This will be a busy year for Rwanda's health centres as the country attempts to reach its goal of medically circumcising 50 percent of men by June 2013 as part of HIV prevention efforts.
"We plan to extend free male circumcision services to all men in Rwanda - we are targeting two million circumcisions by 2013," said Simoni Kanyaruhango, head of the national male circumcision programme at the Rwanda Bio-Medical Centre. "The programme has, under the sponsorship of the Global Fund [to fight AIDS, Tuberculosis and Malaria], extended the necessary kits ... to all district hospitals, which will in turn offer the service free of charge to the public."
The free male circumcision programme began in October 2011, and officials at the Ministry of Health say demand is growing.
"Here we carry out circumcisions every weekend but we are looking at including the working days as the demand is increasing by the day," said Christian Ntizimira, director of Kibagabaga Hospital in the capital, Kigali.
A large randomized controlled trial in Kenya, South Africa and Uganda found that medical male circumcision can reduce a man's risk of contracting HIV through vaginal intercourse by almost 60 percent.
In order to reach 80 percent coverage - a target set by UNAIDS and the World Health Organization (WHO) under a new plan to accelerate medical male circumcision in eastern and southern Africa - Rwanda would need to circumcise 1,746,052 men; at present, some 15 percent are circumcised.
However, with a severe shortage of highly trained medical staff - according to WHO, Rwanda has just two doctors per 100,000 population - the goal is unlikely to be met unless lower cadre health workers are involved in the campaign.
At present, the programme is using circumcision surgery, the only WHO-approved method.
The government is hoping for WHO approval of a device known as the "PrePex system", which delivers "bloodless" male circumcision and would reduce the need for a sterile environment, anaesthetic and highly trained medical personnel. The PrePex system works through a special elastic mechanism that fits closely around an inner ring, trapping the foreskin, which dries up and is removed after a week.
"This device has been clinically studied and found effective. We are only awaiting approval from the World Health Organization Technical Advisory Group on technical innovations in male circumcision," said Vincent Mutabazi, lead investigator in the PrePex Clinical study.
"With WHO approval of the device, we could perform male circumcisions anywhere, any time or even run mobile clinics out to remote communities rather than have men travel long distances for the circumcisions," said Agnes Binagwaho, the Rwandan Minister of Health.
Messages on male circumcision have been widely broadcast using print and electronic media, and health centres are also being used to promote the programme.
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However, many in the target population remain unaware or afraid of the procedure. "I know about it of course and I appreciate its importance, but what would happen if I don't heal properly or even heal at all?" asked James Nkuusi, a restaurant owner in Remera, a Kigali suburb. "Besides, my wives are used to me the way I am now - my size, you know. If I got circumcised it would be difficult for me to satisfy them I guess, and I would never let that happen."
Experts say male circumcision does not affect penis size.
Rwanda Bio-Medical Centre's Kanyaruhango said the government had made significant progress in demystifying the procedure. It is also being careful to emphasize that male circumcision must work in conjunction with other HIV prevention methods to be successful.
"Male circumcision should only be one element of a comprehensive HIV prevention package, which should include the promotion of condom use, the provision of HIV counselling and testing services and treatment of sexually transmitted infections. And this is what we emphasize," said Kanyaruhango.