A New Technology to Support HIV Prevention

By Oscar Abello, PSI

Trymore Chikwiriro is 29 years old, and his wife gave birth to their first child just this past October. Just like they expected, all of their nights were focused on their new baby– so the time seemed right for Trymore to undergo voluntary medical male circumcision (VMMC).

The World Health Organization and UNAIDS, the Joint United Nations Program on HIV/AIDS, began recommending VMMC as an HIV prevention strategy in 2007. Studies in Kenya, Uganda and South Africa showed that medical male circumcision reduces the risk of sexual transmission of HIV from women to men by approximately 60 percent. In 13 priority countries in southern and eastern Africa, nearly six million men — including one million served by the PSI network alone — have since undergone VMMC.

Besides HIV prevention, VMMC offers other benefits for men and even women, especially married couples like Trymore and his wife. “Personal hygiene, reducing the risk of penile cancer for me, and reducing the risk of cervical cancer for my wife,” said Trymore as he recalled the most important benefits he discussed with his wife. The couple had first heard about VMMC more than a year ago, but Trymore was concerned about the operation and having to take time from work post surgery.

But then they learned about a plastic device called PrePex, one of the VMMC devices currently under review for WHO approval. These new technologies could help countries keep momentum going around VMMC efforts.

The PrePex device consists mainly of three rings ‑ a hard plastic ring on the inside of the foreskin, an elastic ring placed against it on the outside and a third ring placed around it to hold everything in place ‑ working together to constrict blood flow. A health professional can apply it in about two minutes. It is then left in place for seven days. Once the foreskin tissue deadens and dries up , a health professional removes the rings and the foreskin in a few minutes.

Without the PrePex device, Trymore doesn’t think he could have gone through the procedure. “I can go to work from the very day they put it on,” he says. “There’s some mild pain but very manageable with painkillers.”

The PrePex procedure requires no locally injected anesthesia, stitches, nor sterile environment for application. It also carries far less risk of excessive bleeding or other complications that can occur with the standard surgical VMMC.  “The great thing about the PrePex device is it’s very simple,” says Dr Karin Hatzold, PSI’s global expert on VMMC. “We can use it at lower-level healthcare facilities, with less infrastructure, and use broader groups of staff, such as primary care nurses , to administer them without the need for a surgeon or physician.”

Hatzold oversees VMMC devices trial studies conducted by PSI in four countries. “PrePex won’t replace surgical VMMC,” she says. “What we can do is explore where PrePex will support VMMC providers in reaching new markets, like rural areas where there aren’t enough physicians or among clients who don’t have time or desire for even a minor surgery.”

PrePex has allowed VMMC teams to move beyond healthcare facilities. “The VMMC team came to my workplace, they applied the device there during lunch hour and came back the next week [to perform the removal],” Trymore says.

According to the latest available statistics from the World , Zimbabwe and Uganda have only one physician per 10,000 people, Botswana has three per 10,000, and even relatively wealthier South Africa has only eight per 10,000, compared with 24 physicians per 10,000 people in the United States. If nurses, nurse practitioners and other licensed health professionals can also safely apply PrePex devices for VMMC, and provide those services where it’s most convenient for men, many of the barriers to VMMC access and scale-up would be removed.

At this stage of the WHO approval process for PrePex, client feedback is key. In one survey, 93.8 percent of clients said they would recommend the device to their peers. “There’s been overwhelming demand in some communities in Zimbabwe, particularly in the southern parts of the country (of Zimbabwe?),” Hatzold says. “People bring in their friends, businesses and workplaces ask for the intervention for their workforces, and the 20-somethings see the device as ‘their thing,’ as opposed to sitting in the same lines with younger adolescents who are the main group of clientsaccessing surgical VMMC.”

“I have since recommended the device to colleagues, and my younger brothers,” Trymore said. “I tell them it doesn’t disturb you when you go to work, the pain is very manageable.”

PrePex devices aren’t for everyone, however. About 7% -10% of adult males are not eligible in large part because of their physiological development. There are other VMMC devices, in earlier WHO approval phases, which are designed for younger clients, including infants.

There are also some issues that providers applying the device will need to be able to address. These include odor issues caused by the dead skin tissue. Client compliance – or making sure men keep the device in place the whole seven days — remains an issue. Counseling can help a client resist the urge to attempt sexual intercourse or masturbation during the seven days and wait six weeks after removal to allow the wound to heal before resuming any sexual activity. Hence, couples like Trymore and his wife, who have just had a child, are an important opportunity for outreach.

“We decided to do the circumcision at this time,” says Trymore. “So we can both heal our wounds together.”