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Glob Health Sci Pract. 2015 Jun 17;3(2):209-29. doi: 10.9745/GHSP-D-15-00020.

Toward a Systematic Approach to Generating Demand for Voluntary Medical Male Circumcision: Insights and Results From Field Studies.

Author information

Bill & Melinda Gates Foundation, Global Development Program, Integrated Delivery, Seattle, WA, USA, and University of Washington, Department of Global Health, Seattle, WA, USA. Now with Surgo Foundation, Seattle, WA, USA, and Harvard T.H. Chan School of Public Health, Boston, MA, USA.
Bill & Melinda Gates Foundation, Independent Consultant, London, UK.
US Centers for Disease Control and Prevention, Atlanta, GA, USA.
US Agency for International Development, Division of Global HIV/AIDS, Washington, DC, USA.
Bill & Melinda Gates Foundation, Global Development Program, Integrated Delivery, Seattle, WA, USA.
BBC Media Action, London, UK.
US Department of State, Office of the US Global AIDS Coordinator, Washington, DC, USA.


By the end of 2014, an estimated 8.5 million men had undergone voluntary medical male circumcision (VMMC) for HIV prevention in 14 priority countries in eastern and southern Africa, representing more than 40% of the global target. However, demand, especially among men most at risk for HIV infection, remains a barrier to realizing the program's full scale and potential impact. We analyzed current demand generation interventions for VMMC by reviewing the available literature and reporting on field visits to programs in 7 priority countries. We present our findings and recommendations using a framework with 4 components: insight development; intervention design; implementation and coordination to achieve scale; and measurement, learning, and evaluation. Most program strategies lacked comprehensive insight development; formative research usually comprised general acceptability studies. Demand generation interventions varied across the countries, from advocacy with community leaders and community mobilization to use of interpersonal communication, mid- and mass media, and new technologies. Some shortcomings in intervention design included using general instead of tailored messaging, focusing solely on the HIV preventive benefits of VMMC, and rolling out individual interventions to address specific barriers rather than a holistic package. Interventions have often been scaled-up without first being evaluated for effectiveness and cost-effectiveness. We recommend national programs create coordinated demand generation interventions, based on insights from multiple disciplines, tailored to the needs and aspirations of defined subsets of the target population, rather than focused exclusively on HIV prevention goals. Programs should implement a comprehensive intervention package with multiple messages and channels, strengthened through continuous monitoring. These insights may be broadly applicable to other programs where voluntary behavior change is essential to achieving public health benefits.

[Indexed for MEDLINE]
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