Background: Voluntary medical male circumcision (VMMC) is one of the first venues for adolescent boys in many African countries to interact with the health care system. This study explored the messages and approaches used during VMMC counseling for adolescents and whether such strategies maximize opportunities for broader HIV prevention, adolescent sexual and reproductive health, and linkages to HIV care.
Methods: Ninety-two semi-structured qualitative interviews were conducted with VMMC clients ages 10-19 years in South Africa, Tanzania, and Zimbabwe 6-8 weeks post-procedure. An additional 55 interviews were conducted with VMMC counselors. Discussions explored HIV prevention counseling, HIV testing services received before VMMC, and counselors┬┤ approaches to HIV testing and disclosure of test results. Audio recordings were transcribed, translated into English, and coded by two independent coders using a thematic approach. Coders discussed discrepancies until at least 85% agreement was reached. Coded text was then assessed for themes.
Results: Male adolescents stated that limited information was provided to them about HIV prevention and care. While VMMC protocols require opt-out HIV testing, some adolescents discussed having blood taken without knowing the purpose, not receiving their test results, nor completely understanding the link between VMMC and HIV. Most boys interviewed assumed they had tested negative because they were subsequently circumcised. Identified themes among counselors included spending little time talking about HIV prevention with male adolescents. Counselors rarely discussed masturbation and expressed frustration over their lack of skills in counseling or disclosing HIV positive results to adolescents. Counselor discussions also revealed inconsistencies with regards to working with HIV infected adolescents, with some providers not wanting to circumcise HIV-positive adolescents, whilst others proceeding with the VMMC to avert stigmatization.
Conclusions: VMMC for adolescents appears to be a missed opportunity to engage in further HIV prevention and care. Counselors require training in counseling HIV positive adolescents, how to link them to care, and whether to offer VMMC to these clients. Counselors could spend more time focused on delivering prevention messages, further limiting the spread of HIV as adolescent males become sexually active.

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