Global Public Health, 2015 Vol. 10, Nos. 5–6, 757–772, http://dx.doi.org/10.1080/17441692.2014.962559

Hesitance towards voluntary medical male circumcision in Lesotho: Reconfiguring global health governance Nicola L. Bulleda,b* a Department of Anthropology, University of Connecticut, Storrs, CT, USA; bCenter for Global Health, University of Virginia, Charlottesville, VA, USA

(Received 29 October 2013; accepted 14 August 2014) Drawing on work examining HIV prevention initiatives in Lesotho, this paper considers the hesitation of national state actors towards the new strategy for HIV prevention – voluntary medical male circumcision (VMMC). Lesotho offers a representative case study on global health governance, given the country’s high HIV burden and heavy dependence on foreign donor nations to implement local HIV prevention initiatives. In this paper, I use the case of VMMC opposition in Lesotho to examine how the new era of ‘partnerships’ has shifted the architecture of contemporary global health, specifically considering how global agreements are translated or negotiated into local practice. I argue that Lesotho’s domestic policy-makers, in employing national statistics to assess if VMMC is an effective approach to addressing the local epidemic, are asserting a claim of expertise. In doing so, they challenge the traditional structures of global health politics, which have largely been managed by experts and funders from and in the global North. I explore the development of global VMMC policy, what drives Lesotho’s resistance to comply, and consider the impact renegotiation efforts may have on future global health architecture. Keywords: global health politics; HIV/AIDS; Lesotho; VMMC

Introduction In recent years, 14 countries in the ‘AIDS belt’ of Southern Africa have been identified as priority areas for voluntary medical male circumcision (VMMC) programmes to address the HIV pandemic. Several of these countries, including Tanzania, Kenya, Zambia, Swaziland, Rwanda, Namibia, Botswana and Lesotho, have introduced or have made plans to expand their current VMMC efforts as part of their national HIV prevention policies. Compelled by rising concerns over the ineffectiveness of efforts to control the HIV pandemic, and the limitations of new prevention technologies (i.e., microbicides (Ramjee, Govinden, Morar, & Mbewu, 2007), vaccines (Kim, Rerks-Ngarm, Excler, & Michael, 2010) and pre-exposure prophylaxis (Forbes & Mudaliar, 2009; Ukpong & Peterson, 2009; Van Damme et al., 2012) that offer promise but little indication of immediate success, VMMC has been lauded as the most promising new HIV prevention technology. As stated by Richard Wamai and colleagues (2012, p. 118), ‘There is no biomedical intervention currently being implemented that has been demonstrated scientifically to be more efficacious or cost-effective than male circumcision’. The VMMC procedure requires only minimal engagement with the health system and, *Email: [email protected] © 2014 Taylor & Francis

758

N.L. Bulled

effectiveness does not depend upon consistent negotiations of risk reduction. Models project that at a cost of 40 USD per surgery and with 80% coverage, up to 3.5 million new HIV infections can be prevented and as much as 16.5 billion USD in HIV care and treatment costs averted in the next 15 years (Kahn, Marseille, & Auvert, 2006; Nagelkerke, Moses, de Vlas, & Bailey, 2007; PEPFAR, 2012; Williams et al., 2006). However, uptake of VMMC has been slow and more limited than needed for the strategy to achieve maximum effect in reducing HIV prevalence in high-burdened regions, as per model projections. Emmanuel Njeuhmeli, senior biomedical prevention adviser in the USAID Office of HIV/AIDS, assessing VMMC as an HIV prevention strategy notes, ‘we have reached only one-third of the 20.3 million interventions [VMMC procedures] needed to achieve maximum public health benefit by the end of 2016’ (MacDonald & Njeuhmeli, 2014). The UNAIDS 2013 Global Report identified five countries – Lesotho, Malawi, Namibia, Rwanda and Zimbabwe – where VMMC was stated to be a priority, yet coverage of VMMC for adults had achieved less than 10% of the targeted number (UNAIDS, 2013). Reasons for this low VMMC uptake in resource-poor settings include barriers to service delivery, such as limited infrastructure (surgical theatres and surgeons) and resource constraints (stock-outs of essential circumcision commodities). In addition to impediments in service delivery, countries also cite low levels of individual interest in VMMC as a hindrance to scale-up. In a review of initial acceptability studies conducted in nine countries in sub-Saharan Africa, VMMC was generally recognised as a suitable practice for disease prevention (Westercamp & Bailey, 2007). The median proportion of uncircumcised men willing to become circumcised was 65%, ranging from a low of 29% to a high of 87%. Women generally favoured circumcision of their partners (47–79%) and were willing to circumcise their sons (70–90%). However, other studies indicate greater variation in acceptability of the practice. Most Xhosa men in a peri-urban area of Cape Town, South Africa, a community that practises traditional male circumcision (MC), were unwilling to undergo VMMC or allow their sons to do so despite knowledge of the preventive benefits, citing religious and cultural concerns, notions of manhood and social disapproval (Mark et al., 2012). A study in Malawi found that acceptability varied based on prior experience with or historical practices of MC, with greater acceptance in districts where MC is practised (Ngalande, Levy, Kapondo, & Bailey, 2006). These variations in acceptability highlight the complexity of social meanings that are attached to MC (Aggleton, 2007; Garenne, Giami, & Perrey, 2013; Vincent, 2008a). As noted by Njeuhmeli, ‘being circumcised involves deep-seated values, beliefs, and motivational factors that vary with ethnic, religious, and cultural identities’ (MacDonald & Njeuhmeli, 2014). In what follows, I focus on the Lesotho Government’s recent failing to scale-up VMMC services to the level of established targets and the overall hesitance towards the global HIV prevention initiative. My interest in this topic emerges from long-term engagement with HIV programming efforts in Lesotho begun in 2004, and my more recent fieldwork conducted between 2010 and 2012, during which I observed how choices about prevention modalities are made by government and its partners, and enacted, modified or ignored by individuals. First, I offer a brief overview of the development of the ‘global’ VMMC policy and the research studies conducted to inform this policy, taking a critical perspective on how, who and what evidence was included in the discussions that informed the final WHO declaration. By ‘global’ HIV initiatives, I mean the directives announced by the leading authoritative global health institutions on HIV/AIDS, the WHO and UNAIDS, intended for universal application in an effort to address the assumed shared, homogeneous, global

Global Public Health

759

HIV pandemic. Increasingly, debates have surfaced about the interactions between different actors in global health agendas, with efforts focused on ensuring democratic and inclusive processes, rules, representation and accountability, and reforming health policy processes (Walt & Buse, 2005). Nevertheless, the agendas of global health institutions remain largely dominated by members from Western states, are based on biomedical ideologies with certain forms of ‘evidence’ receiving priority over others and driven by the interests of funders based in the global North (Crane, 2013; de Camargo, de Oliveira Mendonça, Perrey, & Giami, 2013; Youde, 2007). Second, I examine the Lesotho response to the global VMMC policy. Though only a single lens through which to examine contemporary global health architecture, Lesotho presents a compelling and emblematic case study of hesitance towards HIV directives offered by the institutionalised agents of global health. Lesotho is burdened by a high HIV prevalence; dependence on international donors to fund and implement domestic HIV prevention initiatives; a geography that hinders universal access to knowledge sources, prevention strategies and treatment; continued existence of stigma around the epidemic; and difficulties in addressing persistent social inequalities that fuel infections. In Lesotho, MC also continues to be practised as part of puberty rites ceremonies by a significant proportion of the male population. VMMC policies, therefore, face the additional challenge of being introduced as a ‘new’ form of an ‘old’ practice (Bulled, 2013a). Finally, I position the response of Lesotho’s domestic policy-makers within current discussions of global health politics. In recent years, the development of the Bill and Melinda Gates Foundation, the Global Fund and a multitude of other large global health funders has shifted global health architecture from one of health reforms driven by coordinated social movements with no dominant actor in the policy process to an era of collaborative relationships between corporations and intergovernment organisations (Buse & Walt, 2000). These new partnerships transcend national boundaries and share a common goal, but frequently battle competing interests (Walt, Spicer, & Buse, 2009). David Fidler (2007) argues that the result is a climate of ‘anarchy’ with an unruly melange of actors at global and national levels. MacFarlane, Jacobs, and Kaaya (2008, p. 384) warn that: all this new energy for global health will result in [global health] becoming an activity developed through the lens of rich countries, ostensibly for the benefit of poor countries, but without the key ingredients of a mutually agreed, collaborative endeavour.

Steven Feierman further asserts that the social relations of global health governance are being defined as ‘authorities in rich countries [debating and determining] what is to be done for (or to) the poor’ (2011, p. 190). Lesotho’s case of hesitation, joining opposition offered by other prominent figures in Africa and a history of public resistance to global health strategies, indicates that global health governance, which has very much been driven by the HIV epidemic, continues to be a space of ‘friction’ (Tsing, 2004). Lesotho’s hesitance to VMMC provides further evidence of the continuing struggle for power over ‘who gets to decide’ in HIV and global health politics. The development of the ‘global’ VMMC policy The link between HIV and MC status was observed early on in the HIV pandemic. However, geographical correlations and ecological case/control and cohort studies from around the world were inconclusive in establishing a relationship.1 Nevertheless, in a

760

N.L. Bulled

literature review published in the Lancet in 1999, Bailey and Halperin urged international public health organisations to implement programmes that incorporated MC as a new HIV prevention strategy. Utilising both earnest and accusatory tones, the authors stated, ‘In the face of such compelling evidence, we would expect the international health community to at least consider some form of action’ (Halperin & Bailey, 1999, p. 1814). In response, a small consultation of experts was called at the XIII International AIDS Conference in 2000 to review the data and propose a way forward. The resulting recommendation was for randomised control trials (RCTs) to be conducted to identify a causal relationship. Three large RCTs were conducted in South Africa (Auvert et al., 2005), Kenya (Bailey et al., 2007) and Uganda (Gray et al., 2007). Independently these trials identified an almost a 60% reduction in HIV infection risk among circumcised men as compared to uncircumcised men. While proving biological effectiveness of VMMC in individuals, a similar level of effectiveness remains uncertain at the population level. Data collected via Demographic and Health Surveys (DHS) from large representative samples of national populations in 19 African countries, which include data on MC (self-report) and HIV status (blood sample), suggest no difference in HIV prevalence by circumcision status (Denniston, Hodges, & Milos, 2010; Garenne, 2006, 2008, 2010; Mishra, Hong, & Khan, 2006; Way, Mishra, & Hong, 2006). Two countries showed significantly lower HIV prevalence among circumcised men (Kenya and Uganda) while three countries (Lesotho, Malawi and Tanzania) showed higher levels of HIV infection among circumcised men. These discrepancies between trial and population-level data continue to be fervently contested in the literature (Boyle & Hill, 2011; Garenne et al., 2013; Wamai et al., 2012). In response to the increasingly active conversation on MC as an HIV prevention strategy, and the early termination due to ethical considerations of the RCTs taking place in Kenya and Uganda, the WHO and UNAIDS convened the conference ‘Male circumcision and HIV prevention: Research implications for policy and programming’ in Montreux, Switzerland, 6–8 March 2007. As described by Dr Kim Dickson (coordinator of the joint WHO/UNAIDS working group and the Inter-agency Task Team) in an interview prior to the meeting, the aim was ‘to bring around the table as many stakeholders as possible to look at and discuss many of the issues that male circumcision can raise, and, if possible, give guidance and recommendations for Member States and other stakeholders’. Yet warning, ‘at this stage, we cannot pre-empt the outcome. Maybe we will conclude the meeting with more questions than we began with’ (emphasis added UNAIDS, 2007). A diverse group of participants attended the meeting including academic researchers, members of international health organisations, gender relations specialists, representatives of UN funding agencies and of other public and private institutions (Global Fund, ANRS [the French Agence nationale de recherches sur le sida et les hépatites virales], Gates Foundation), association members, youth organisation members and human rights activists. In addition, 16 representatives from member states and 11 from civil society including women’s health advocates and a representative from the Global Network of people living with HIV were invited to ‘present their own reading of the results and also to raise the issues that they face in their countries and in the context of their activities’ (Dickson quoted in UNAIDS, 2007). In all 80 participants attended. According to Dickson, particular attention had been paid to inviting people representing different positions as this was the first time that such a wide range of stakeholders were able to exchange views and discuss the consequences of VMMC as an additional prevention method in response to HIV. She added, ‘No need to say that we expect intense discussions that will touch upon many difficult issues’ (UNAIDS, 2007).

Global Public Health

761

The meeting programme focused discussions on VMMC’s medical, scientific and technical aspects, with epidemiologists presenting discussions of meta-analyses, observational studies, clinical trials, cost-effectiveness analyses and models of potential impact. A whole day was devoted to implementation strategies. Only two hours were devoted to ethical issues (human rights) and to the discussions of the Social Aspects for HIV/AIDS Research Alliance (SAHARA) group, charged with coordinating MC-related studies (WHO/UNAIDS, 2007). Global health officials had not waited for the study results from the SAHARA group before making their determination. This has caused some to speculate that global public health planners and researchers only cared to consult social scientists to facilitate strategy implementation at the country level, not for insight on developing global policy (Garenne et al., 2013). Two weeks after Montreux, Kevin de Cock (director of the HIV/AIDS Department at WHO), Catherine Hankins (associate director, strategic information and chief scientific adviser to UNAIDS) and Jean-François Delfraissy (the director of ANRS) presented the official VMMC statement at a press conference in Paris, which read2: the partial protective effect of male circumcision is remarkably consistent across the observational studies (ecological, cross-sectional and cohort) and the three randomized controlled trials conducted in diverse settings … the efficacy of male circumcision in reducing female to male transmission of HIV has been proven beyond reasonable doubt. This is an important landmark in the history of HIV prevention.

The timing of events, meeting content and attendees reveal a heavy emphasis on biomedical evidence for this new prevention technology with little concern for unique social contexts. Indeed, with such a short time between study findings and no time to conduct additional research on contextual variations, might the intentions of the Montreux conference as an open-ended technical consultation among stakeholders be an overstatement? Dr Dickson’s pre-meeting commentary suggested a democratic process of policymaking, a heterogeneous collection of meeting participants gathering around a table each to offer their voice for the development of a multidisciplinary, multi-occupational and truly global policy under the new global health ‘partnership’ framework. However, the structure and content of the meeting and rapid publication of results raise numerous questions: Were all stakeholders in the MC conversation actually invited? Was the formal style of a policy meeting conducive to allowing everyone to speak especially those who may be less familiar with these types of discourse platforms? Was sufficient time allowed for the evidence from the trials to be fully evaluated? Were alternative perspectives valued or did a moral claim of ‘inappropriate not to act’ win out over ‘first do no harm’? Were considerations raised in the meeting integrated into the rapidly published global policy or had the decision to support a universal strategy on VMMC already been largely formulated? These questions have been framed by sociologist Gary Dowsett, the sole critic of VMMC in attendance at the Montreux conference, and his colleague Murray Couch (2007, p. 43) in terms of epistemology and politics, ‘what is at stake, how is that defined and by whom, what evidence suffices, who decides and on what basis?’

Reluctance towards VMMC scale-up in Lesotho Lesotho currently has one of the highest prevalence of adult HIV/AIDS in the world (23.1% of people aged 15–49; UNAIDS, 2012). The generalised, heterosexual epidemic driven by inconsistent condom use; multiple, concurrent and transactional sexual

762

N.L. Bulled

partnerships; and unequal gender, economic and political dynamics has had significant impact. While the population annual growth rate averaged 2.2% from 1970 to 1990, it has since dropped to 1.18% (World Bank, 2012). Life expectancy has fallen to 49 years, 17 years less than what it would have been without AIDS. Since the first identified case of HIV in 1986, the Lesotho Government has, for the most part, complied with global HIV directives (Bulled, 2013b). Though slow to initiate a domestic HIV response due to funding and infrastructural limitations, domestic health policy now includes universal testing and treatment, behaviour change communication messages of abstain, be faithful to a single sex partner and use condoms for every sexual encounter (ABC) and the implementation of school-based ‘Life Skills’ training. The government structures managing the national response to HIV have even been organised following the UNAIDS’ ‘Three Ones’ directive (UNAIDS, 2005) that calls for one national AIDS framework, one national AIDS authority and one system for monitoring and evaluation to make optimal use of the limited resources available. With significant support from Western donor agencies and institutions, Lesotho was the first country to implement universal voluntary counselling and testing in its 2006 ‘Know Your Status’ campaign. By 2013, more than half of eligible HIV-infected patients were receiving antiretroviral treatments in over 200 decentralised facilities throughout Lesotho (WHO, 2013). In spite of pressures from global health organisations and international funders and buy-in of neighbouring countries, recent hesitation regarding VMMC is the first moment of pause offered by Lesotho’s national leaders in aligning domestic policy with the directives offered by global health governance institutions.3 In 2007, both an initial rapid assessment and cost-effectiveness analysis of VMMC in Lesotho were conducted. A full situational analysis was completed in 2008. These assessments aimed to address the following: current levels of MC in Lesotho, capacity for scale-up, forms of investment needed, cost-effectiveness of the strategy, delivery process as stand-alone or integrated, the demand, public awareness of benefits and misconceptions (MoHSW, 2008). Results indicated a minimum coverage of 52% complete VMMC prevalence in order to evoke significant impact on reducing HIV prevalence or close to 35,000 VMMC performed in 2009 and 44,000 annually thereafter (NAC, 2010). Provision of VMMC would have to increase by a factor of seven in order to meet this target. For such a scale-up, an additional annual investment of 9 million LSL (1.2 million USD) was deemed necessary. The situational analysis determined that given the projected impact, of one averted HIV infection for every 6.1 surgeries conducted, such an investment would prove cost-effective, given the limited success of current prevention measures and the alternative costs of lifelong treatment. As only medical doctors are authorised to perform VMMC, expansion of authorisation to nurse clinicians was considered necessary with additional trainings, mentoring and supervision. Two-thirds of health centres reported not having the capacity to perform VMMC surgeries, and most would need significant facility upgrades in addition to trained health care personnel. Furthermore, the report determined that a national awareness campaign was needed to increase understanding and demand for VMMC, given misconceptions of immunity from HIV following the procedure and confusion regarding VMMC and traditional circumcision as part of initiation rites (MoHSW, 2008). At the time, guidelines, protocols, site assessment and monitoring and evaluation tools and a counselling package were identified as close to finalised (NAC, 2010). In addition, nine hospitals were assessed and equipment and consumables procured to support the scale-up plan. However, in 2009, two years following the release of the Montreux conference decision and a year after the Ministry of Health and Social Welfare finalised their MC

Global Public Health

763

situational analysis, a Lesotho national newspaper headline read, Health Ministry has no intention of campaigning for circumcision. The title of this article was misleading as the then Director General of Health Dr Mpolai Moteetee was specifically referencing neonatal circumcision, stating that ‘circumcising young children … is against the Basotho culture’ (Linake, 2009, p. 8). Even so, the government has hesitated to support VMMC as an HIV prevention strategy for adult males. The scale-up of services detailed in the situational analysis has not occurred – only four public hospitals are equipped to provide VMMC – and the guidelines were not finalised until 2012. Rather than citing concerns over cultural appropriateness, as Dr Moteetee expressed, the national government draws on domestic surveillance data (the Lesotho DHS), as established to align with global health bureaucracies, to point out that: The relationship between male circumcision and HIV levels in Lesotho does not conform to the expected pattern of higher prevalence among uncircumcised men. HIV prevalence is substantially higher among circumcised men age 15–59 (21%) than among men age 15–59 who are not circumcised (16%). Moreover, the pattern of higher HIV prevalence among circumcised men is the same across a large majority of subgroups. (Emphasis added, MoHSW, 2009, p. 212)4

According to the recent Lesotho DHS, 52% of men in Lesotho self-identify as circumcised, with 90% of these operations occurring during the traditional initiation process of lebollo (MoHSW, 2009). The importance of lebollo rites for transitioning boys to men has repeatedly been challenged through time by international agents. First, Christian missionaries arriving in Lesotho in the 1800s proclaimed initiation rites, and their associated circumcision ceremonies, to be ungodly and backwards. Education was to be conducted in schools and result in employment in the formal economy of a growing capitalist society. The advent of the AIDS era offered further cause to abandon the practice, given concerns that the reuse of unsterilised cutting instruments for initiation associated rituals, particularly MC, contributes to HIV transmission (Brewer, Potterat, Roberts, & Brody, 2007). This was noted by Mathoriso Monaheng, former director of Administration at the Lesotho AIDS Program Coordinating Agency, quoted in a local newspaper in 2003 as saying, ‘The problem [of initiation rites] is that they are using one knife to circumcise boys, that knife is used by everybody’ (Staff reporter, 2003, p. 10). Widely reported accounts of deaths, hospitalisations and penile amputations, the result of untrained traditional circumcisers, have been reported in neighbouring South Africa, heightening concerns of unnecessary risk (Ledwaba, 2013; Vincent, 2008b). Reticence to implement global health policy recommendations of VMMC in Lesotho has not been directly tied to cultural sensitivities, but rather positioned as an informed response to national population-level data. Domestic policy-makers have not drawn on lebollo practices as a basis for their hesitation towards VMMC (see Bulled, 2013b, for further discussion). Domestic health agents are not regarding VMMC with suspicion or drawing on abundant conspiracy theories and rumours of Western attempts to dominate the African body (Kalichman, 2009; Niehaus & Jonsson, 2005; Posel, 2004; Stadler, 2003; Van der Vliet, 2001). National policy-makers are also not against transferring MC practices from traditional to biomedical venues (personal conversation John Nkanyana, Director of Disease Control at the MoHSW). Instead, they employ scientific/biomedical methodologies and vocabularies, specifically drawing on the DHS data, to counter directives on VMMC set by global health governance institutions.

764

N.L. Bulled

I argue that by drawing on normalised population-level statistical data, the national government is renegotiating Lesotho’s position in the structure of global public health governance. Basing an argument for opposition towards VMMC on DHS data (collated and largely interpreted by people in the global North) may not provide equal footing in generating new knowledge or policies from that knowledge. However, as Dowsett and Couch (2007) posit, what is the ‘right kind of evidence’ when it comes to managing disease prevention at a population level, and is there enough of this type of evidence to generate and force nation states to comply with global policies? Furthermore, although Africans and other experts from the global South have participated in global health knowledge production for some time (Crane, 2013; Feierman, 2011; Fullwiley, 2011; Iliffe, 1998), others and I question the agency and the equivalence of contributions made, or allowed to be made, by individuals in developing worlds who are more heavily impacted by disease (Briggs, 2003; Briggs & Hallin, 2010; Dutta, 2008, 2011; Walt et al., 2009). As observed in discussions on other matters of global health, country leaders often feel beholden to the priorities of multilateral funders (Gill et al., 2013), resulting in external interests being favoured over national priorities. Given that over 90% of Lesotho’s 2011 HIV budget was provided by funds from international agencies (NAC, 2011), international pressures to scale-up public VMMC efforts cannot or will not be ignored despite national policy-makers’ misgivings or concerns. Clearly, just having someone present at the discussion table does not afford them the ability to speak or to be heard. Global health architecture Resistance to public health strategies and specifically HIV-related approaches have been observed throughout history. For example, in colonial Africa, public health teams seeking to eradicate sleeping sickness extracting lymph fluid from the neck of suspected patients were consciously avoided. In the Belgian Congo, people would flee into the bush to escape the mobile public health disease eradication teams or persuade traditional physicians to remove their lymph nodes so that they would not be subjected to the dreaded needles (Lyons, 1988). In northern Nigeria, in 2004, a campaign to eradicate polio was abandoned due to widespread rumours that the vaccine was a Western plot aimed at sterilising Muslim women and infecting children with HIV (Jegede, 2007). In recent years in Pakistan, Taliban leaders refused entrance of polio vaccination teams in protest against the US drone strikes (Walsh, 2012). In Central Africa, members of Ebola outbreak control teams have been physically attacked by local residents (Diarra & Hussain, 2014). Opposition to Western directives on HIV has also routinely been voiced by state and community leaders. South Africa’s President Mbeki is likely the most well known, resisting foreign and domestic pressures to provide HIV treatments with his denialist perspective. President Yahya Jammeh of the Gambia claimed to use the ‘seven herbs named in the Koran’ to cure AIDS (Cassidy & Leach, 2007; PlusNews, 2012). Teguest Guerma of the African Medical and Research Foundation argued that the international AIDS community dictates global prescriptions on HIV, of making promises and rapidly shifting priorities stating, ‘if we [Africans] don’t know what we want to do, we don’t want others to come and tell us what to do’ (Martin, 2012). In this, Guerma is not suggesting that Africans have not been involved in the production of knowledge, but rather excluded from discussions of how that knowledge might best be applied in diverse contexts where limitations in social, political, economic and geographic arrangements

Global Public Health

765

might restrict the implementation of life-saving interventions. She called for ‘country ownership, [for Africans] to take over responsibilities for the [HIV] epidemic and other health problems in Africa’ (Martin, 2012). Guerma pointed to the empowerment of communities, training health workers in Africa, using innovative health technologies and learning tools. The important focus for future HIV and health responses in Africa, she argued, should come from within, with local needs identified by locals, to gain the support of those involved and ensure that new initiatives are ‘owned by Africans’. I view Lesotho’s hesitance towards VMMC scale-up as aligned with Guerma’s argument, yet, also unique. Lesotho’s domestic health leadership has utilised established disease surveillance to direct their limited health resources and to counter global health agency and funder directives – not rumour, flawed logics, belief in conspiracy theories or infringements on cultural practices, rights or empowerment. Disease surveillance has long been employed to standardise and de-contextualise health and illness as a way to manage and direct resources. In this case, interpretations of national data by domestic policymakers run counter to the evidence upon which the WHO based its decision to promote universal VMMC, and the evidence global health funders [including the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the Gates Foundation] are drawing on to make determinations on whom to fund and for what purpose. There is a long history of recipient states carefully guarding, controlling the release of or deliberately falsifying data, particularly during disease outbreaks and environmental catastrophes such as the 1992/1993 cholera epidemic in Venezuela (Briggs & Mantini-Briggs, 2003), the AIDS and severe acute respiratory syndrome (SARS) epidemics in China, by the allies and axes powers during the influenza epidemic of First World War and by the Soviets during the Chernobyl disaster (Petryna, 2002), to reduce blame and secure international funding. For global health policy-makers, VMMC may have become the new ‘magic bullet’ against HIV, resulting in large amounts of funding dedicated to implementing the vertical programme (perhaps with some diagonal influences through necessary infrastructural development). As recent history has shown us, such approaches are doomed to fail as few resources are leftover to address the fundamental drivers of the epidemic (Biehl, 2007). Although this is only a single case, I argue that this type of hesitance to global health directives shines a spotlight on contemporary global health architecture. There is no longer a dominant actor in global health. The new global health ‘partnerships’ involve constant renegotiations with diverse interests and incentives directing how evidence is understood. Brazil’s former AIDS coordinator, Dr Paulo Teixeira, noted at a Global Health Governance Workshop in São Paulo in June 2005: The negotiating power of developing countries is simply too low, be it at the United Nations or at the World Trade Organization. AIDS gave poorer countries a small window of opportunity to intervene in global governance and to try to recast the uneven correlation of forces. (As cited in Biehl, 2007, p. 1102)

Conclusion The case of VMMC as a new HIV prevention strategy presents itself as a global endeavour – an interconnectedness of ideas, interpretations and reflexivity across national borders and geographical and ideological boundaries (Guillén, 2001; Robinson, 2001; Tomlinson, 1999). The RCTs, cost-effectiveness and acceptability studies on the link between VMMC and HIV prevention were conducted in the global South. Yet, the studies’ conceptualisation, organisation and funding were developed in the global North.

766

N.L. Bulled

Following on this globally interconnected trend, in a concerted effort to ignore (social) boundaries in setting the global policy on VMMC, the WHO and UNAIDS convened the Montreux conference inviting a diverse group of interdisciplinary participants from the global North and global South. However, Western-biomedical ideologies predominated, with the results of the gold standard RCTs considered more valid than discussions on how these scientific findings might be interpreted (or implemented) in diverse social contexts. Consequently, despite the efforts to obtain multiple perspectives, the VMMC agenda of global health institutions is heavily influenced by Western-based biomedical ideologies of the global North, founded on scientific claims of truth. Community members invited to provide their insights continue to serve as mere token representatives in the global discussions (Dutta, 2011). Little opportunity is provided to consider the diverse concerns and realities of those seeming to stand the most to gain from what could potentially be a highly effective intervention. Continued debates raised over the translation of biological effectiveness into effective public health interventions given highly varied geopolitical and cultural context (Aggleton, 2007; de Camargo et al., 2013; Dowsett & Couch, 2007; Garenne et al., 2013) is touted as anti-scientific, or ‘reject[ing] established scientific norms and rules, so making scientific discourse all by impossible’ (Wamai et al., 2012, p. 119). Yet, as noted by anthropologist Merrill Singer (1994, p. 1323), ‘The AIDS text is multivocal, and includes not only the voice of authority but also the voice of resistance’. Hesitance of nation states to adopt the global VMMC agenda is regarded as noncompliance. The UNAIDS Global Report 2013 identifies six countries that have failed to meet their national targets for number of VMMC operations performed, stating ‘where scale-up of voluntary medical male circumcision has been slow, [policy makers and leaders] should take immediate action to promote and deliver this essential HIV prevention method, using lessons learnt from setting where rapid scale-up has occurred’ (UNAIDS, 2013, p. 27). Such language suggests that certain governments or communities are recalcitrant in delaying or seeking other tactics for implementation of the globally agreed-upon agenda. Seen in this light, the case of domestic policy-makers’ hesitance to promote the global VMMC strategy in the Lesotho context suggests resistance to an assumption of the homogeneity of HIV epidemics and social and cultural conditions, the universal applicability of Western biomedical approaches and the continued inequitable structures of global health governance. Furthermore, in employing scientific discourse, pointing to national health statistics, domestic policy-makers are asserting their expertise, not in an effort to reassert local or indigenous knowledge, but rather to negotiate for a shared position of authority within current global public health structures. In challenging traditional global health structures, there is recognition of their inherent inequality and the limitations for meaningful involvement of those on the margins of global society. Use of national statistics to determine domestic agendas that counter the directives of global health institutions and call for the development of ‘African solutions to African problems’ suggest that attempts continue to be made to rework the arrangements of global health structures. To do this, spaces of discourse must be made available to the subaltern who may not have the skills or the confidence to operate in established venues of communication (Dutta, 2008, 2011). Although the work of redressing health inequities can generate new forms of exclusion (Briggs & MantiniBriggs, 2003), it can also provide space for new forms of inclusion (Crane, 2013). Challenges to expertise should be embraced and viewed as a way to promote dialogue and the exchange of ideas, rather than dissuaded. Should global communication structures

Global Public Health

767

continue to be opposed to voices of hesitation and dissent, the ‘AIDS Free Generation’ will continue to be elusive. Acknowledgement This study was supported by the Fulbright Foundation and the University of Connecticut’s Graduate School.

Notes 1. Geographical correlations suggested a negative relationship between HIV disease and circumcision practices in Africa, with lower HIV prevalence in Sahelian, West Africa, where MC is more uniformly conducted, as compared to Eastern Africa where circumcision is less routinely practised (Bongaarts, Reining, Way, & Conant, 1989; Moses et al., 1990). Ecological case/ control and cohort studies revealed a less conclusive relationship. While appearing to hold in some countries in Africa, this was not the case in all the countries (Baeten et al., 2005; Bongaarts et al., 1989; Drain, Halperin, Hughes, Klausner, & Bailey, 2006; Halperin & Bailey, 1999; Moses et al., 1990; Quinn et al., 2000; Reynolds et al., 2004; Siegfried et al., 2005; Weiss et al., 2008; Weiss, Quigley, & Hayes, 2000). Throughout Europe, in the USA, New Zealand and Australia, MC had no effect on sexually transmitted infections (STIs) transmitted through either homosexual or heterosexual routes (Darby, 2005; Dave et al., 2003; Dickson, van Roode, Herbison, & Paul, 2008; Laumann, Masi, & Zuckermann, 1997; Richters, Smith, de Visser, Grulich, & Rissel, 2006). 2. The full text of the recommendations can be found at: http://www.who.int/hiv/mediacentre/ MCrecommendations_en.pdf. 3. In February 2012, VMMC was initiated at Berea, Mafeteng, St Joseph and Scott hospitals following the release of the VMMC policy and Operational Plan. VMMC services are available at a public ‘male clinic’ in Maseru, the capital city. In addition, international organisations (Jhpiego funded by PEPFAR and Population Services International working with the Lesotho military) continue their efforts to increase public access to VMMC services. 4. This statement does not recognise or account for the limitations in the national data. An insufficient number of men have undergone VMMC in Lesotho to clearly tease out whether one form of MC (traditional or clinic-based VMMC) offers protection while the other increases risk (perhaps due to partial circumcision; Thomas et al., 2011; WHO, 2014).

References Aggleton, P. (2007). “Just a snip”? A social history of male circumcision. Reproductive Health Matters, 15(29), 15–21. doi:10.1016/S0968-8080(07)29303-6 Auvert, B., Taljaard, D., Lagarde, E., Sobngwi-Tambekou, J., Sitta, R., & Puren, A. (2005). Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 Trial. PLoS Medicine, 2(11), e298. Baeten, J. M., Richardson, B. A., Lavreys, L., Rakwar, J. P., Madaliya, K., Bwayo, J. J., & Kreiss, J. K. (2005). Female-to-male infectivity of HIV-1 among circumcised and uncircumcised Kenyan men. Journal of Infectious Diseases, 191, 546–553. doi:10.1086/427656 Bailey, R. C., Moses, S., Parker, C. B., Agot, K., Maclean, I., Krieger, J. N., …Ndinya-Achola, J. O. (2007). Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomised controlled trial. Lancet, 369, 643–656. doi:10.1016/S0140-6736(07)60312-2 Biehl, J. (2007). Pharmaceuticalization: AIDS treatment and global health politics. Anthropology Quarterly, 80, 1083–1126. doi:10.1353/anq.2007.0056 Bongaarts, J., Reining, P., Way, P., & Conant, F. (1989). The relationship between male circumcision and HIV infection in African population. AIDS, 3, 373–378. doi:10.1097/000020 30-198906000-00006 Boyle, G., & Hill, G. (2011). Sub-Saharan African randomized clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns. Journal of Law and Medicine, 19, 316–334.

768

N.L. Bulled

Brewer, D. D., Potterat, J. J., Roberts, J. M., Jr, & Brody, S. (2007). Male and female circumcision associated with prevalent HIV infection in virgins and adolescents in Kenya, Lesotho, and Tanzania. Annals of Epidemiology, 17, 217–226. doi:10.1016/j.annepidem.2006.10.010 Briggs, C. L. (2003). Why nation-states and journalists can’t teach people to be healthy: Power and pragmatic miscalculation in public discourses on health. Medical Anthropology Quarterly, 17, 287–321. doi:10.1525/maq.2003.17.3.287 Briggs, C. L., & Hallin, D. (2010). Health reporting as political reporting: Biocommunicability and the public sphere. Journalism, 11, 149–165. doi:10.1177/1464884909355732 Briggs, C. L., & Mantini-Briggs, C. (2003). Stories in the time of cholera: Racial profiling in a medical nightmare. Berkeley, CA: University California Press. Bulled, N. (2013a). New lives for old: Modernity, biomedicine, traditional culture and HIV prevention in Lesotho. Global Discourse, 3, 284–299. doi:10.1080/23269995.2013.804700 Bulled, N. (2013b). (Re)distribution of blame: Examining the politics of biomedical HIV knowledge in Lesotho. Critical Arts, 27, 267–287. doi:10.1080/02560046.2013.800664 Buse, K., & Walt, G. (2000). Global public-private partnerships: Part I—A new development in health? Bulletin of the World Health Organization, 78, 549–561. Cassidy, R., & Leach, M. (2007). Citizenship, global funding and AIDS treatment controversy: A Gambian case study. Brighton, UK: Citizen Engagement in a Globalizing World. Crane, J. T. (2013). Scrambling for Africa: AIDS, expertise, and the rise of American Global Health Science. Ithaca, NY: Cornell University Press. Darby, R. (2005). The sorcerer’s apprentice: Why can’t the United States stop circumcising boys? Retrieved from www.historyofcircumcision.net/index.php?option=content&task=view&id=61 Dave, S., Johnson, A., Fenton, K., Mercer, C., Erens, B., & Wellings, K. (2003). Male circumcision in Britain: Findings from a national probability sample survey. Sexually Transmitted Infections, 79, 499–500. doi:10.1136/sti.79.6.499 de Camargo, K. R., de Oliveira Mendonça, A. L., Perrey, C., & Giami, A. (2013). Male circumcision and HIV: A controversy study on facts and values. Global Public Health, 8, 769– 783. doi:10.1080/17441692.2013.817599 Denniston, G., Hodges, F., & Milos, M. (Eds.). (2010). Genital autonomy. Protecting personal choice. Dordrecth: Springer Science & Business Media B.V. Diarra, A., & Hussain, M. (2014). Mob attacks Ebola treatment centre in Guinea, suspected cases reach Mali. Retrieved from http://www.reuters.com/article/2014/04/04/us-guinea-ebola-maliidUSBREA331ZP20140404 Dickson, N., van Roode, T., Herbison, P., & Paul, C. (2008). Circumcision and risk of sexually transmitted infections in a birth cohort. Journal of Pediatrics, 152, 383–387. doi:10.1016/j. jpeds.2007.07.044 Dowsett, G. W., & Couch, M. (2007). Male circumcision and HIV prevention: Is there really enough of the right kind of evidence? Reproductive Health Matters, 15(29), 33–44. doi:10.1016/ S0968-8080(07)29302-4 Drain, P. K., Halperin, D. T., Hughes, J. P., Klausner, J. D., & Bailey, R. C. (2006). Male circumcision, religion, and infectious diseases: An ecologic analysis of 118 developing countries. BMC Infectious Diseases, 6, 172. doi:10.1186/1471-2334-6-172 Dutta, M. J. (2008). Communicating health: A culture-centered approach. Cambridge, UK: Polity Press. Dutta, M. J. (2011). Communicating social change: Structure, culture, and agency. New York, NY: Taylor & Francis. Feierman, S. (2011). When physicians meet: Local medical knowledge and global public goods. In W. Geissler & C. Molyneux (Eds.), Evidence, ethos and experiment: The anthropology and history of medical research in Africa (pp. 171–196). New York, NY: Berghahn Books. Fidler, D. (2007). Reflections on the revolution in health and foreign policy. Bulletin of the World Health Organization, 85, 243–244. doi:10.2471/BLT.07.041087 Forbes, A., & Mudaliar, S. (2009). The Cambodia story. In M. Ukpong & K. Peterson, (Eds.), Oral Tenofovir controversy II—Voices from the field: A series of reports on the Oral Tenofovir trials from the perspectives of active community voices in Cambodia, Cameroon, Nigeria, Thailand and Malawi (pp. 9–19). Lagos: New HIV Vaccines and Microbicides Study. http://www.nhvmasng.org/publication/TDF2.pdf. Fullwiley, D. (2011). The enculturated gene: Sickle cell health politics and biological difference in West Africa. Princeton, NJ: Princeton University Press.

Global Public Health

769

Garenne, M. (2006). Male circumcision and HIV control in Africa. PLoS Medicine, 3(1), e78. doi:10.1371/journal.pmed.003.0078 Garenne, M. (2008). Long-term population effect of male circumcision in generalised HIV epidemics in sub-Saharan Africa. African Journal of AIDS Research, 7(1), 1–8. doi:10.2989/ AJAR.2008.7.1.1.429 Garenne, M. (2010). Mass campaigns of male circumcision for HIV Control in Africa: Clinical efficacy, population effectiveness, political issues. In G. Denniston, F. Hodges, & M. Milos (Eds.), Genital autonomy. Protecting personal choice (pp. 49–60). Dordrecht: Springer Science & Business Media B.V. Garenne, M., Giami, A., & Perrey, C. (2013). Male circumcision and HIV control in Africa: Questioning scientific evidence and the decision-making process. In T. Giles-Vernick, & J. L. Webb, Jr. (Eds.), Global health in Africa: Historical perspectives on disease control (pp. 185– 210). Athens, OH: Ohio University Press. Gill, C. J., Young, M., Schroder, K., Carvajal-Velez, L., McNabb, M., Aboubaker, S., … Bhutta, Z. A. (2013). Bottlenecks, barriers, and solutions: Results from multicountry consultations focused on reduction of childhood pneumonia and diarrhoea deaths. Lancet, 381, 1487–1498. doi:10.1016/S0140-6736(13)60314-1 Gray, R. H., Kigozi, G., Serwadda, D., Makumbi, F., Watya, S., Nalugoda, F., … Wawer, M. J. (2007). Male circumcision for HIV prevention in men in Rakai, Uganda: A randomised trial. Lancet, 369, 657–666. doi:10.1016/S0140-6736(07)60313-4A Guillén, M. (2001). Is globalization civilizing, destructive or feeble? A critique of five key debates in the social science literature. Annual Review of Sociology, 27, 235–260. doi:10.1146/annurev. soc.27.1.235 Halperin, D., & Bailey, R. C. (1999). Male circumcision and HIV infection: Ten years and counting. Lancet, 354, 1813–1815. doi:10.1016/S0140-6736(99)03421-2A Iliffe, J. (1998). East African doctors: A history of the modern profession. Cambridge: Cambridge University Press. Jegede, A. S. (2007). What led to the Nigerian boycott of the polio vaccination campaign? PLoS Medicine, 4(3), e73. doi:10.1371/journal.pmed.0040073 Kahn, J. G., Marseille, E., & Auvert, B. (2006). Cost-effectiveness of male circumcision for HIV prevention in a South African setting. PLoS Medicine, 3(12), e517. doi:10.1371/journal.pmed.00 30517 Kalichman, S. (2009). Denying AIDS: Conspiracy theories, pseudoscience and human tragedy. New York, NY: Copernicus Books. Kim, J., Rerks-Ngarm, S., Excler, J., & Michael, N. (2010). HIV vaccines: Lessons learned and the way forward. Current Opinion in HIV and AIDS, 5, 428–434. doi:10.1097/COH.0b013e328 33d17ac Laumann, E., Masi, C., & Zuckermann, E. (1997). Circumcision in the United States. Prevalence, prophylactic effects and sexual practice. Journal of the American Medical Association, 277, 1052–1057. doi:10.1001/jama.1997.03540370042034 Ledwaba, L. (2013, September 18). Severed penises shock. The Sowetan. Retrieved from: http:// www.journaids.org/index.php/blog/blog-entry/severed_penises_shock/ Linake, M. (2009, July 13). Health ministry has no intentions of campaigning for circumcision. Informative, p. 8. Lyons, M. (1988). Sleeping sickness, colonial medicine and imperialism: Some connections in the Belgian Congo. In R. Macleod & L. Milton (Eds.), Disease, medicine and empire (pp. 242–256). London: Routledge. MacDonald, R., & Njeuhmeli, E. (2014). Assessing voluntary medical male circumcision for HIV prevention in a unprecendented public health intervention. Retrieved from http://blogs.plos.org/ speakingofmedicine/2014/05/06/assessing-voluntary-medical-male-circumcision-hiv-preventionunprecendented-public-health-intervention/ Macfarlane, S. B., Jacobs, M., & Kaaya, E. E. (2008). In the name of global health: Trends in academic institutions. Journal Public Health Policy, 29, 383–401. doi:10.1057/jphp.2008.25 Mark, D., Middelkoop, K., Black, S., Roux, S., Fleurs, L., Wood, R., & Bekker, L.-G. (2012). Low acceptability of medical male circumcision as an HIV/AIDS prevention intervention within a South African community that practises traditional circumcision. South African Medical Journal, 102, 571–573.

770

N.L. Bulled

Martin, M. (Host). (2012, July 26). Finding Africa's solution to HIV/AIDS [Audio podcast]. Retrieved from http://www.npr.org/2012/07/26/157424209/finding-africas-solutions-to-hiv-aids Ministry of Health and Social Welfare (MoHSW). (2008). Situation analysis report: Male circumcision in Lesotho. Maseru: Author. Ministry of Health and Social Welfare (MoHSW). (2009). Lesotho demographic and health survey 2009. Maseru: Ministry of Health and Social Welfare, Bureau of Statistics, ORC Macro. Retrieved from http://www.measuredhs.com/pubs/pdf/FR171/FR171-LS04OneLgFile.pdf Mishra, V., Hong, R., & Khan, S. (2006). Risk behaviors and patterns of HIV seroprevalence in countries with generalised epidemics: Results from the demographic and health surveys. XVI International AIDS Conference, Toronto, ON. Moses, S., Bradley, J. E., Nagelkerke, N. J., Ronald, A. R., Ndinya-Achola, J. O., & Plummer, F. A. (1990). Geographical patterns of male circumcision practices in Africa: Association with HIV seroprevalence. Internationl Journal of Epidemiology, 19, 693–697. doi:10.1093/ije/19.3.693 Nagelkerke, N. J., Moses, S., de Vlas, S. J., & Bailey, R. C. (2007). Modelling the public health impact of male circumcision for HIV prevention in high prevalence areas in Africa. BMC Infectious Diseases, 7, 16. doi:10.1186/1471-2334-7-16 National AIDS Commission (NAC). (2010). UNGASS country report: Lesotho, January 2008– December 2009. Maseru: Author. National AIDS Commission (NAC). (2011). Report on the national response to HIV and AIDS, reporting period 2006–2010. Maseru: Author. Ngalande, R. C., Levy, J., Kapondo, C. P., & Bailey, R. C. (2006). Acceptability of male circumcision for prevention of HIV infection in Malawi. AIDS and Behavior, 10, 377–385. doi:10.1007/s10461-006-9076-8 Niehaus, I., & Jonsson, G. (2005). Dr. Wouter Basson, Americans, and wild beasts: Men’s conspiracy theories of HIV/AIDS in South African lowveld. Medical Anthropology Quarterly, 24, 179–208. doi:10.1080/01459740590933911 PEPFAR, Presidents Emergency Plan for AIDS Relief. (2012). PEPFAR blueprint: Achieving an AIDS-free generation. Washington, DC: The Office of the Global AIDS Coordinator. Retrieved from http://www.pepfar.gov/documents/organization/201386.pdf Petryna, A. (2002). Life exposed: Biological citizens after Chernobyl. Princeton, NJ: Princeton University Press. PlusNews. (2012, 14 August). President’s herbal HIV/AIDS‘cure’ boosts ARV use. Retrieved from http://www.plusnews.org/Report/81266/GAMBIA-President-s-herbal-HIV-AIDS-cure-boosts-ARVuse Posel, D. (2004, October). Sex, death and embodiment: Reflections on the stigma of AIDS in Agincourt, South Africa. Life and death in a time of AIDS: The southern African experience, Witwatersrand Institute for Social and Economic Research, Johannesburg. Quinn, T. C., Wawer, M. J., Sewankambo, N., Serwadda, D., Li, C., Wabwire-Mangen, F., …Gray, R. H. (2000). Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. New England Journal of Medicine, 342, 921–929. doi:10.1056/ NEJM200003303421303 Ramjee, G., Govinden, R., Morar, N. S., & Mbewu, A. (2007). South Africa’s experience of the closure of the Cellulose Sulphate Microbicide Trial. PLoS Medicine, 4(7), e235. doi:10.1371/ journal.pmed.0040235 Reynolds, S. J., Shepherd, M. E., Risbud, A. R., Gangakhedkar, R. R., Brookmeyer, R. S., Divekar, A. D., … Bollinger, R. C. (2004). Male circumcision and risk of HIV-1 and other sexually transmitted infections in India. Lancet, 363, 1039–1040. doi:10.1016/S0140-6736(04)16417-9 Richters, J., Smith, A., de Visser, R., Grulich, A., & Rissel, C. (2006). Circumcision in Australia: Prevalence and effects on sexual health. International Journal of STD and AIDS, 17, 547–554. doi:10.1258/095646207779949943 Robinson, W. (2001). Social theory and globalization: The rise of a transnational state. Theory and Society, 30, 157–200. doi:10.1023/A:1011077330455 Siegfried, N., Muller, M., Deeks, J., Volmink, J., Egger, M., Low, N., … Williamson, P. (2005). HIV and male circumcision: A systematic review with assessment of the quality of studies. Lancet Infectious Diseases, 5, 165–173. doi:10.1016/S1473-3099(05)01309-5 Singer, M. (1994). The politics of AIDS: Introduction. Social Science and Medicine, 38, 1321– 1324. doi:10.1016/0277-9536(94)90270-4

Global Public Health

771

Stadler, J. (2003). Rumour, gossip and blame: Implications for HIV/AIDS prevention in the South African lowveld. AIDS Education and Prevention, 15, 357–368. doi:10.1521/aeap.15.5.357. 23823 Staff reporter. (2003, September 26). Culture undermines prevention efforts in Lesotho, Public Eye, p. 10. Thomas, A. G., Tran, B. R., Cranston, M., Brown, M. C., Kumar, R., & Tlelai, M. (2011). Voluntary medical male circumcision: A cross-sectional study comparing circumcision self-report and physical examination findings in Lesotho. PLoS One, 6(11), e27561. doi:10.1371/journal. pone.0027561 Tomlinson, J. (1999). Globalization and culture. Cambridge, MA: Polity Press. Tsing, A. (2004). Friction: An ethnography of global connection. Princeton, NJ: Princeton University Press. Ukpong, M., & Peterson, K. (2009). Voices from the field: A series of reports on the oral Tenofovir trials from the perspectives of active community voices in Cambodia, Cameroon, Nigeria, Thailand and Malawi. UNAIDS. (2005). The “Three Ones” in action: Where we are and where we go from here. Geneva: Author. Retrieved from http://data.unaids.org/publications/irc-pub06/jc935-3onesinaction_en.pdf. UNAIDS. (2007). Male circumcision: Global trends and determinants of prevalence, safety and acceptability. Geneva: Author. UNAIDS. (2012). Global report: UNAIDS report on the global AIDS epidemic 2012. Geneva: Author. UNAIDS. (2013). Global report: UNAIDS report on the global AIDS epidemic 2013. Geneva: Author. Van Damme, L., Corneli, A., Ahmed, K., Agot, K., Lombaard, J., Kapiga, S., … Taylor, D. (2012). Preexposure prophylaxis for HIV infection among African women. New England Journal of Medicine, 367, 411–422. doi:10.1056/NEJMoa1202614 Van der Vliet, V. (2001). AIDS: Losing the “new struggle”? Daedalus, 130, 151–184. Vincent, L. (2008a). Boys will be boys: Traditional Xhosa male circumcision, HIV and sexual socialisation in contemporary South Africa. Culture, Health & Sexuality, 10, 431–446. doi:10.1080/13691050701861447 Vincent, L. (2008b). Cutting tradition: The political regulation of traditional circumcision rites in South Africa’s liberal democratic order. Journal of Southern African Studies, 34(1), 77–91. doi:10.1080/03057070701832890 Walsh, F. (December 19, 2012). Polio killings a major setback. BBC News. Walt, G., & Buse, K. (2005). Global cooperation in international public health. In M. Merson, D. Jamison, & A. Mills (Eds.), International public health (pp. 649–680). Boston, MA: Jones and Bartlett. Walt, G., Spicer, N., & Buse, K. (2009). Mapping the global health architecture. In K. Buse, W. Hein, & N. Drager (Eds.), Making sense of global health governance: A policy perspective (pp. 47–71). New York, NY: Palgrave Mcmillan. Wamai, R. G., Morris, B. J., Waskett, J. H., Green, E. C., Banerjee, J., Bailey, R. C., … Hankins, C. A. (2012). Criticisms of African trials fail to withstand scrutiny: Male circumcision does prevent HIV infection. Journal of Law and Medicine, 20(1), 93–123. Way, A., Mishra, V., & Hong, K. (2006). Is male circumcision protective of HIV infection? Poster exhibition. XVI International AIDS Conference, Toronto, ON. Weiss, H. A., Halperin, D., Bailey, R. C., Hayes, R. J., Schmid, G., & Hankins, C. A. (2008). Male circumcision for HIV prevention: From evidence to action? AIDS, 22, 567–574. doi:10.1097/ QAD.0b013e3282f3f406 Weiss, H. A., Quigley, M. A., & Hayes, R. J. (2000). Male circumcision and risk of HIV infection in sub-Saharan Africa: A systematic review and meta-analysis. AIDS, 14, 2361–2370. doi:10.1097/00002030-200010200-00018 Westercamp, N., & Bailey, R. C. (2007). Acceptability of male circumcision for prevention of HIV/ AIDS in sub-Saharan Africa: A review. AIDS and Behavior, 11, 341–355. doi:10.1371/journal. pone.0007687 World Health Organization (WHO). (2013). Global update on HIV treatment 2013: Results, impact and opportunities. Geneva: Author. World Health Organization (WHO). (2014). Traditional circumcision. Retrieved from http://www. malecircumcision.org/country_updates/traditional_circumcision.html

772

N.L. Bulled

WHO/UNAIDS. (2007). New data on male circumcision and HIV prevention. Geneva: Author. Williams, B. G., Lloyd-Smith, J. O., Gouws, E., Hankins, C. A., Getz, W. M., Hargrove, J., … Auvert, B. (2006). The potential impact of male circumcision on HIV in sub-Saharan Africa. PLoS Medicine, 3(7), e262. doi:10.1371/journal.pmed.0030262 World Bank. (2012). Lesotho: Country data. Retrieved from http://data.worldbank.org/country/ lesotho Youde, J. R. (2007). AIDS, South Africa, and the politics of knowledge. Burlington, VT: Ashgate.

Copyright of Global Public Health is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.