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

A decade of PrEP: the evolution of HIV pre-exposure prophylaxis content and sentiments in South African print news media, 2012-2021

After nearly a decade of HIV pre-exposure prophylaxis (PrEP) rollout in sub-Saharan Africa, there has been limited study of PrEP messaging in news media. We selected twenty South African newspapers with the highest circulation volumes to retrieve articles published in 2012-2021 mentioning PrEP (N = 249). Using inductive content analysis, we developed a structured codebook to characterise PrEP-related content and sentiments, as well as their evolution over time, in the South African press. Many articles espoused favourable attitudes towards PrEP (52%), but a sizeable fraction espoused unfavourable attitudes (11%). Relative to PrEP-favourable articles, PrEP-unfavourable articles were significantly more likely to emphasise the drawbacks/consequences of PrEP use, including adherence/persistence requirements (52% vs. 24%, p = .007), cost (48% vs. 11%, p < .001), and risk compensation (52% vs. 5%, p < .001). Nevertheless, the presence of these drawbacks/consequences in print media largely declined over time. Key populations (e.g. adolescents, female sex workers) were frequently mentioned potential PrEP candidates. Despite message variations over time, prevention effectiveness and adherence/persistence requirements were the most widely cited PrEP benefits and drawbacks, respectively. Study findings demonstrate the dynamic nature of PrEP coverage in the South African press, likely in response to PrEP scale-up and real-world PrEP implementation during the study period.

A review of public health, social and ethical implications of voluntary medical male circumcision programs for HIV prevention in sub-Saharan Africa

Ideally, the benefits of public health interventions should outweigh any associated harms, burdens, and adverse unintended consequences. The intended benefit of voluntary medical male circumcision (VMMC) programs in eastern and southern Africa (ESA) is the reduction of HIV infections. We review the literature for evidence of reductions in HIV incidence, evaluate the extent to which decreases in HIV incidence can be reasonably attributed to VMMC programs, and summarize social harms and ethical concerns associated with these programs. Review findings suggest that HIV incidence had been declining across ESA since before the large-scale rollout of VMMC as a public health intervention, and that this decline may be due to the combined effects of HIV prevention and treatment interventions, such as expanded antiretroviral therapy. The independent effect of VMMC programs in reducing HIV infections at the population level remains unknown. On the other hand, VMMC-associated evidence is increasing for the existence of negative social impacts such as stigmatization and/or discrimination, and ethically problematic practices, including lack of informed consent. We conclude that the relationship between the benefits and burdens of VMMC programs may be more unfavorable than what has been commonly suggested by proponents of global VMMC campaigns.

Circumcision as conquest: Masculinity in Eswatini's voluntary medical male circumcision campaign materials

As a public health intervention related to sexual transmission and involving genital surgery, male circumcision for HIV prevention necessarily relates to understandings of sexuality and gender, a relationship which public health campaign materials have shaped in varying ways. Here, I employ discourse analysis to examine messages about gender and sexuality in Eswatini's Soka Uncobe (Circumcise and Conquer) public health campaign for voluntary medical male circumcision (VMMC). The slogan 'conquest' echoes nationalist imagery and extends throughout campaign materials, such as in a comic book presenting the circumcising man as a hero vanquishing an enemy. Elsewhere, campaign materials use the slogan to link sexual conquest to the conquest of HIV in a move that is misleading and potentially harmful. As with several circumcision campaigns in the region, messages about the HIV protection offered through the intervention and the limits to this protection are minimal and are overshadowed by a framing of circumcision as a newly necessary norm for appropriate masculine citizenship and sexuality. This consideration of the positioning of gender, sexuality, and sex in campaign materials promoting VMMC is pertinent to the global public health effort to reduce HIV transmission, particularly given the social complexities at stake in the context of sexual transmission.

Towards a context-specific understanding of masculinities in Eswatini within voluntary medical male circumcision programming

Compelling evidence from three randomised controlled trials, which showed that voluntary medical male circumcision (VMMC) reduces HIV acquisition from women to men by up to 60%, led to WHO recommending that VMMC be implemented in 14 priority countries. As one of the priority countries, Eswatini aimed to reach 80% VMMC coverage among boys and men aged 10-49 years since programme inception in 2009. By the end of 2019, however, the country had reached a modest 40%. VMMC is intrinsically tied to perceptions of masculinity and male gender identity. Comprehending the role of context-specific masculinity as it relates to VMMC may contribute to our understanding of community attitudes towards VMMC and men's decision-making. Drawing on focus group discussion data, this study aimed to explore the linkage between sexuality, masculinity and health interventions within Eswatini. Using critical discourse analysis, the study identified two discourses: sexuality, masculinity and circumcision, and income, masculinity, and circumcision. In the first discourse, participants constructed discursive linkages between circumcision as an adult and loss of penile sensitivity, decreased libido and sexual performance, and adverse events. The second discourse, income, masculinity, and circumcision located circumcision within the social and material realities faced by Swazi men, gender norms and provision within family structures.

Genital Cutting as Gender Oppression: Time to Revisit the WHO Paradigm

The World Health Organization (WHO) condemns all medically unnecessary female genital cutting (FGC) that is primarily associated with people of color and the Global South, claiming that such FGC violates the human right to bodily integrity regardless of harm-level, degree of medicalization, or consent. However, the WHO does not condemn medically unnecessary FGC that is primarily associated with Western culture, such as elective labiaplasty or genital piercing, even when performed by non-medical practitioners (e.g., body artists) or on adolescent girls. Nor does it campaign against any form of medically unnecessary intersex genital cutting (IGC) or male genital cutting (MGC), including forms that are non-consensual or comparably harmful to some types of FGC. These and other apparent inconsistencies risk undermining the perceived authority of the WHO to pronounce on human rights. This paper considers whether the WHO could justify its selective condemnation of non-Western-associated FGC by appealing to the distinctive role of such practices in upholding patriarchal gender systems and furthering sex-based discrimination against women and girls. The paper argues that such a justification would not succeed. To the contrary, dismantling patriarchal power structures and reducing sex-based discrimination in FGC-practicing societies requires principled opposition to medically unnecessary, non-consensual genital cutting of all vulnerable persons, including insufficiently autonomous children, irrespective of their sex traits or socially assigned gender. This conclusion is based, in part, on an assessment of the overlapping and often mutually reinforcing roles of different types of child genital cutting—FGC, MGC, and IGC—in reproducing oppressive gender systems. These systems, in turn, tend to subordinate women and girls as well as non-dominant males and sexual and gender minorities. The selective efforts of the WHO to eliminate only non-Western-associated FGC exposes the organization to credible accusations of racism and cultural imperialism and paradoxically undermines its own stated goals: namely, securing the long-term interests and equal rights of women and girls in FGC-practicing societies.

Barriers, benefits, and behaviour: Voluntary medical male circumcision ideation in a population-based sample of Zambian men

Reaching ambitious voluntary medical male circumcision (VMMC) coverage targets requires a deeper understanding of the multifaceted processes shaping men's willingness to access VMMC. Guided by the Ideation Model for Health Communication, this population-based study identifies correlates of Zambian men's future VMMC intentions. Multistage cluster sampling was used to identify households with adult men in 14 districts. Multivariable Poisson regression with robust standard errors modelled associations of future VMMC intent with ideational factors (e.g. perceived benefits and barriers) and sexual behaviours respectively. Forty per cent (40%) of uncircumcised men (N = 1 204) expressed future VMMC intentions. In multivariable analysis, VMMC intent was associated with secondary education or higher (Adjusted Prevalence Ratio [APR] 1.30, 95% Confidence Interval [95% CI]: 1.02-1.66), perceiving VMMC to increase sexual satisfaction (APR 1.45, 95% CI: 1.11-1.89), reporting distance to services as a barrier to VMMC uptake (APR = 0.54, 95% CI: 1.27-1.87), unprotected last sex (APR 1.54, 95% CI: 1.11-2.14), and ≥ 2 sexual partners in the past 12 months (APR 1.45, 95% CI: 1.05-1.99). Being aged ≥ 45 years (vs 18-24 years: APR 0.23, 95% CI: 0.13-0.40) and perceiving that circumcision: (1) is unimportant (APR 0.71, 95% CI: 0.51-0.98); (2) is incompatible with local customs (APR 0.41, 95% CI: 0.18-0.94); or (3) reduces sexual satisfaction (APR 0.10, 95% CI: 0.02-0.62) were inversely associated with future VMMC intent. Demand-creation efforts must confront salient cognitive and social barriers to VMMC uptake, including concerns around incompatibility with local customs. Simultaneously, promotional efforts should emphasise relevant VMMC benefits beyond HIV prevention that resonate with men (e.g. penile hygiene) without reinforcing harmful gender norms.

The Ethics of Stigma in Medical Male Circumcision Initiatives Involving Adolescents in Sub-Saharan Africa

Ongoing global efforts to circumcise adolescent and adult males to reduce their risk of acquiring HIV constitute the largest public health prevention initiative, using surgical means, in human history. Voluntary medical male circumcision (VMMC) programs in Africa have significantly altered social norms related to male circumcision among previously non-circumcising groups and groups that have practiced traditional (non-medical) circumcision. One consequence of this change is the stigmatization of males who, for whatever reason, remain uncircumcised. This paper discusses the ethics of stigma with regard to uncircumcised adolescent males in global VMMC programs, particularly in certain recruitment, demand creation and social norm interventions. Grounded in our own experiences gained while conducting HIV-related ethics research with adolescents in Kenya, we argue that use of explicit or implicit stigma to increase the number of VMMC volunteers is unethical from a public health ethics perspective, particularly in campaigns that leverage social norms of masculinity. Ongoing global efforts to circumcise adolescent and adult males to reduce their risk of acquiring HIV constitute the largest public health prevention initiative, using surgical means, in human history. VMMC programs in Africa have significantly altered social norms related to male circumcision among previously non-circumcising groups and groups that have practiced traditional (non-medical) circumcision. One consequence of this change is the stigmatization of males who, for whatever reason, remain uncircumcised. This paper discusses the ethics of stigma with regard to uncircumcised adolescent males in global VMMC programs, particularly in certain recruitment, demand creation and social norm interventions. Grounded in our own experiences gained while conducting HIV-related ethics research with adolescents in Kenya, we argue that use of explicit or implicit stigma to increase the number of VMMC volunteers is unethical from a public health ethics perspective, particularly in campaigns that leverage social norms of masculinity.