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Background: Male adolescents represent the majority of individuals seeking voluntary medical male circumcision services (VMMC) services in sub-Saharan Africa. VMMC counselors interact with adolescents of various developmental stages and sexual experience. This study assessed the counseling adolescents receive and evaluated counselors'' knowledge and any biases when working with adolescent clients.
Methods: Qualitative interviews were conducted with 55 VMMC counselors and 92 adolescent clients in South Africa, Tanzania, and Zimbabwe. Interviews with counselors focused on describing the VMMC counseling process, their knowledge and training, and opinions and attitudes towards adolescent clients. Adolescent interviews focused on the content of counseling received, their feelings during the sessions, and perceptions of counselors'' attitudes. Audio recordings were transcribed, translated into English, and thematically coded.
Results: Counselors expressed hesitation in communicating complete information?including HIV prevention, future sexual partners, and abstinence from sex or masturbation during the wound healing period?with younger males (< 15 years) and/or those assumed to have no sexual experience. Counselors also discussed the limitations of current guidelines and training in providing parameters on how to engage in adolescent-appropriate counseling. Many counselors discussed not assessing an adolescent client''s sexual experience in order to gauge appropriate counseling content. Counselors reported giving full information, per VMMC protocols, to older adolescents since the counselors are not as hesitant in talking about sexual topics with them as compared with younger adolescents. Adolescents reported counseling content focused primarily on VMMC procedures or wound care. Finally, counselors discussed a preference for counseling younger adolescents with their parents/guardians to ensure adherence to wound care instructions. Some younger adolescents expressed reservation with this approach; they felt they would be unable to disclose personal experiences, including sexual ones, if parents/guardians are present.
Conclusions: VMMC counselors appear biased in how much information they communicate to younger versus older adolescent clients and sexually experienced versus inexperienced clients. VMMC may be more effective in providing complete HIV prevention and care messaging if all adolescents are given age and sexual experience-appropriate information during counseling sessions. Strengthening VMMC counselors'' interpersonal communication and counseling skills requires guidelines and training to fully address the range of adolescent client needs.

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