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Reply to “Minimally Invasive Male Circumcision,” from Sokal et al

Binagwaho, Agnes MD, M (Peds)

JAIDS Journal of Acquired Immune Deficiency Syndromes: April 15th, 2012 - Volume 59 - Issue 5 - p e100–e101
doi: 10.1097/QAI.0b013e3182460c38
Letters to the Editor

Ministry of Health, Kigali, Rwanda

Correspondence to: Agnes Binagwaho, MD, M (Peds), Minister of Health, BP 3622 Kigali, Rwanda; Senior Lecturer, Harvard University (e-mail:

The author has no funding or conflicts of interests to disclose.

To the Editors

We thank Sokal et al1 for their letter and also for their work in facilitating male circumcision in Africa.

In planning a rapid male circumcision (MC) scale-up program, the Rwanda Ministry of Health reviewed innovations in MC and had received information about the Shang Ring and the PrePex devices, and considered both. Our national goal is a voluntary program to reach 2 million men in 2 years, but 87% of our population live in rural areas with very limited access to clinics equipped for surgery.

We therefore needed a safe nonsurgical means of performing MC, that is, a procedure that is completely bloodless, involves no cutting of live/viable tissue, and requires no penile block (injected local anesthesia) or sterile setting. We also sought a procedure that would be easy to teach low-cadre nurses, with no surgical training, and potentially even community health workers. We opted to study the PrePex device because it had the strongest potential to meet our requirements.

In their letter, Sokal et al1 described both devices as a minimally invasive surgical procedure for MC. However, in our opinion, the PrePex device is altogether nonsurgical and more comparable with the necrotic process by which the umbilical cord is removed after childbirth.

In our study, we found that oral paracetamol (acetaminophen) is useful when there is discomfort that begins about an hour postplacement and lasts for about an hour; but contrary to what is suggested in the letter to the editor, there was no use of or need for injected local anesthesia in any of the more than 1060 PrePex procedures we have performed to date in clinical studies. By contrast, penile block (injected) is required with the Shang Ring because it crushes the foreskin, whereas the PrePex device applies radial compression on the foreskin and causes no pain upon placement. Injection of local anesthesia adds time, complicates the procedure, and reduces the number of patients we will be able to see per day.

Both devices offer a safe means of performing MC, but the setting ultimately matters. Rwanda lacks the infrastructure to support even minimally invasive surgery on 4000 men each day, the number required to reach our aforementioned target.

We hope that our research and the research being conducted by Sokal et al will contribute to identifying the optimal means of performing MC in different regions and settings in Africa and in other resource-limited areas, and thereby significantly reducing the spread of HIV.

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1. Sokal D, Barone M, Li P, et al.. Minimally invasive male circumcision. J Acquir Immune Defic Snydr. 2012;59:e100.
© 2012 Lippincott Williams & Wilkins, Inc.