Rwanda is in the process of adopting male circumcision as a part of its national HIV prevention strategy, but experts worry that a spike in requests before a planned public awareness campaign has been launched could have negative implications.
Alphonse Ndakengerwa, a surgeon at King Faisal Hospital in the capital, Kigali, said clinics in the city had recently been overwhelmed by requests for the procedure, largely as a result of media reports on research indicating a lower risk of HIV infection in circumcised men.
Three randomised controlled trials in Kenya, South Africa and Uganda produced results showing that circumcision could significantly reduce the risk of sexually transmitted HIV infection in men.
Unlike many other cultures in Africa, Rwandan men and boys are not circumcised as a rite of passage, and although unofficial information has filtered through to the population, few people properly understand the benefits as well as the risks of the procedure.
"For me, I believe that when you make circumcision, it's like an invisible condom," said Ignace Hategekimana, 27, a student in Kigali who was recently circumcised. "It reduces the chance to get infections."
Antoine Rwego, a circumcision expert at Rwanda's Treatment and Research AIDS Centre (TRAC), told IRIN/PlusNews there was a danger that many Rwandan men would see circumcision as a substitute for condoms. "If we don't give the right message we can increase the risk of HIV transmission," he told IRIN/PlusNews.
Rwego was particularly worried by a belief among many young men that the procedure improved a man's sexual prowess and provided total immunity from sexually transmitted infections, and Hategekimana's comments to IRIN/PlusNews justified this concern.
"Before I went to the hospital I spoke with many friends and they told me it was a good thing ... when the foreskin is not there, you feel the sex very well. When you have made the circumcision you can't get wounds when you are having sex," he said.
Dr Stephenson Musime, a surgeon at King Faisal Hospital agreed with Rwego. "Some people feel that you will be more of a man ... very many people believe it will make them stronger and that it increases their sexual energy," he said.
"For someone who is circumcised it provides some protection ... but it doesn't mean that it is 100 percent protection - alone, it can't prevent HIV transmission - it has to be done with other protective mechanisms," Musime pointed out.
|When the foreskin is not there, you feel the sex very well ... you can't get wounds when you are having sex|
Agripine Tunga, 40, who had just given birth to a son at King Faisal Hospital, held a different view: "I believe the association is that they [circumcised men] feel sexy ... I don't want my son to be so sexual."
Studies to investigate these assertions were conducted in 2008 in Kenya and Uganda.
Both studies found that circumcised men reported increased penile sensitivity and enhanced ease of reaching orgasm, but experts say there is no evidence that the procedure actually improves sexual performance or prowess.
Urgent need for an effective communication strategy
Health workers say it is important that the public understands how circumcision protects men from sexually transmitted infections, and that they also know the procedure is not a guarantee of protection.
"There are many different reasons that people get circumcised ... medical, cultural, religious ... it has to be accompanied by counselling," Rwego said. "We have to develop the right message for the population."
The Rwandan government is embarking on a Knowledge Attitude and Practice (KAP) survey to ascertain the levels of awareness and information about male circumcision.
"Some people can think that male circumcision is a full protection, like an invisible condom, so with the KAP study we will know what to tell the people and what message to develop," Rwego said. "After that we have to develop guidelines, train staff and buy equipment."
The government began rolling out male circumcision in the army in 2008, as a precursor to widespread adoption of the measure by the rest of the population. Rwanda's national AIDS control council will start the national campaign by offering circumcision to newborn babies.