Although he has heard that circumcision could be beneficial, Elie Kananura, a farmer living in Nyamata sector, Bugesera district is not yet convinced he should undertake it. The father of five, now 48, says he does not yet see any need to go for circumcision since his current status never caused him any harm or illness.

The more pressing issue though is how he would tell his wife that he wants to get circumcised. "How would I introduce it to my wife? I can imagine her asking what my intentions are," he says, adding that he would be interested were he still younger.

Kananura believes other people might still be reluctant to embrace circumcision for various reasons even after the country launched a massive campaign that targets two million men as part of HIV prevention efforts.

Elizabeth Mukamana, the deputy manager of Nyamata health center, confirms they receive only few people seeking circumcision, although she says they have been carrying out sensitization through umuganda, community health workers and some outreach visits by the health center's staff.

"We get about three people per month," she says, adding that while her health center still has few tools, they can ably provide all services. She notes that her staff has been well trained to offer the service.

The Global Aids Report 2012 released last Tuesday says that scaling up voluntary medical male circumcision has the potential to prevent an estimated one in five new HIV infections in Eastern and Southern Africa by 2025. Studies have confirmed that male circumcision reduces HIV infection risk by 60%, though it is not a complete safeguard in case one has sex without a condom.

"It's not a replacement, but an additional strategy," says Dr Sabin Nsanzimana, the head of HIV and other Sexually Transmitted Infectious Diseases Unit at Rwanda Biomedical Center (RBC).

The male circumcision campaign in Rwanda started two years ago with the target to circumcise two million men, but only 50,000 have been circumcised so far, according to statistics provided by RBC. But the doctor remains confident that the target can be reached in two years.

"The program was launched two years ago, but we started with training, resource mobilization and then a pilot phase. All these took a year and a half," explains Nsanzimana, adding that even 50,000 men were circumcised during this year after training medical personnel around the country and providing them with necessary tools.

So far, 450 hospitals and health centers countrywide have got the required tools and trained personnel, he adds. The drive got support from Global Fund, Unaids, and the World Health Organization among other partners.

Now that material and human resources have been put in place, according to Nsanzimana, the health sector will in the next two years be very busy with male circumcision activities. "We still hope that we will have circumcised two million men in two years," he says.

Not covered by mutuelle

The use of Prepex, a non-surgical adult male circumcision procedure performed using the PrePex device will expedite the campaign, he affirms. The Ministry of Health has been carrying out clinical trials on the use of Prepex device since 2009 and has now gained WHO's approval.

The bloodless device was developed for rapid male circumcision and has been used to circumcise 15,000 men.

Though some people are still unenthusiastic, others have already owned the program. For instance, RBC targeted to circumcise 300 students at the National University of Rwanda in a week-long campaign that took place last month, but more than 750 students registered and physicians were able to circumcise only 672.

In a sense, it can be understood that such special promotional occasions might attract many people because the service if offered for free. Yet that is not the case throughout the year, when people go to their health centers or hospitals seeking the service. It isn't even covered by mutuelle de santé.

Nsanzimana says there has been a ministerial meeting to examine whether the circumcision would be covered by mutuelle, but it was realized that this would jeopardize other health services covered by the health insurance scheme.

He therefore notes that there needs to be a further comprehensive examination to look at possibilities to include it into the scheme.

In the meantime, Nsanzimana says they invested a lot in the program to minimize the cost of the service. The investment has been put in buying required tools and this has helped the cost to drop to Frw 2,000 from Frw 10,000.

For needy people, he notes, the government provides support to cover the whole treatment.