Promoting male circumcision as HIV prevention in sub-Saharan Africa: An evaluation of the ethical and pragmatic considerations of adopting a demand creation approach

ABSTRACT

Male circumcision for HIV prevention is being promoted in 14 sub-Saharan African countries. Campaigns take a demand creation approach, a strategy based on generating awareness of and demand for an intervention. This article analyzes campaign materials, making the case that a focus on demand per se, at the expense of quality public health information, constitutes an ethical and pragmatic campaign flaw. Clinical trials have demonstrated that circumcision can reduce transmission of HIV from women to men by 53–60%. Since circumcision does not approach 100% prevention efficacy for men and does not directly protect women, behavioural and structural interventions remain necessary, leading international health bodies to position circumcision as an add-on to behavioural interventions. However, in practice, circumcision promotion often lacks information about behavioural prevention. At times, campaigns omit any HIV prevention message. Instead, campaigns variously favour representing circumcision as a route to normative masculinity, to sexual prowess, or to good citizenship, among others. Alongside their targeted outcomes, public health campaigns also contribute to public discourses around sexuality and non-HIV aspects of health, in this case potentially leading to confusion and mistrust. The current public health promotion strategy for circumcision threatens to undermine the social processes needed to support HIV prevention.

KEYWORDS:

• Circumcision
• HIV prevention
• sub-Saharan Africa
• demand creation
• VMMC

Acknowledgements

I would like to thank Malia Rogers for her research support on this project.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

1 Two of the fourteen countries identified by the WHO as part of MC rollout were not included: Ethiopia and Rwanda. Ethiopia has a high national rate of circumcision, but was included in the list of fourteen targeted countries due to high rates of HIV in one non-circumcising Gambella, Ethiopia (Patrick et al., 2009). MC has been introduced in Gambella, but my review did not identify campaign materials. Rwanda has been introducing MC via a series of quasi-experimental rollouts (Patrick et al., 2009); however, unlike other countries, there are no campaign materials for Rwanda in the clearinghouse for male circumcision or otherwise widely available, and therefore I did not analyze campaign materials.

Additional information

Funding

This research was supported in part by the Acadia University Research Fund.