A non-surgical circumcision tool could provide a way for initiation schools to eliminate initiate deaths from traditional circumcision complications.
A non-surgical circumcision tool could provide a way for initiation schools to eliminate initiate deaths from traditional circumcision complications.

Government is looking to fast track the introduction of a non-surgical medical male circumcision device, PrePex, that officials believe will decrease
the number of deaths and injuries caused by unsafe circumcision practices
during initiation ceremonies.  

PrePex, which was endorsed or ‘prequalified’ by the World Health
Organisation (WHO) in May 2013, is expected to be introduced in South Africa by
mid-2015, says health department deputy director general for medical male
circumcision Dayanund Loykissoonlal.

PrePex consists of an elastic band that compresses the foreskin,
restriciting blood supply until the foreskin dries and can be cut off after a
week of the PrePex being administered, without stitches, bleeding or
anaesthetic. But before the device can be rolled out nationally, three studies
have to be conducted.

The first PrePex study was carried out at three medical male
circumcision sites in Gauteng and Mpumalanga between August and October 2013.
Further studies must still be carried out in June 2014, followed by a final
round of tests towards the end of the year.

“It is only then that men can access the device in medical male
circumcision sites [around the country],” says Loykissoonlal. “There
is [a] need to revitalise medical male circumcision and I think PrePex will be
a good option for men.”

Reduced HIV risk
South Africa first introduced medical male circumcision in 2010, after scientific studies conducted in Orange Farm west of Johannesburg in 2005 found
evidence that surgically removing the whole foreskin of a penis can reduce a
heterosexual male’s risk of contracting HIV through sex by 60%. Since then,
1.4-million men have been circumcised.

“I am sure the PrePex is going to help us reach out to many men
and therefore scale up circumcision in the country,” says 
Dirk Taljaard,
the principal investigator of the 2005 Orange Farm research.

Sifiso Motha was one of 81 men who took part in the PrePex study in
eMalahleni, Mpumalanga, in August 2013. Motha (26) says that prior to hearing
about PrePex he had delayed getting medically circumcised because of his fear
of the injections, blood and stitches that come with surgical male
circumcision.

According to the activist organisation Global Advocacy for HIV
Prevention (AVAC) surgical male circumcision is a clinical procedure in which
an injectable anaesthesia is administered, the foreskin is removed and the
wound is closed with stitches.

The procedure can only be performed by a medical doctor in a sterile
environment. Healing from surgical circumcision takes six weeks and minor
complications such as infections and bleeding can occur. 

The PrePex method, on the other hand, is bloodless and doesn’t require
stitches.

“The whole [PrePex] procedure was painless but towards the end of
the week the drying foreskin had a bad odour, I even had to apply baby powder
to cover the smell,” Motha laughs. 
“But I’m happy I did it, I’ll definitely recommend it to those
afraid of operations.”

At eight weeks of recovery time, wound healing (a period during which
men can’t have sex) with the PrePex procedure does however take longer than
with surgery, according to AVAC.

Potential
complications

The organisation also says the PrePex procedure has potential for
complications, including displacement of the device or the device being removed
early, in which case the foreskin would need to be surgically removed.

But the procedure to administer the PrePex is faster than the surgical
circumcision method.

Limakatso Lebina, programme director at the Perinatal HIV Research
Unit at the University of Witswatersrand says, “With PrePex one health provider
can do 50 to 60 circumcisions daily without tiring whereas with surgical
circumcision one can only do 20 or 30.”

However, Lebina says that 40% of the men who participated in the study
were wary of the device as they believe that circumcision – which is also part
of traditional initiation in some cultures – should be a painful procedure.

As previously reported by Bhekisisa, traditional circumcision
is often performed in unsterile conditions where no anaesthetic is
administered; pain is perceived to be part of the rite of passage into manhood.
If the wound is not treated properly it can lead to sepsis and dehydration,
which has in the past lead to initiate deaths.

“PrePex might be the solution to traditional botched
circumcisions as the device does not require electricity, a sterile environment
or high surgical skills meaning it can be used in the mountains [initiation
schools],”  says Lebina .

More research is, however, needed before this could become a reality,
as the WHO has only endorsed the device for use on men that are 18 years and
older (initiates are often younger).

According to the WHO’s prequalification regulations the lowest level
health worker that can safely administer the device is low cadre nurses.
Studies would therefore have to determine whether traditional circumcisers
would be able to safely administer PrePex. 

The plastic device was tested on men in Rwanda, Zimbabwe and Uganda as
part of those countries’ medical male circumcision campaigns. Since February this year Rwanda has rolled out the device as part of a national health programme. 

Thandeka Moyo is a Bhekisisa fellow