Risk Communication and Demand Creation In the Context of Male Circumcision to Reduce HIV

Theoretical Background and research questions/hypothesis: The theory of planned behavior provides a useful context for examining health communication to increase the number of African men undergoing circumcision to reduce the risk of female-to-male HIV transmission. As countries with high HIV prevalence and low rates of male circumcision increasingly scale up circumcision programs, there is concern that risk compensation, or the tendency for people who feel they have some degree of protection to engage in riskier behaviors, may negate the full impact of male circumcision programs. Are circumcision campaigns in Africa communicating risk clearly to an audience that goes beyond uncircumcised men?

Methods: This content analysis examined 75 health communication materials collected from a 2010 meeting organized by UNAIDS and the U.S. Government on communication for male circumcision in sub-Saharan Africa. Primary points of interest included whether communication materials clearly communicated the partial protective effect of circumcision in lowering the risk of female-to-male transmission and the need to maintain other HIV prevention behaviors following circumcision, including abstinence for six weeks following the procedure. The analysis also examined the extent to which messages targeted women and bolstered men’s perceived ability to undergo circumcision.

Results:  Most of the reviewed materials (69%) clearly stated that male circumcision provided men only partial protection from HIV transmission, but less than half (44%) communicated that men were at increased risk of HIV during the six-week recovery period. Communication campaigns appear to appeal not only to potential circumcision clients but also important male referents, especially women. Although the majority of communication campaigns framed circumcision as either a safe or medical procedure or both (55%), far fewer included information about the availability of services (43%), the availability of medication to control pain (33%), or the cost of the procedure (19%).

Conclusions: Although the majority of materials in this analysis clearly communicated that male circumcision provides only partial protection from female-to-male HIV transmission, over a quarter of the materials did not. The findings suggest that many campaigns appear to be grounded in the constructs of the theory of planned behavior and seek to influence the perception of women and other important referents for men. However, given the concerns about risk compensation, communicators should strive to be clear that circumcision provides only partial protection from female-to-male HIV transmission and increasingly appeal to women and employers of men to increase men's self-efficacy and reduce barriers to circumcision services.

Implications for research and/or practice:  Regardless of claims that male circumcision may or may not lead to riskier behaviors, communication materials must be clear and specific about the risk reduction associated with circumcision. Furthermore, communication has an important role to play in stimulating acceptability and demand for male circumcision services.  Tailoring messages to influence the wider community and bolster self-efficacy based on health communication theory could result in greater uptake of male circumcision in traditionally non-circumcising communities, where circumcision programs are especially needed to have a meaningful impact on HIV epidemics