Counseling Received by Adolescents Undergoing Voluntary Medical Male Circumcision: Moving Toward Age-Equitable Comprehensive Human Immunodeficiency Virus Prevention Measures

Abstract

BackgroundThe minimum package of voluntary medical male circumcision (VMMC) services, as defined by the World Health Organization, includes human immunodeficiency virus (HIV) testing, HIV prevention counseling, screening/treatment for sexually transmitted infections, condom promotion, and the VMMC procedure. The current study aimed to assess whether adolescents received these key elements.MethodsQuantitative surveys were conducted among male adolescents aged 10–19 years (n = 1293) seeking VMMC in South Africa, Tanzania, and Zimbabwe. We used a summative index score of 8 self-reported binary items to measure receipt of important elements of the World Health Organization–recommended HIV minimum package and the US President’s Emergency Plan for AIDS Relief VMMC recommendations. Counseling sessions were observed for a subset of adolescents (n = 44). To evaluate factors associated with counseling content, we used Poisson regression models with generalized estimating equations and robust variance estimation.ResultsAlthough counseling included VMMC benefits, little attention was paid to risks, including how to identify complications, what to do if they arise, and why avoiding sex and masturbation could prevent complications. Overall, older adolescents (aged 15–19 years) reported receiving more items in the recommended minimum package than younger adolescents (aged 10–14 years; adjusted β, 0.17; 95% confidence interval [CI], .12–.21; P < .001). Older adolescents were also more likely to report receiving HIV test education and promotion (42.7% vs 29.5%; adjusted prevalence ratio [aPR], 1.53; 95% CI, 1.16–2.02) and a condom demonstration with condoms to take home (16.8% vs 4.4%; aPR, 2.44; 95% CI, 1.30–4.58). No significant age differences appeared in reports of explanations of VMMC risks and benefits or uptake of HIV testing. These self-reported findings were confirmed during counseling observations.ConclusionsMoving toward age-equitable HIV prevention services during adolescent VMMC likely requires standardizing counseling content, as there are significant age differences in HIV prevention content received by adolescents.

Adolescent Male Circumcision for HIV Prevention in High Priority Countries: Opportunities for Improvement

“…Older adolescents were more likely to receive HIV education and testing, condom demonstrations, and condoms to take home than younger boys. Observations confirmed that condom demonstrations occurred less frequently for younger adolescents [ 24 ]. Older adolescents had greater knowledge of the importance of condom use, about having fewer sex partners, and about the importance of faithfulness [ 25 ].…”

“…When researchers observed interactions, they found that counselors demonstrated respectful interest with young clients, and they used supportive body language, indicating that they were likely to be perceived as supportive by adolescents engaged in the service [ 24 ]. Nearly all adolescents (97%) reported high satisfaction with VMMC, and >72% were very likely to recommend VMMC to their peers [ 23 ].…”

“…There were gaps, however, in the information and counseling provided, particularly to younger boys. Many did not receive WHO’s full VMMC “minimum package,” although those aged 15–19 years received more package items than did boys aged 10–14 years [ 24 ]. VMMC program adherence to protocols should be closely monitored to address gaps in the response.…”

“…Parental involvement and community sensitization and engagement are also important. Kaufman and colleagues [ 24 ] suggest that all adolescents should receive comprehensive prevention messages but that younger adolescents may require less technical descriptions. Information should be easily comprehensible, relevant to the adolescent client’s experience, and delivered in ways that respect adolescent privacy and confidentiality [ 24 , 26 ].…”

Perceived Quality of In-Service Communication and Counseling Among Adolescents Undergoing Voluntary Medical Male Circumcision

“…It is essential to reach adolescents aged 10–14 years as their in-depth knowledge of sex and ways to prevent HIV acquisition, including the use of condoms, is often quite low; condom use among sexually active males in this age group is typically lower than that of older adolescents [ 31 , 32 ]. As outlined in other findings from this study population [ 33 ], younger adolescents aged 10–14 years received fewer elements of the minimum package overall than did 15- to 19-year-olds, despite the fact that adolescents stated they wish they had more of this information.…”