Male Circumcision News
Rwanda rolls out PrePex
Rwanda became the first country to begin nationwide use of a device for performing adult male circumcision, The New Times reports. Minister of Health Agnes Binagwaho said scaling up use of the PrePex device would help the national programme achieve its goal of circumcising 700,000 men by 2016. PrePex-assisted male circumcision does not required local injection of anaesthesia or sutures, and it can be performed by nurses in a clean, non-sterile setting. The PrePex device was pre-qualified by the World Health Organization in May 2013 after a clinical and regulatory evaluation (The New Times, 27 November 2013).
Creating a new norm
Ethiopia has one of the highest rates of male circumcision in sub-Saharan Africa, but until recently people in one region have viewed the procedure with suspicion, IPS reports. The dominant ethnic groups in Gambella Province considered male circumcision alien to their culture, but attitudes toward the procedure have begun to change since the launch of a voluntary medical male circumcision programme in 2009. When the programme began, less than 47 percent of men in Gambella were circumcised and the province had an HIV prevalence rate three times the national average. To date, the programme has served more than 32,000 clients (Inter Press Service, 25 November 2013).
Ugandan provider has circumcised 13,000
His peers say that clinical officer George Mwidu Lyavala has circumcised more men than anyone else in Uganda. In an interview with New Vision, Mwidu described his work as a health care provider and trainer for Uganda’s voluntary medical male circumcision programme (VMMC), which aims to reach about 4.2 million men by 2015. Mwidu has circumcised some 13,000 men, or about 3 percent of the 418,223 Ugandans who have received VMMC services to date. Circumcising men makes him happy, Mwidu told New Vision, because “I feel like I’m directly contributing to the fight against HIV” (New Vision, 21 November 2013).
POZ analyzes circumcision debates
Major studies support male circumcision as HIV prevention in Africa, but a small yet vocal group argues the science is flawed, POZ Magazine reports. The article analyzes the arguments in this debate, quoting proponents and opponents of male circumcision for HIV prevention and providing links to publications written from both points of view (POZ Magazine, October 2013).
Safer traditional male circumcision promoted
Provincial health authorities in South Africa’s Western Cape will provide sterile male circumcision kits to traditional circumcisers, reports IOL News. Under an agreement signed by the province’s health minister and the traditional leader of the greater Robinson area, initiates are to be circumcised in a more sterile environment and receive health support services, such as post-operative and HIV counseling. The agreement is designed to support safer traditional circumcision while respecting the initiation process. It applies only to the greater Robinson area, but the provincial health minister said it was “a forerunner” of agreements with traditional leaders in other parts of the province (IOL News, 23 September 2013).
Community-based study shows impact
A male circumcision programme in South Africa was associated with a community-wide reduction in HIV prevalence, Medpage Today reports. A study conducted in Orange Farm from 2007 to 2011 found that in the first three years of the programme, the percentage of men who were circumcised rose from 12 percent to 53 percent. Without these circumcisions, the researchers estimate, HIV prevalence would have been 19 percent higher in Orange Farm, site of an earlier clinical trial of male circumcision for HIV prevention. This follow-up study of male circumcision’s impact in a “real-world” setting also found no evidence that male circumcision was accompanied by an increase in risky sexual behavior, such as not using a condom or having multiple partners (Medpage Today, 7 September 2013).
Male circumcision findings reported at conference
Three studies on voluntary medical male circumcision (VMMC) were presented at the 6th South African AIDS Conference, reports the Aidsmap newsletter HIV & AIDS Treatment and Practice. One study examined the sexual practices of circumcised men after the procedure, another compared the outcomes of VMMC for HIV-positive and HIV-negative men, and a third found high acceptance of VMMC among secondary school students. The first study found that 76 percent of the circumcised men observed the recommended six weeks of sexual abstinence during wound healing. Reported condom use during last sex declined from almost 66 percent before male circumcision to 52 percent 12 months after the procedure. In the second study, none of the HIV-positive men developed wound infections after circumcision, but five of 648 HIV-negative men did (HIV & AIDS Treatment and Practice, 9 September 2013).
Male circumcision uptake rises in Zimbabwe
More than 50,000 men were circumcised in Zimbabwe during the first half of this year, surpassing the total number of men reached in 2012, NAM News Network reports. The country’s voluntary medical male circumcision (VMMC) programme, which aims to reach 1.3 million men by 2017, circumcised 11,000 men in 2010, 36,000 in 2011, and 40,000 last year. The article quotes Brian Nachipo, AIDS and TB Unit advocacy and communications officer, saying that after reaching 50,348 men in the first six months of 2013, the VMMC programme “has since continued to witness an increase in males circumcised as more doctors, nurses, and other team members are trained to provide safe medical services” (NAM News Network, 5 September 2013).
Regulation of traditional circumcision urged
Medical methods of male circumcision should be integrated with traditional practices, advocates an editorial in South Africa’s Mail & Guardian. Noting that traditional circumcision has caused almost 100 deaths this past initiation season and left other boys without penises or with mutilated penises, the editorial says that “the ceremony that was supposed to give them manhood has, in fact, deprived them of it.” Based on an article about the dangers of traditional circumcision in South Africa, the editorial also calls for training and regulation of traditional circumcisers. It recommends using the health department’s medical circumcision programme as a resource for initiation schools (Mail & Guardian, August 2013).
Review examines sex after male circumcision
A review found that the most rigorous studies of the effects of male circumcision on sex show no adverse impact on male sexual function, sensitivity, sexual sensation, or satisfaction, reports The Daily Telegraph. The researchers identified 2,675 articles on the subject, but only 36 met the study criteria of presenting original data. Of the 36, the 23 rated as high-quality or well-conducted studies (according to the Scottish Intercollegiate Guidelines Network grading system) uniformly found no adverse effects; 10 of the 13 low-quality studies reported a negative effect on one or more measures of sexual function or satisfaction. In the highest-quality studies, however, most men who had been circumcised as adults reported that sex was more enjoyable after circumcision (The Daily Telegraph [Australia], 15 August 2013).
Chief champions male circumcision
Risking impeachment by members of his tribe, a Zambian chief became circumcised at age 47 after learning of the health benefits of the procedure, The Washington Post reports. Chief Jonathan Eshiloni Mumena is one of a growing number of men getting circumcised in Zambia, where 17 percent of adults are infected with HIV. His tribe does not traditionally circumcise young men, so the chief was surprised when his son declared that he planned to go for the procedure. Now the chief, who is also a lay preacher, has become an advocate for medical male circumcision (The Washington Post, 2 August 2013).
Male circumcision acceptable in Papua New Guinea
A significant number of men in Papua New Guinea (PNG) are willing to be circumcised once they learn that the procedure can reduce the risk of HIV infection, reports IRIN. Complete male circumcision is uncommon in PNG, but almost half the men there have undergone some type of penile cutting. (It is unknown whether partial removal of the foreskin protects against HIV.) A survey of 860 men found that 71 percent of those with no penile cut would get circumcised if it reduced their risk of HIV, as would 84 percent of those who had already had their penises partially cut. In another study, men cited four main reasons for agreeing to be circumcised: prevention of HIV and sexually transmitted infections, improved penile health and hygiene, cultural acceptance, and increased sexual pleasure (IRIN, 22 July 2013).
Save the date: Devices for Adult Medical Male Circumcision for HIV Prevention: What's the Current Situation? What's Next?'
Hosted by PEPFAR, this webinar is the third in a series of five focused on VMMC. The webinar will be hosted from 8:00–10:00 a.m. US EDT on 21 August.
To join, click here, enter your name as a GUEST and type the pasword 1776. For more information, For more information, contact Emmanuel Njeuhmeli at or Tigistu Adamu Ashengo.
Uganda to launch national programme
The Ugandan government will begin a nationwide male circumcision programme in July as part of its HIV prevention strategy, reports IRIN news service. Dr Alex Opio, assistant commissioner for health services in the Ministry of Health, told IRIN that male circumcision will be available in national referral hospitals, district hospitals, and county-level health centres that have the capacity to conduct minor surgeries. He added that male circumcision is not a “magic bullet,” but an additional tool in the country’s prevention arsenal. The government started drafting its male circumcision policy in 2008 and says it now has the funding and plans in place to begin the programme (IRIN, 29 June 2013).
South Africa to pilot PrePex
The South African health department will consult with traditional leaders about the possibility of training traditional circumcisers to use PrePex, a device for performing male circumcision that was recently “prequalified” by the World Health Organization, reports the Mail & Guardian. The government seeks to make traditional circumcision safer following the deaths of 35 boys in one month after they were circumcised during initiation ceremonies. The health department will also test the feasibility of introducing the device as part of its medical circumcision campaign, with eight pilot sites offering the option of PrePex-assisted circumcision or conventional surgery set to launch in Gauteng, Mpumalanga, and North West provinces in the next two months (Mail & Guardian, 18 June 2013).
Male circumcision and sexual function
Male circumcision is unlikely to have an adverse effect on men’s sexual function, concludes a study published online 10 June 2013 in the Asian Journal of Andrology. Researchers from Sichuan University conducted a meta-analysis of 10 studies that described a total of 9,317 circumcised men and 9,423 uncircumcised men who were evaluated for an association between male circumcision and sexual function. There were no statistically significant differences between the two groups in sexual desire, pain during intercourse, premature ejaculation, erectile dysfunction, or difficulties achieving orgasm. The authors caution, however, that well-designed prospective studies are needed to better understand this topic.
PrePex studies continue
The World Health Organization announced on 31 May that it has “prequalified” the PrePex device for performing circumcision on adult men, but safety and acceptability studies of the device continue because prequalification does not replace countries’ own regulatory processes, reports Africa Science News. The article quotes Dr. Walter Obiero, Nyanza Reproductive Health Society director, who is a co-investigator on a PrePex implementation study his organization is conducting with the Male Circumcision Consortium and the National AIDS and STD Control Programme in Kenya’s Nyanza Province. Dr. Obiero says this research will provide the information the Ministry of Health needs to decide whether to add PrePex to the national voluntary medical male circumcision programme (Africa Science News, 9 June 2013).
Join AVAC's 11 June Webinar on Non-surgical Devices
Please join AVAC for a global advocates’ webinar on VMMC devices Tuesday, 11 June at 10am US Eastern time (4pm Johannesburg / 5pm Nairobi time) and discussion of the recent news that the WHO prequalified the PrePex device. This webinar, "VMMC Non-Surgical Devices: WHO pre-qualification and beyond," is designed to help advocates understand the pre-qualification process, recent events and next steps for rollout. It will include brief presentations followed by a moderated discussion.
Advance questions are welcome at firstname.lastname@example.org.
PrePex first device to “prequalify”
The World Health Organization has “prequalified” a device for performing circumcision for adult men based on a review that included studies conducted in Rwanda, Uganda and Zambia, reports the Science Speaks blog. PrePex™ became the first such device to achieve prequalification, which indicates that the device meets international standards but does not replace countries’ own regulatory processes. A statement from the U.S. Office of the Global AIDS Coordinator announced that the President’s Emergency Plan for AIDS Relief (PEPFAR) will provide immediate support to help countries evaluate the device for their local settings (Science Speaks, 31 May 2013). For information about the prequalification process and the status of pre-qualification applications for PrePex and other male circumcision devices, click here.
Study may help explain protective effect
Changes in the bacteria living on and around the penis may be partly responsible for male circumcision’s protective effect against HIV infection, a study suggests. Scientists conducted a detailed genetic analysis of the microbial inhabitants of the coronal sulcus, the groove behind the head of the penis, among a group of Ugandan men ages 15 to 49 years who participated in a randomised clinical trial of male circumcision for HIV prevention. After 12 months, the circumcised men harbored dramatically fewer bacteria that survive in low-oxygen conditions compared to the uncircumcised men. The researchers suspect that in uncircumcised men, these anaerobic bacteria may provoke an inflammatory response that favors HIV infection. In an article published in the journal mBio, they call for more research to understand how reductions in anaerobic bacteria may contribute to the reduced risk of HIV acquisition conferred by male circumcision (Los Angeles Times, 15 April 2013).
Campaign aims to reach university students
The University of KwaZulu-Natal has launched a medical male circumcision campaign to inform students about the benefits of male circumcision and behaviours that promote good sexual health, SABC News reports. A provincial health official performed two male circumcisions to mark the launch of the programme. Saying that he is circumcised, he urged other men to go for the procedure. The university’s HIV/AIDS programme coordinator said that the campaign also includes HIV testing and counselling and information about how to practice safe, healthy sex (SABC News, 11 April 2013).
Youth respond to Malawi campaign
While the voluntary medical male circumcision (VMMC) programme in Malawi aims to reach men ages 15 to 49, most of its clients have been 15 to 25 years of age, Capital FM of Malawi reports. PSI has established VMMC clinics in government health centres in Blantyre and Thyolo districts and hopes to provide VMMC services to 16,500 men ages 15 to 49 by September of this year. At one of the clinics, PSI had to erect tents and bring in more surgeons to meet a demand of more than 50 clients per day. Factors contributing to the age discrepancy have yet to be elucidated (Capital FM, 9 April 2013).
Why adults seek or avoid male circumcision
A perception that male circumcision is inappropriate after puberty, and particularly after marriage, may keep men from going for the procedure, suggests a study involving 16 focus group discussions with 142 men and women in Iringa and Njombe, Tanzania. Reaching men 20 years and older is a priority for Tanzania’s programme, but 85 percent of the 110,000 men circumcised in these regions were ages 10 to 19. Other barriers to circumcision among men older than 19 included being ashamed to seek services in facilities also serving boys, concerns about marital infidelity during the post-operative period of sexual abstinence and loss of income, and fear of pain associated with post-surgical erections. But male circumcision is viewed as a desirable procedure. Factors encouraging men to get circumcised include awareness of its HIV-prevention benefit and perceptions of cleanliness and enhanced attractiveness to women (Global Health: Science and Practice, 21 March 2013).
PrePex study launched in Kenya
A study in Kenya is the first to assess the safety and acceptability of the PrePex device for performing adult male circumcisions in routine health care settings, Jaluo.com reports. Launched by the National AIDS/STI Control Programme (NASCOP) and the Male Circumcision Consortium, the study will enroll 425 men ages 18 to 49 who seek VMMC services. “Our study will provide the information that the Ministry of Public Health and Sanitation needs to decide whether to add PrePex to the national programme on voluntary medical male circumcision,” says Dr. Peter Cherutich, NASCOP director for HIV prevention and co-investigator for the study (Jaluo.com, 22 February 2013).
Scale-up slow despite health benefits
Progress toward increased prevalence of voluntary medical male circumcision (VMMC) in sub-Saharan Africa remains slow, reports an Aidsmap article about presentations given at two sessions of the 20th Conference on Retroviruses and Opportunistic Infections (CROI 2013) on 4 March. This slow pace is due as much to men’s concerns about the procedure as it is to resource constraints, despite low rates of complications of VMMC. Links are provided to abstracts presented at the sessions, including ones on the cost-effectiveness of VMMC, its health benefits to women in Rakai, Uganda, and the safety of the procedure in Nyanza, Kenya (Aidsmap, 7 March 2013).
Services expand access to STI screening
Voluntary medical male circumcision services (VMMC) services offer an opportunity to diagnose and treat or refer clients with HIV and other sexually transmitted infections, write the authors of an abstract presented at the 20th Conference on Retroviruses and Opportunistic Infections (CROI 2013) on 4 March. A review of data on 33,854 clients ages 15 and older who sought VMMC services in Tanzania’s Iringa and Tabora regions found that 1.37 percent tested positive for HIV. The prevalence of all STIs was 1.66 percent, including 1,296 confirmed cases of HIV and 310 cases of other STIs. Almost three-quarters of the STI clients were self-referred to VMMC services, and none had been referred by STI clinics.
Infant male circumcision in Botswana
Ninety-three percent of 547 mothers surveyed at three Botswana maternity wards said they wanted their newborn sons circumcised, but only 55 percent (302) took their sons to have the procedure, researchers reported in an abstract presented at the 20th Conference on Retroviruses and Opportunistic Infections (CROI 2013) on 4 March. Mothers who said that they made the decision alone were more likely to have their sons circumcised; conversely, infant sons were less likely to get circumcised if their fathers made the decision. The researchers concluded that education about infant male circumcision should be directed toward mothers, fathers, and maternal grandmothers, who are all likely to participate in decision-making about the procedure.
Canadian paediatricians to change policy
The Canadian Paediatric Society is poised to change its policy on infant male circumcision, based on recent evidence of health benefits, the Ottawa Citizen reports. The current policy, issued in 1996, opposes routine circumcision of newborns. The new statement is expected to be more neutral, balancing the “potential role of the avoidance of infection" against the risks of a surgical procedure. A new study suggests that half of expectant parents in Canada would consider circumcision if they had a son and the single most important factor in that decision is whether the father is circumcised (Ottawa Citizen, 4 March 2013).
PEPFAR Webinar, March 19
A webinar about voluntary medical male circumcision (VMMC) by the President's Emergency Plan For AIDS Relief (PEPFAR) will include discussion of PEPFAR technical considerations and revised VMMC indicators, data quality assessment and reporting, continuous quality improvement, and external quality assessment. This session will be the first of a series of PEPFAR VMMC webinars.
When: March 19, all day
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Results of device trial promising
A randomised trial in Rwanda found that male circumcision was performed much faster with the PrePex device, but the healing time was longer, the International AIDS Society reports. The trial among 217 men compared male circumcision performed with Prepex, a procedure that does not require stitches, with conventional male circumcision surgery. The average time to complete the procedure was 3.1 minutes with PrePex, compared to an average of 15.4 minutes for traditional surgery; time to complete healing was seven days longer for PrePex-assisted surgery. The reported rate of complications with PrePex was 2.7 percent. In an article in the Journal of Acquired Immune Deficiency Syndromes, the authors conclude that PrePex takes significantly less time than conventional surgery, is safe and bloodless, and seems suitable for nurses to perform.
Evidence favors infant male circumcision
The benefits of infant male circumcision (IMC) outweigh the risks, and the procedure should be available to families who choose to circumcise their sons, a group of US pediatricians has concluded. Previously the American Association of Pediatricians had taken a neutral stance towards IMC. The updated policy, published 27 August in the journal Pediatrics, is based on a review ofrecent evidence on the benefits of IMC. Voice of America reports that the policy does not recommend routine circumcision of infant boys, but it does say that health insurance should cover the procedure. A study published in the Archives of Pediatrics and Adolescent Medicine estimates that in the United States, a 20-year decline in the prevalence of IMC from 79 percent to 55 percent — which has coincided with decreased insurance coverage for the procedure — has already cost up to $2 billion in health care costs (VOA, 29 August 2012).
Criticisms of trials refuted
The scientific evidence of male circumcision’s protective effect against male-to-female transmission of HIV is “solid, consistent and beyond a reasonable doubt,” experts from leading universities and other institutions conclude in an article published in the Australian.Journal of Law and Medicine. The authors provide a comprehensive overview of the evidence that male circumcision reduces men’s risk of acquiring HIV through vaginal sex by about 60 percent. Aiming to “put science back at the core of the debate,” they also evaluate each claim made in an article published in JLM in December, demonstrating how its authors used flawed statistical analyses, outmoded evidence, selective reporting of studies, data from non-peer-reviewed sources and misleading statements to question the effectiveness of male circumcision for HIV prevention (JLM, 5 September 2012).
Taking services to the streets
Rather than wait for clients to come to their clinics, providers of voluntary medical male circumcision have taken their services to the streets of Nairobi. The providers say that pitching tents in the central business district of Kenya’s capital each day has enabled them to serve men who otherwise would not have been reached. The large tents serve as health information and counseling centers for men and women; men who decide to get circumcised are referred to a nearby clinic. In the first three months, 1,000 men who accessed services through the information tents became circumcised (Coastweek,30 August 2012).
Musician advocates for male circumcision
One of Zimbabwe’s most influential musicians has joined a campaign to encourage men to get circumcised to prevent HIV infection, New Zimbabwe reports. Musician Oliver Mtukudzi became an advocate for HIV prevention after the AIDS-related deaths of four members of his band, including his younger brother, in 1996. In an interview before a concert in London, he hailed the success of Zimbabwe’s efforts to reduce HIV transmission but said more needs to be done. “If we are to have an HIV-free generation, it has to start with this generation,” he said (New Zimbabwe, 16 August 2012).
Male circumcision a PEPFAR priority
President Barack Obama has committed the US President’s Emergency Plan for AIDS Relief (PEPFAR) to providing 4.7 million men and boys with voluntary medical male circumcision (VMMC) by 2014, according to an article published in the 15 August supplement to the Journal of Acquired Immune Deficiency Syndromes. The article summarises the scientific evidence for male circumcision for HIV prevention, describes the public health benefits of expanding access to VMMC services, and reviews progress to date, presenting Kenya’s programme as a case study of successful scale-up. The challenges faced in scaling-up VMMC are greatly outweighed by the benefits of its impact on the HIV epidemic, the authors conclude.
Protective effect sustained
Study results from South Africa and Kenya presented at the AIDS 2012 conference on 24 July offer further evidence of the protective effect of male circumcision against HIV infection. In Orange Farm, South Africa, an increase in the prevalence of male circumcision from 17 percent to 54 percent coincided with a drop in HIV prevalence from 15.4 percent to 12.3 percent. Providing free voluntary medical male circumcision along with condoms and counseling about the need for circumcised men and their partners to continue taking precautions against HIV infection prevented an estimated 1,040 HIV infections in the township from 2008 to 2011. In Kenya, continued follow-up of 1,500 men who had participated in the randomised controlled trial of male circumcision in Kisumu revealed that getting circumcised reduced men’s risk of acquiring HIV by more than half after five-and-a-half years. The article notes that male circumcision offers men partial, but not complete, protection from HIV (ScienceNews, 25 July 2012).
South Africans embrace HIV prevention measures
More South Africans are getting tested for HIV, using condoms and becoming circumcised, the National HIV Communication Survey has revealed. The survey found that more than half of South African men are circumcised, and almost 1 million men were considering getting the procedure done in the next year to help protect themselves from HIV. In a telephone interview, Health Minister Aaron Motsoaledi said that skeptics had feared that promoting male circumcision would reduce condom use. “Eight-five percent of men who are circumcised know they must use condoms, which shows that fear was misplaced," he said (BusinessDay, 25 July 2012).
Chief champions male circumcision
Shocked at first when his son said he wanted to get circumcised, the chief of a non-circumcising clan in Zambia learned about the benefits of the procedure and risked community censure by agreeing to his son’s request. Chief Jonathan Mumena then decided to get circumcised himself, to serve as an example to his people, and he has worked with health centres to mobilise hundreds of men in his chiefdom to seek voluntary male circumcision services. “Culture is very important, but the number one priority is to keep our people healthy and alive,” he says (Mail & Guardian, 20 July 2012).
Zimbabwean MPs to be circumcised
25 June update!
Zimbabwe MPs Get Circumcised, Tested for HIV
A total of 106 members of Parliament were tested for HIV and more than 40 male MPs were circumcised in an HIV prevention initiative among lawmakers and high-ranking government officials that was the first of its kind in Africa. After receiving HIV counseling and testing at a mobile clinic in Harare, the deputy prime minister, speaker of the House of Assembly and seven MPs revealed that they had tested negative for HIV prevention. Speaker Lovemore Moyo that said by going public about their testing and circumcision, the lawmakers were "leading by example." Several officials discussed the experience and urged others to come forward for HIV testing and male circumcision (Newsday [Zimbabwe], 25 June 2012, AFP, 23 June 2012).
Friday, 22 June 2012 — Male members of Zimbabwe’s Parliament are getting counseled, tested for HIV and circumcised at a temporary clinic set up in the Parliament House in Harare, the BBC News reports. About 120 men from the 175-member body are expected to receive these services to set a public example and reduce their risk of HIV infection. In May The Telegraph (UK) reported that the MPs had formed a group, Zimbabwe Parliamentarians against HIV and AIDS, and they planned to disseminate information about HIV to their constituents in an effort to reduce the country’s 15 percent HIV prevalence rate (BBC News, 22 June 2012; The Telegraph, 20 May 2012).
Botswana’s new pitch for male circumcision
Botswana’s government has enlisted the help of popular musicians and has launched an advertising campaign touting the benefits of safe male circumcision, AFP reports. In the past three years the country’s male circumcision programme has circumcised only 7 percent of the 460,000 men it aims to reach. Male circumcision programmes in other countries in southern Africa, the region hardest hit by HIV, are also falling short of their goals. The article notes that Botswana has no tradition of male circumcision, “giving the government a tough sales pitch — even for a procedure done with local anesthetic, taking only a few minutes and requiring only a few days recovery.” Popular musicians Odirile Vee Sento and Oliver Mtukudzi have teamed up to compose a song in English about male circumcision that is being broadcast across southern Africa (AFP, 14 May 2012).
Safety assessed in rural outreach settings
A study of male circumcision performed at Marie Stopes International mobile outreach sites in Kenya’s Nyanza and Western Provinces in 2008 found low rates of complications and high rates of client satisfaction. A total of 240 men and boys were circumcised over three months by registered nurses, surgical technicians, or nurse aides. Complications occurred in just three (1.3 percent) of the 240 procedures. At the follow-up visits on days three and seven, more than 91 percent of clients were capable of resuming their daily activities; by day 30, all could do so. The majority of patients (99 percent) reported being satisfied with the procedure, counseling, and information received. “Male circumcisions can be delivered safely and successfully by mid-level providers in rural settings with high client satisfaction, thereby increasing access to HIV prevention services” the authors concluded (HIV AIDS [Auckl.], 10 April 2012).