Attachment 6_SANAC Communications Strategy on Male Circumcision FINAL VERSION 07_March_10.pdf

Attachment 6: SANAC Communications Strategy on Male Circumcision

A SOCIAL AND BEHAVIOURAL APPROACH TO

COMMUNICATING ABOUT MALE CIRCUMCISION FOR

THE REDUCTION OF HIV RISK

Table of Contents

Introduction

The Scientific Evidence for Male Circumcision

Male Circumcision in South Africa Other benefits of Male Circumcision Complications Challenges

A social and behavioural change communication approach to Male Circumcision

A strategic approach to communicating male circumcision Formative Research Positioning Communication Interventions and Linkages Service Delivery Audiences Advocacy for Social and Behavioural Change Monitoring and Evaluation

Conclusion

Summary of Key Issues for Communicators o Messages on male circumcision need to be framed within the broader context of male sexual and reproductive health.

o Messages critically must emphasise the need for continued HIV prevention through continued condom usage and limiting of sexual partners.

o Mass Media communication programmes need to be supported with interpersonal communication, such as counselling for men about their sexual and reproductive health and, voluntary counselling and testing, ensuring that men fully understand the partial protective benefits of male circumcision. They also need to understand the need for full healing before the resumption of sex (6 weeks and preferably following an assessment by a physician).

o Communication about male circumcision within settings where circumcision is practiced for cultural, traditional or religious purposes must promote safe male circumcision and be respectful of local customs and traditions.

o Communication needs to distinguish between Male Circumcision and female genital mutilation, which must be discouraged.

o Messages need to be targeted recognising that at present the evidence concerning the reduction of HIV risk owing to male circumcision for HIV prevention only pertains to heterosexual HIV negative men.

Introduction The evidence regarding the linkages between male circumcision and HIV prevention initially arose from observational studies and ecological studies that showed a link between lower rates of HIV prevalence and high levels of circumcision in certain countries. The link was proven through randomised controlled trials that were undertaken in South Africa, Uganda and Kenya. These studies show that male circumcision has a partial protective benefit of reducing the risk of HIV infection by up to

60%.

In certain African communities male circumcision has cultural meaning. It is performed on young men in their teens as a rite of passage that marks the transition from ‘boyhood’ to

‘manhood.’ It is thus a symbol of masculinity and adulthood. In some cultural settings, male circumcision serves as a symbol that distinguishes between different cultural groups (UNAIDS & CAPRISA

20071). This may be less important in multicultural environments, such as urban areas. (Weiss & Polonsky

2007).

In addition to this, male circumcision has been performed on infants (known as neonatal circumcision) in societies such as a number of West African countries, the

United States, Canada, Australia and New Zealand because of the perceived health and sexual benefits (Weiss & Polonsky 2007).

In Eastern and Southern Africa, male circumcision varies from 15% in many countries of southern Africa to more than 70% in countries such as Rwanda, Tanzania, Kenya and Ethiopia (WHO 20062; Weiss & Polonsky).

Male Circumcision is challenging to communicate for a number of reasons. Firstly it is linked to a number of social, cultural and religious beliefs and practices.

Secondly, the protection is not full. Therefore, if circumcised men do not continue to have safer sex they may well become infected and place their partners at risk.

1 UNAIDS/CAPRISA. (2007). Social Science Perspective on Male Circumcision for HIV Prevention: 18 – 19 January: Summary Report.

2 WHO Meeting Report: Strategies and Approaches for Male Circumcision Programming, 5 – 6 December 2006, Geneva.

This document provides guidance on approaches that can be used to effectively communicate around male circumcision.

The Scientific Evidence for Male Circumcision The scientific evidence regarding the benefits of male circumcision for reducing the risk of HIV infection has been speculated upon for many years. Observational studies showed that in areas where male circumcision is commonly practiced there were lower rates of HIV infection compared to those where it is not practiced much.

These observations have recently been confirmed by three randomized controlled studies undertaken in South Africa, Kenya and Uganda that all concluded that male circumcision reduces the risk of HIV infection of between 48 – 60% (Lancet 2007).

Modelling suggests that the introduction of male circumcision as part of a package of

HIV prevention may be able to avert 2 million new HIV infections and over 300000 deaths in sub-Saharan Africa if scaled up significantly (Williams, Lloyd Smith, Gouws, Hankins et al 20063).

A country level analysis on high prevalence countries in southern Africa has indicated that the introduction of male circumcision on a population wide scale for example in Swaziland (332 639 circumcisions) will result in more than 43 782 new infections averted even if condom use and the number of partners were to remain consistent. Male circumcision as part of HIV prevention will save future costs in relation to ARV treatment. For example the estimated cost of introducing a mass male circumcision programme at present in Zambia will cost the Government of

Zambia in the region of $96.8million, however the cost of ARV to treat the number of new infections not averted as a result of Male Circumcision in eight years time is estimated to be in the region of $161.7 million. Therefore the introduction of male circumcision as part of a package of HIV prevention in the longer term will result in a saving of $64.9 million for the government of Zambia (Martin, Stover, Relebohile, et al 20074).

The evidence regarding the use of male circumcision to reduce the risk of HIV infection is so strong that WHO/UNAIDS has recommended that male circumcision be considered by countries with hyper endemic scenarios where

HIV prevalence exceeds 15% as part of a package of HIV prevention together with delaying the onset of sexual activity, partner limitation, abstinence from penetrative sex; correct and consistent condom use, HIV counseling and testing and treatment of STIs (UNAIDS 20075).

3 Williams, B.G; Lloyd-Smith, J.O; Gouws, E; Hankins, C; Getz, W.M; et al. (2006). The Potential Impact of Male Circumcision on HIV in Sub-Saharan Africa. Plos Med 3(7):e262 doi:10.131/journal.pmed.0030262.

4 Martin, G; Stover, J; Relebohile, T. et al. (2007). Cost of Male Circumcision and Implications for Cost

Effectiveness of Circumcision as an HIV Intervention. USAID: Health Policy Initiative. Presentation to the PEPFAR Implementers Meeting.

5 UNAIDS. (2007). Practical Guidelines for Intensifying HIV Prevention: Towards Universal Access. Geneva:

UNAIDS.

Male Circumcision in South Africa

In South Africa approximately 45% of men report being circumcised with circumcision rates being the highest in the Western Cape (67.5%) and Free State (70%) and the lowest in KwaZulu-Natal (26.8%) and Gauteng (25.2%). The levels of circumcision are highest amongst men (53%) over the age of 30 (DOH, 20076). The late age of circumcision may negatively impact on the risk reduction benefits that male circumcision confer. Acceptability studies have indicated that there are high levels of acceptability amongst men and women in South Africa of male circumcision. Table 1 contrasts the level of circumcision in the various provinces in relation to the rates of

HIV Prevalence.

Table 1: Levels of Male Circumcision and HIV Prevalence per province in South

Africa

Province

Circumcision

Rate

HIV

Prevalence

Rate

Western Cape 67.5 3.2

Free State 70.7 19.2

Limpopo 47.5 11.0

Eastern Cape 43.8 15.5

Mpumalanga 36.3 23.1

Northern Cape 34.1 9.0

North West 32.8 18.0

KwaZulu-Natal 26.8 21.9

Gauteng 25.2 15.8

Source:Department of Health, 2007; HSRC/Nelson Mandela Household Survey7, Age of sexual debut, numbers of concurrent partners and incorrect and/or inconsistent condom usage are two known variables that are likely to increase one’s risk of HIV infection. In comparing provinces, it may be observed that male circumcision does confer an added benefit in provinces with lower levels of HIV prevalence.

6 Department of Health, Medical Research Council, OrcMarco. 2007. South Africa Demographic and Health Survey 2003. Pretoria: Department of Health.

7 Shisana O; Rehle T, Simbayi LC, Parker W, Zuma K, Bhana A, Connolly C, Jooste S, Pillay V et al. (2005). South African National HIV Prevalence, HIV Incidence, Behaviour and Communication Survey, 2005. Cape Town: HSRC Press.

There is a 12.6% difference in HIV prevalence between the Western Cape (3.2%) with the highest levels of Male Circumcision (67.5%) and Gauteng with the lowest level of male circumcision (15.8%) and a high level of HIV prevalence (15.8%).

Condom usage at last sex is the lowest in the Western Cape (50%) compared to

Gauteng (59%). Men reporting have more than one concurrent sexual partner is 9% in the Western Cape and 17% in Gauteng (SA National Communication Survey, 20088). High levels of male circumcision combined with lower levels of multiple and concurrent partners in the Western Cape are the only two factors that may explain the difference in HIV prevalence between these two provinces.

There is a 12% difference in HIV prevalence between the Limpopo province (11.0%) with high levels of male circumcision (47.5) and Mpumalanga which has the highest level of HIV prevalence (23.1%). Condom usage in Mpumalanga (63%) is higher than Limpopo (58%) and men in the Limpopo province report having greater numbers of multiple and concurrent sexual partners (17%) as opposed to amongst men in Mpumalanga (13%). In this instance the only significant factor that could account for a difference in HIV prevalence levels is that of male circumcision.

There is a six percentage difference in HIV prevalence between the Eastern Cape

(15.5%) a known traditional male circumcising area where approximately 43.8% of men reported being circumcised and KwaZulu-Natal with the second lowest level of circumcision (26.8%) and the second highest levels of HIV prevalence (21.9). The

Eastern Cape has the highest number of men reporting condom usage at last sex

(73%) compared to KwaZulu-Natal (56%), however, men in the Eastern Cape report higher numbers of concurrent sexual partners 13% as opposed 11% of men in

KwaZulu-Natal (SA National Communication Survey, 2008). The only significant difference between the two provinces that can explain the difference in HIV prevalence is that of male circumcision. However, this benefit may be reduced as traditional circumcision tends to take place in the late teens or early twenties which may diminish the protective benefits of male circumcision as many men may have been infected prior to circumcision (Jewkes et al, 20069) .

More investigation is required as to why there is a no significant difference between the levels of male circumcision in the Free State Province and HIV prevalence. This may be owing to the age of circumcision in relation to the age of sexual debut as

57% young people in the Free State report having sex before the age of 17 as compared to the national average of 41% which may negate the partial protective benefits of male circumcision. Furthermore it is important to establish whether the degree of male circumcision in the Free State provinces is sufficient enough to confer the protective benefits of male circumcision.

This analysis supports observational studies elsewhere that by contrasting the three provinces with the highest levels of male circumcision and the lowest levels of HIV prevalence with those provinces that have the lowest levels of HIV prevalence and highest levels male circumcision taking into account age of sexual debut, number of

8 Schierhout G, Delate R & Ridgard N. (2008). First HIV and AIDS National Communication Survey, 2006: Summary of the findings from the Provincial Analysis.

Pretoria. JHHESA.

9 R Jewkes, K Dunkle, M Duna et al. 2006. Factors associated with HIV sero-positivity in young, rural South African men. International Journal of Epidemiology.

Oxford Unviersity Press.

sexual partners and condom usage that male circumcision does have a significant impact in lower levels of levels of HIV prevalence.

Other benefits of Male Circumcision

Male circumcision has other sexual and reproductive health benefits for men. These include reducing the risk of ulcerative sexually transmitted infections, such as chancroid, syphilis as well as reducing penile cancer.

Male circumcision also provides an entry point to engage with men on their sexual and reproductive health in particular promoting responsible male sexual behaviour and awareness of STIs such as gonorrhea and Chlamydia.

The introduction of male circumcision provides an entry point to engage with men around HIV preventative behaviours such as the need to use condoms, reducing the number of sexual partners and knowing their HIV status (WHO & UNAIDS 2007).

Complications

Male Circumcision is a surgical procedure and thus there may be complications of the procedure. These are rare especially where well trained medical and well-equipped traditional practitioners are involved. Complications include excessive bleeding, infection, excessive pain; too much skin removed, penile damage or amputation, erectile dysfunction, psycho-behavioural complications and in extreme cases, death.

Challenges

The greatest challenge confronting communications practitioners is to promote the benefits of male circumcision in conjunction whilst other preventive practices continue to be practiced (limiting partners and condom use)

A further challenge may be the lack of services available for men to receive safe circumcision and the cost of scaling up.

A social and behavioural change communication approach to Male Circumcision In order for communication to have an impact it needs to address not only the sexual behaviours by men and women but the social context in which these practices take place. For example a woman may wish to practice safer sex but power relations within her partnership may prevent her from being able to do so.

There are a number of social change models that emphasise the need for continued efforts that aim to impact upon individuals and their sexual practices while also addressing their social networks, communities and broader society as a whole

(Kincaid, Figueroa & Storey 2007).

This requires that communication practitioners undertake participatory formative research, using qualitative approaches (focus groups and individual in-depth interviews) seeking to understand the behaviours, intention, knowledge, beliefs and values, social norms, cultural imperatives, and perceived risk of men in relation to male circumcision to inform the design of programmes and communication.

The decision by a man to be circumcised may be influenced by many factors, including his sexual partners, who may express a desire one way or another. In

Lesotho women are known to be encouraging their male partners to be circumcised.

Peer pressure may also influence the decision of a man to be circumcised, especially where circumcision is not the norm.

The facilitation of community dialiogue and public debate using participatory approaches (such as peer education, counselling, radio and television talk shows) can contribute towards challenging existing social constructions of circumcision and motivate social change in the perspectives of social networks and communities in relation to male circumcision.

In 1999 UNAIDS/Penn State University10 developed a Communications Framework through a series of international consultations that recognised the need to impact upon the contextual factors that facilitate or impede individual change.

The contextual domains were identified as spirituality government policy, socio-economic status, culture, gender

A strategic approach to communicating male circumcision

Formative Research

Formative research involves the undertaking of qualitative and quantitative research that examines male sexual attitudes and behaviours, their knowledge on issues relating to sexual and reproductive health, and their interpretations of the reduced risks of male circumcision. Formative research provides insight into the meanings that men are deriving of male circumcision and checks the potential for risk compensation. In addition it should investigate the views and perspectives of women and parents regarding male sexual and reproductive health. The formative research will determine the key messages necessary for the communication.

Audiences need to be involved and engaged in the development of the communication messages, concepts and materials. Pretesting of materials is critical to ensure that the meanings that audiences interpret of the message closely match those that that they were intended to convey.

Positioning Communication Interventions and Linkages with Service Delivery

Services for male circumcision are not widely developed and many health personnel have not been trained in circumcision. In certain communities, circumcision is undertaken by traditional circumcisors. Personnel who are or have undergone some form of training on providing safe medical and/or traditional circumcisions could be provided with a certificate that illustrates their compentency in this area. Thus linking communication programmes to service delivery through the use of an easily identifiable, culturally appropriate brand symbol that can be developed to designate and distinguish between accredited (state and private) and non-accredited service providers.

10 Kincaid, D.L; Figueroa, M.E; Storey, D. (2007). A Social Ecology Model for Social and Behavioural Change Communication. Baltimore: Johns Hopkins Bloomberg School of Public Health, Centre for Communications Programmes.

Audiences11

Audiences can be segmented according to primary and secondary audiences.

The primary audiences for male circumcision are men, women, and parents.

Men are a primary audience for male circumcision as ultimately they will be ones who will decide whether or not to be circumcised.

Women are a primary target audience as the decision by a man to be circumcised can directly influence the health and wellbeing of women. Women can also influence the decision of their male sexual partners as to whether or not to be circumcised, and often decide on the circumcision of their children.

Parents need to be considered as a key target audience for messages around male circumcision in particular in relation to neonatal male circumcision and the decision by young men to be circumcised.

Core Messages and Strategies for Male Circumcision

Annexure 1 outlines the key issues for communication, the messages for male circumcision, strategies to be applied and monitoring and evaluation indicators segmented by target audience. The following are core messages in relation to the roll-out of male circumcision communication strategy. The creative execution may differ. The communication implementation strategy will be developed to mirror the roll-out of circumcision in partnership with the Department of Health.

Medical male circumcision improves hygiene, reduces the risk of HIV infection, some STIs and penile cancer.

Reducing the risks of HIV and STIs amongst men reduces the risk of women getting HIV, STIs and cervical cancer.

Men who are circumcised still need to use condoms as circumcision does not fully protect from HIV.

Men who are circumcised still need to reduce sexual partners to prevent HIV.

Male circumcision is only effective if the entire foreskin is removed. In some cultures circumcision means cutting a slit into the foreskin – this is PARTIAL

CIRCUMCISION and does not reduce the risk of HIV infection.

If a man is circumcised it does not mean that he is HIV negative

11 UNAIDS; WHO. (2007). New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications. WHO/UNAIDS Technical Consultation, Male Circumcision and HIV Prevention Research Implications for Policy and Programming, Montreux, 6-8 March 2007.

If you are an HIV positive male, circumcision does not reduce your or your partner’s risk of HIV infection.

Male circumcision does not reduce the risk of HIV through anal sex whether between men who have sex with women or men who have sex with men.

Male Circumcision is a surgical procedure and there may be complications. These are rare especially where well trained medical and well-equipped traditional practitioners are involved. If you experience any complications immediately consult your clinic or doctor.

Advocacy for Social and Behavioural Change

Advocacy is an integral part of the strategic communications process aimed at bringing about a change through addressing the social and contextual factors that may impede or facilitate the ability of a man to be circumcised or not. In particular advocacy seeks to (Policy Project 1995):

Build support for a cause – e.g. provision of male sexual and reproductive health programmes that include safe male circumcision.

Bring about change - reduction of new HIV infections through addressing male sexual and reproductive health including circumcision.

Encourage others to support it – advocate with different audiences to support the adoption of safe male circumcision.

Influence or reform programmes and policies that ensure the adoption of policies and the provision of additional resources for safe circumcision.

An advocacy strategy generally is based on an analysis of the environment, policies which hinder or promote your objective and research with the intended beneficiaries and organizations who may be potential allies or potential discouragers.

Again there are many media available for advocacy and tools used include social mobilization, media advocacy and lobbying.

Monitoring and Evaluation

Monitoring the advocacy process is critical. Process indicators that highlight progress made, challenges and obstacles in achieving the advocacy objective are helpful in refining messages and exploring additional strategies. Social change is not a quick fix solution rather it is a process that requires patience, and constant refinement of the strategy, message and approach in relation to the audience.

Conclusion The randomised controlled trials and the provincial analysis indicates that male circumcision can have a significant impact on new HIV interventions and should be included within a broader HIV prevention and sexual and reproductive health strategy targeting men.

Strategic communication is lagging behind in relation to media reporting and public awareness and perceptions of the risk reduction benefits of male circumcision.

Strategic communication needs to be included as an integral component of any strategy that seeks to roll out male circumcision to ensure that the correct messages are conveyed to the public. A national strategic communication intervention targeting men is being discussed amongst civil society organisations working on men and HIV that will incorporate male circumcision once SANAC and the NDOH have approved the integration of male circumcision within a broader HIV prevention, sexual and reproductive health strategy targeting men.