P6.039 Why Did Plausible Research Evidence Fail to Inform Policy? A Lesson from Male Circumcision Evidence on Efficacy For the Prevention of HIV in Malawi

Abstract

On the basis of three randomised controlled trials showing that male circumcision (MC) is effective in reducing HIV transmission, WHO/UNAIDS recommend that high HIV prevalence countries include MC in their HIV prevention programmes. Malawi delayed to adopt such a policy. This study examines evidence-to-policy processes in Malawi, using MC as a case study. Separate but similar semi-structured interviews were conducted with national health policy decision-makers, researchers, politicians and traditional leaders regarding the decision-making processes concerning the adoption of MC and, as a comparison, to the adoption of acyclovir for management of STIs and nevirapine for PMTCT. We observed that although policy-makers are aware of the evidence in Sub-Saharan Africa that MC reduces the risk of HIV acquisition among circumcised men, the adoption of a MC policy is resisted. Policy-makers and international actors are embroiled in policy controversies that have historical resonance in Malawi; MC is perceived as something that comes from outside-a Western 'imposition' is being forced onto Malawians. Malawi was settled by Muslims and by non-circumcised Christians; ethnic and religious rivalries have characterised politics since Independence. Thus, politicians have framed MC in-terms of tribal and religious identities. In contrast, acyclovir and nevirapine were perceived as culturally neutral, and were accepted without debate. The call for evidence-based policy is likely to be received as unproblematic when, as with acyclovir and nevirapine, the issue does not touch controversies especially those related to religion and ethnic politics. But, when a core issue that identifies ethnicities is at the centre of controversy and it threatens what powerful local actors consider being in their best interest - there is invariably opposition. Thus reframing a new policy to minimise controversy - and in the case of MC, from "MC" to "voluntary medical MC" might result in actors' reflection and thus provide a path towards resolution.