Kigali — The government of Rwanda has put considerable effort in curbing the spread of HIV in the country, to a greater extent the government has succeeded.

In Sub Saharan Africa, which has 70 per cent of HIV/Aids victims in the world (estimated at just below 60 million victims) the HIV prevalence in Rwanda is 3 per cent and is the lowest in the region. Little wonder therefore, that Rwanda was chosen by the UN agencies concerned with fighting HIV/Aids to host this year's conference bringing together all HIV/Aids activists. This success however stands to face many risks; the government has a challenge to cope up with the ever changing behavioural changes especially among the youth.

According to the World Bank latest report on HIV/Aid, "Rwanda has demonstrated strong commitment to both HIV prevention and treatment. It quickly recognized the negative development impact of the Aids epidemic, adopted a multi-sectoral approach, and developed a national HIV/Aids strategic plan."

Under the MAP operation over 5,000 patients have benefited from highly subsidized access to life saving antiretroviral therapy or roughly 60 per cent of those in need.

The majority are poor women who might have succumbed to the disease. In total, Rwanda through The Aids Research and Treatment centre has placed over 32,000 patients on ART at 130 sites nationwide, in comparison to 870 patients/7 sites in December 2002.

There is also encouraging news on the prevention side. The percentage of females who correctly identify ways of preventing sexual transmission and reject misconceptions rose dramatically to over 51% in 2005 from about 23% in 2000. There has also been a reported decline in HIV infection rates among youth in Rwanda (UNAIDS 2006). The government has made major interventions in the HIV sector, many people have been encouraged to go for voluntary testing, in 2006 over 12 million condoms were distributed, and according to the World Bank report 27000 orphans and vulnerable children benefited from financial assistance for school fees.

However, the fight against HIV/Aids needs a multi sectoral approach, but the Ministry of Health currently does not have a policy supporting male circumcision nor does it support male circumcision as a means of fighting HIV/Aids. This according to a senior official from the Aids Treatment and Research centre (TRAC) speaking on condition of anonymity "is because the government does not want to confuse citizens....because they will stop practicing other safe methods like abstinence or condom use."

The U.N. health agencies recently recommended that heterosexual men undergo circumcision because of "compelling" evidence that it can reduce their chances of contracting HIV by up to 60 per cent. Though World Health Organization and UNAIDS experts said men need to be aware that circumcision is only partial protection against the virus and must be used with other measures. The scientist unanimously agreed on promoting circumcision as important in fighting HIV/Aids especially in Sub Saharan Africa where HIV/Aids is a huge problem.

"We must be clear," said Catherine Hankins of UNAIDS. "Male circumcision does not provide complete protection against HIV."

Studies suggest 5.7 million new cases of HIV infection and 3 million deaths over 20 years could be prevented by male circumcision in sub-Saharan Africa, the agencies said.

Health experts insist that, men and women who consider male circumcision as an HIV preventive method need to continue using other forms of protection such as male and female condoms, abstinence, delaying the start of sexual activity and reducing the number of sexual partners, she said.

Otherwise, they could develop a false sense of security and engage in high-risk behaviors that could undermine the partial protection provided by male circumcision, the report from WHO and UNAIDS suggests. For the same reason the ministry of health will not encourage Rwandans to go for circumcision. A senior official with The Aids Research and treatment centre talking off record said the government does not have yet a set policy to support circumcision, but is concentrating its efforts in encouraging condom use, abstinence and faithfulness.

Men that allow going for circumcision should be sensitized about proper hygiene after the operation and warned about the risk of being infected with HIV if they resume sex before their wound has healed. Likewise an HIV-positive man can more easily pass on the disease to his partner if the wound is still unhealed.

Circumcision as a major means of avoiding HIV/Aids was issued in recommendations from a meeting recently held in Switzerland, where experts discussed three trials _ in Kenya, Uganda and South Africa _ that produced "strong evidence" of the risk reduction resulting from heterosexual male circumcision.

However, the practice creates a false sense of confidence among men, circumcision changes sexual behavior. Research in the US shows that circumcised men have a greater tendency to engage in riskier, "more highly elaborated" sexual practices. Such behavior includes unsafe sex (less frequent use of condoms, which deaden sensation even more for circumcised men; anal sex, or sex with multiple partners).

Dr Anita Asiimwe the Managing Director of The Aids Research and Treatment centre says, her organization has received information about the World Health Organization report on male circumcision, "but we are still discussing, Rwanda has not yet decided on male circumcision but we know about the research that was carried about in several countries."

"Based on the evidence presented, which was considered to be compelling, experts attending the consultation recommended that male circumcision now be recognized as an additional important intervention to reduce the risk of heterosexually acquired HIV infection in men," a joint statement from WHO and UNAIDS said.

The public health impact is likely to be most rapid where there is a high rate of HIV infection among men having sex with women.

"It was therefore recommended that countries with high prevalence, generalized heterosexual HIV epidemics that currently have low rates of male circumcision consider urgently scaling up access to male circumcision services," the agencies said.

The agencies said much depends on the situation in a given country, and little general benefit will result in countries where the HIV epidemic is concentrated among sex workers, injecting drug users or men who have sex with men.

"The recommendations represent a significant step forward in HIV prevention," said Dr. Kevin De Cock, director of WHO's HIV/Aids department. "Countries with high rates of heterosexual HIV infection and low rates of male circumcision now have an additional intervention which can reduce the risk of HIV infection in heterosexual men."

Increasing male circumcision in areas where the procedure is rare will result in immediate benefit to the men circumcised, but it will take years before there will be an impact on the epidemic. Although the rate of circumcision varies considerably from country to country, globally an estimated 665 million men, or 30 percent of men in the world, are circumcised, the statement said.

The agencies said the risks involved in male circumcision are generally low, but can be serious if the operation is performed in unhygienic settings by poorly trained, ill-equipped health workers.

Priority should be given to providing circumcision to age groups at highest risk of acquiring HIV because it will have the most immediate impact on the disease. But, it said, circumcising younger males also will have a public health impact over the longer term.

It gave no estimate how much providing the service would cost, but said more money would be needed, but that donors should regard it as "an important, evidence-based intervention."

During the 2007 G8 meeting German, donor countries agreed to release $60m to help in the war against HIV/Aids especially in Sub Saharan African. The money will be used to make ARVs more accessible to the poor; hopefully even the campaign for circumcision will be benefit from the donations.

ENDS