Hesitance towards voluntary medical male circumcision in Lesotho: Reconfiguring global health governance

Abstract

Drawing on work examining HIV prevention initiatives in Lesotho, this paper considers the hesitation of national state actors towards the new strategy for HIV prevention – voluntary medical male circumcision (VMMC). Lesotho offers a representative case study on global health governance, given the country's high HIV burden and heavy dependence on foreign donor nations to implement local HIV prevention initiatives. In this paper, I use the case of VMMC opposition in Lesotho to examine how the new era of ‘partnerships’ has shifted the architecture of contemporary global health, specifically considering how global agreements are translated or negotiated into local practice. I argue that Lesotho's domestic policy-makers, in employing national statistics to assess if VMMC is an effective approach to addressing the local epidemic, are asserting a claim of expertise. In doing so, they challenge the traditional structures of global health politics, which have largely been managed by experts and funders from and in the global North. I explore the development of global VMMC policy, what drives Lesotho's resistance to comply, and consider the impact renegotiation efforts may have on future global health architecture.

Keywords:

• global health politics
• HIV/AIDS
• Lesotho
• VMMC

Acknowledgement

This study was supported by the Fulbright Foundation and the University of Connecticut's Graduate School.

Notes

1. Geographical correlations suggested a negative relationship between HIV disease and circumcision practices in Africa, with lower HIV prevalence in Sahelian, West Africa, where MC is more uniformly conducted, as compared to Eastern Africa where circumcision is less routinely practised (Bongaarts, Reining, Way, & Conant, 1989; Moses et al., 1990). Ecological case/control and cohort studies revealed a less conclusive relationship. While appearing to hold in some countries in Africa, this was not the case in all the countries (Baeten et al., 2005; Bongaarts et al., 1989; Drain, Halperin, Hughes, Klausner, & Bailey, 2006; Halperin & Bailey, 1999; Moses et al., 1990; Quinn et al., 2000; Reynolds et al., 2004; Siegfried et al., 2005; Weiss et al., 2008; Weiss, Quigley, & Hayes, 2000). Throughout Europe, in the USA, New Zealand and Australia, MC had no effect on sexually transmitted infections (STIs) transmitted through either homosexual or heterosexual routes (Darby, 2005; Dave et al., 2003; Dickson, van Roode, Herbison, & Paul, 2008; Laumann, Masi, & Zuckermann, 1997; Richters, Smith, de Visser, Grulich, & Rissel, 2006).

2. The full text of the recommendations can be found at: http://www.who.int/hiv/mediacentre/MCrecommendations_en.pdf.

3. In February 2012, VMMC was initiated at Berea, Mafeteng, St Joseph and Scott hospitals following the release of the VMMC policy and Operational Plan. VMMC services are available at a public ‘male clinic’ in Maseru, the capital city. In addition, international organisations (Jhpiego funded by PEPFAR and Population Services International working with the Lesotho military) continue their efforts to increase public access to VMMC services.

4. This statement does not recognise or account for the limitations in the national data. An insufficient number of men have undergone VMMC in Lesotho to clearly tease out whether one form of MC (traditional or clinic-based VMMC) offers protection while the other increases risk (perhaps due to partial circumcision; Thomas et al., 2011; WHO, 2014).