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PrePex could cut down on botched circumcision deaths

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

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