Mayange, Rwanda, one of 14 Millennium Village sites across sub-Saharan Africa, is working to combat HIV, including Mother to Child Transmission (MTCT), through sensitization campaigns, condoms, and antiretrovirals (ARVs). However, such efforts only address half the battle. Addressing the other half—preventing new infections through behavior changes going against deeply ingrained cultural beliefs—is an unavoidable, challenging, and often neglected issue.
In September 2009, to strengthen HIV prevention efforts within the MVP sites, UNAIDS and MVP signed a memorandum of understanding to establish “MTCT-Free Zones”. In these designated zones, which include Mayange, coordinated application of rights-based and evidence-informed best practice in Prevention of Mother-to-Child Transmission (PMTCT) of HIV could be amplified by community engagement and support. Such efforts could help to provide access to high quality services that meet WHO guidelines and to overcome social barriers to the uptake and continuation of PMTCT regimens. Mother-to-child transmission of HIV can be virtually eliminated through a four-pronged strategy implemented simultaneously:
In low resource settings, implementation of this comprehensive response faces a host of well-documented obstacles, especially a lack of actions centered on preventing new infections. Strong evidence now indicates that circumcision reduces the risk of HIV infection in heterosexual men by 38-66%. The WHO and UNAIDS currently recommend circumcision be part of a comprehensive program in preventing HIV transmission in areas with high endemic rates of HIV.
In that context, our team focused on a recent male circumcision campaign in Mayange, Rwanda, with extremely encouraging findings.
Historically, Rwandans did not get circumcised. In Rwanda, most Muslims were circumcised for religious reasons, and non-Muslim circumcision remained a social stigma. Only a limited number of people were aware of its importance and implication in reducing HIV transmission. Outside the Muslim community, people were circumcised mostly due to medical problems (e.g. phimosis or paraphimosis, balanitis).
However, through recent waves of information and behavior change campaigns, the knowledge that circumcision prevents Sexually Transmitted Infections including HIV has started to spread in communities. In Mayange sector, situated in the Eastern Province in the Bugesera District with a population of over 25,000 people, the community’s approach to circumcision was no different than such efforts in other areas of Rwanda. However, thanks to the positive influence of MVP and the Rwandan Ministry of Health’s efforts to halt new HIV infections, Mayange Community Health Workers (CHWs) were trained with basic information about circumcision. Subsequently, CHWs sensitized the entire Mayange community about Voluntary Counseling and Testing (VCT) as well as the benefits of circumcision in a weeklong campaign.
Fortunately, many youth were on school holidays and could be reached by the CHWs during their home visits. Following their sensitization messages, CHWs immediately registered all male who were willing to be circumcised. A week before the procedures started, qualified health workers were selected to perform them. Twelve (12) health workers, ranging from doctors, clinical officers to nurses, each signed to operate on 50 male clients. VCT and circumcision were conducted simultaneously. Over a course of 5 days, the VCT component resulted in 946 males getting tested (of which only 1 tested positive). An encouraging number of 600 circumcisions performed over the the course of 10 days. Following the procedures, nurses were tasked with post-operation care of the circumcised male clients.
Due to the sensitization campaign and the recent circumcision procedures in Mayange, many more men are now requesting the same procedure for themselves. The numbers are overwhelming! Due to the high demands from the community, it is expected that the next campaign, scheduled for 2013, will reach at least 3,000 Rwandans.
Written by Dr. Felicien Rwagasore, Health Coordinator MVP Mayange cluster, and Dr. Yanis Ben Amor, Director of the HIV/AIDS Initiative, MVP