beyond the clamp, which means the circumciser must inject anesthetics directly into the penis and groin, wait for them to take effect, create a sterile surgical field and be trained in minor surgery.
“The Shang is not as fast, but it’s faster than full-fledged surgery,” Mr Warren said. “And it hasn’t submitted as much safety data.”

In a safety study presented at an Aids conference last month, scientists from Rwanda’s health ministry said they had used PrePex to circumcise 590 men. Only two had “moderate” complications; one was fixed with a single suture, and one required a new band in a different spot.

According to Dr Jason Reed, an epidemiologist in the global Aids division of the Centre for Disease Control and Prevention, two of 590, or 0.34 per cent, is a tenth the typical complication rate of surgical circumcision.
On the 10-point pain scale, they reported on average only about 1 when the ring was placed and only three when it was removed (about the same level of pain caused by erections during the week they wore it).

None of the men became infected.
By the end of the study, the two-nurse teams could do a procedure in three minutes. By contrast, Dr Reed said, the best surgical “assembly lines”—a practice being pioneered in Africa with American taxpayer support—can get down to seven minutes per patient, but only by getting six nurses and a surgeon into a tight harmony.
In theory, he said, breaking that into three two-nurse PrePex teams could mean circumcising around 400 men a day, rather than the 60 to 80 a busy team now does. And the surgeon could go do something more important.

In fact, Dr Reed said, American Aids dollars for circumcisions often go toward an operating room with lights and an instrument steriliser. Instead of circumcisions, hospitals are more likely to use it for procedures like saving women in obstructed labor.