A Demand Creation Toolkit for Voluntary Medical Male Circumcision (VMMC) in Southern and Eastern Africa

Background:  Voluntary medical male circumcision (VMMC) has been shown in three independent studies to afford significant (60%) HIV protection to males exposed to HIV through heterosexual intercourse.  Subsequent to confirmation of these findings, the World Health Organization (WHO) endorsed VMMC has a primary component for HIV prevention across areas of Africa where HIV prevalence is high and the proportion of sexually active circumcised males is low.  The US government, through the President’s Emergency Plan for AIDS Relief (PEPFAR) advances VMMC in accordance with the WHO directive, across 14 countries of eastern and southern Africa (priority countries) in advancement of the US stated goal for achieving an AIDS-free generation in areas of the highest HIV prevalence in the world.  For maximum public health benefit, the WHO and PEPFAR have determined that a VMMC uptake of 80 percent of males aged 15-49 is necessary.  

Program background: 

The VMMC Demand Creation Toolkit grew from the understanding that conventional messaging was insufficient to reach VMMC targets.  Demand creation has  been of inconsistent quality and focused primarily on HIV prevention.   The toolkit   expands messaging opportunities through broader, strategic channels, and content based on  audience segmentation, analysis, and engagement. The toolkit consolidates diverse demand creation attempts   and offers fresh message frames for local refinement, testing, and implementation.  These frames are based on explicit audience analysis, employing empathy, and determination of audience values and perceived needs, identification of barriers to VMMC compliance, alignment with cultural and traditional beliefs and practices, and respect for all stakeholders autonomy, believes, and safety. 

Evaluation Methods and Results:  The Toolkit is based on qualitative and quantitative stakeholder analysis that characterize  primary (VMMC candidates) and secondary (key-influencer) audiences.  These analyses yield message frames that extend beyond VMMC’s primary HIV prevention benefit.  Collateral benefits including a reduced risk of (other) sexually transmitted infections (STI) in both males and females, along with perceived  hygienic advantages, women’s attitudes and preferences, and reconciliation of VMMC with traditional (cultural) believes and practices have shown promise in expanding interest in VMMC and greater acceptance in electing VMMC services. 

Conclusions:  Advancing VMMC uptake by focusing exclusively on its contribution to HIV prevention has been shown to be inadequate in attracting sufficient numbers of VMMC candidates to achieve the maximum public health benefit, across the 14 priority countries.  The toolkit presents new options for expanded message framing that encompasses the perceived needs and values of both the primary target audience and secondary audiences including women, cultural leaders, policy makers, elders, parents, and employers.

Implications for research and/or practice:  Public health communication too often fails to achieve maximum efficacy due to a values-gap between health advocates and their target audiences.  The toolkit, while specific to VMMC demand creation, embraces a broad strategy inviting public health communicators to more fully consider how their recommended behavior change coincides with target audience values and perceived needs.  This approach may facilitate compliance with recommended guidelines by appealing to values that may or may not include the those espoused by public health advocates, but whose advantages nonetheless accrue to audience members who comply, if only for their own reasons.