Background
Methods
Study Setting
Study Population
Data Collection
Measures
Message Exposure
Client Age and Group Age Composition
Counselor Age and Experience
Data Analysis
Results
Service Delivery Model of study sites | Clients observed in group education | Clients observed in individual counseling | Total observed clients | |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Young Adolescent (15–17 years.) | Older adolescent (18–19 years.) | Adult (20 + years.) | Young Adolescent (15–17 years.) | Older adolescent (18–19 years.) | Adult (20 + years.) | |||||||||
Weighted % | n | Weighted % | n | Weighted % | n | Weighted % | n | Weighted % | n | Weighted % | n | Weighted % | n | |
Routine | 15.7 | 7 | 30.0 | 14 | 54.3 | 26 | 13.9 | 9 | 24.4 | 18 | 61.6 | 43 | 21.8 | 70 |
Outreach low | 53.6 | 37 | 12.8 | 9 | 33.7 | 23 | 29.3 | 37 | 7.0 | 9 | 63.7 | 68 | 35.6 | 114 |
Outreach high | 16.0 | 23 | 46.8 | 53 | 37.2 | 49 | 16.9 | 26 | 46.9 | 58 | 36.2 | 52 | 42.5 | 136 |
Total | 23.1 | 67 | 38.0 | 76 | 39.0 | 98 | 19.7 | 72 | 32.4 | 85 | 47.9 | 163 | 100 | 320 |
Group Composition for Group Education Sessions
Participants in group counseling by age | Mostly 15–17 year olds Group (n = 10) | Mostly 18+ Group (n = 44) | Mixed ages Group (n = 26) | Total Group (n = 80) | ||||
---|---|---|---|---|---|---|---|---|
Weighted % (95 % CI) | n | Weighted % (95 % CI) | n | Weighted % (95 %CI) | n | Weighted % (95 % CI) | n | |
15–17 | 76.4 (46.6–100) | 21 | 6.1 (0.8–11.4) | 9 | 34.6 (3.0–66.2) | 34 | 23.5 (6.9–40.0) | 64 |
18–19 | 20.5 (0–55.0) | 5 | 36.7 (25.2–48.2) | 43 | 42.5 (15.0–69.9) | 23 | 37.1 (23.2–50.9) | 71 |
20+ | 3.1 (0–10.7) | 1 | 57.2 (42.2–72.1) | 75 | 22.9 (7.2–38.7) | 16 | 39.4 (21.3–57.6) | 92 |
Message Exposure During Group education
Message | 15–17 (younger adolescents) | 20 + (adults) | ||
---|---|---|---|---|
Unadjusted OR (95 % CI) t, p value | Adjusted OR∇,
(95 % CI) | Unadjusted OR (95 % CI) | Adjusted OR∇,
(95 % CI) | |
Explained that the test is confidential, meaning they will not tell anyone else client results |
5.0* (1.0–25.2)
t = 2.24, p = 0.049
| 3.7 (0.5–26.0) t = 1.49, p = 0.168 | 1.0 (0.7–1.5) t = 0.17, p = 0.868 | 1.0 (0.6–1.6) t = −0.08, p = 0.939 |
Explained that the test will be performed unless client declined (test is optional) | 1.0(0.2–4.3) t = 0.03, p = 0.980 | 0.9 (0.2–4.2) t = −0.14, p = 0.892 | 1.1 (0.5–2.5) t = 0.36, p = 0.723 | 1.7 (0.7–4.2) t = 1.40, p = 0.192 |
Prevention: Abstinence | 3.3^ (0.8–13.9) t = 1.88, p = 0.089 | 3.1^ (0.8–12.6) t = 1.83, p = 0.097 | 1.0 (0.6–1.7) t = −0.07, p = 0.942 | 0.9 (0.6–1.4) t = −0.42, p = 0.684 |
Prevention: Being faithful to one sexual partner | 5.1 (0.5–54.3) t = 1.53, p = 0.157 | 5.1 (0.5–53.1) t = 1.56, p = 0.150 | 1.7^ (0.9–3.2) t = 1.99, p = 0.074 |
1.8** (1.3–2.5)
t = 4.18, p = 0.002
|
Prevention: Reducing the number of sexual partners |
3.9* (1.0–14.7)
t = 1.60, p = 0.140
|
3.8* (1.1–13.8)
t = 2.32, p = 0.043
| 1.7 (0.8–3.3) t = 1.60, p = 0.140 |
2.2*** (1.5–3.0)
t = 5.19, p < 0.001
|
Prevention: Wearing condoms correctly and consistently | 5.2 (0.6–48.7) t = 1.64, p = 0.132 | 4.7 (0.6–34.7) t = 1.74, p = 0.113 | 2.7^ (1.0–7.6) t = 2.17, p = 0.055 |
3.6*** (2.4–5.5)
t = 6.78, p < 0.001
|
Prevention: Condom demonstration | 2.1 (0.5–8.7) t = 1.19, p = 0.260 | 2.4 (0.7–8.1) t = 1.64, p = 0.133 |
4.2** (1.7–10.5)
t = 3.55, p = 0.005
|
5.3** (2.1–13.4)
t = 3.96, p = 0.003
|
Prevention: Gave client condoms | 3.8 (0.6–23.2) t = 1.64, p = 0.132 | 2.0(0.4–24.9) t = 1.14, p = 0.280 | 7.7^ (0.6–23.2) t = 1.83, p = 0.097 | 9.4^ (0.8–110.7) t = 2.03, p = 0.070 |
Prevention: Talk with partner about HIV prevention | 0.6 (0.2–2.2) t = −0.90, p = 0.388 | 0.5 (0.1–2.1) t = −1.10, p = 0.298 | 1.9 (0.7–4.9) t = 1.44, p = 0.181 | 1.9 (0.8–4.8) t = 1.65, p = 0.131 |
Prevention: Talk with partner about HIV testing | 0.5 (0.1–1.6) t = −1.35, p = 0.208 | 0.4 (0.1–1.5) t = −1.49, p = 0.168 | 1.9 (0.6–5.7) t = 1.30, p = 0.223 | 2.3^ (1.0–5.7) t = 2.12, p = 0.060 |
Explained that for HIV-positive men, MC does NOT prevent them from transmitting the virus to others |
3.7** (1.7–8.0)
t = 3.75, p = 0.004
|
3.3** (1.6–6.5)
t = 3.80, p = 0.003
| 1.4^ (1.0–2.0) t = 2.21, p = 0.051 |
1.6* (1.1–2.4)
t = 2.78, p = 0.019
|
Explained the importance of sexual abstinence for 6 weeks after circumcision |
6.9* (1.4–33.4)
t = 2.71, p = 0.022
|
6.2* (1.1–36.3)
t = 2.32, p = 0.043
|
3.4** (1.7–7.0)
t = 3.80, p = 0.003
|
4.7*** (3.1–7.0)
t = 8.40, p < 0.001
|
Message | Age composition | ||||
---|---|---|---|---|---|
Mostly 15–17 (n = 10 groups) Weighted % (95 % CI) | Mostly 18+ (n = 44 groups) Weighted % (95 % CI) | Mixed (n = 26 groups) Weighted % (95 % CI) | χ2, p value | Total (n = 80 groups) Weighted % (95 % CI) | |
Explained that the test is confidential, meaning they will not tell anyone else client results | 32.8 (0–100) | 21.8 (0–46.8) | 43.6 (21.1–66.1) | χ2 = 3.82, p = 0.467 | 30.6 (17.3–43.9) |
Explained that the test will be performed unless client declined (test is optional)^ | 53.6 (13.3–93.9) | 75.9 (49.2–100) | 47.7 (36.1–59.3) | χ2 = 6.27, p = 0.069 | 63.7 (45.4–82.0) |
Prevention: Abstinence | 100 | 79.0 (62.3–95.8) | 73.0 (46.1–100) | χ2 = 2.93, p = 0.138 | 79.2 (61.5–96.9) |
Prevention: Being faithful to one sexual partner* | 100 | 90.3 (79.6–100) | 78.0 (57.5–98.5) | χ2 = 3.73, p = 0.028 | 87.1 (75.2–99.0) |
Prevention: Reducing the number of sexual partners** | 100 | 91.9 (84.0–99.7) | 73.0 (46.1–100) | χ2 = 6.63, p = 0.009 | 86.2 (74.4–98.0) |
Prevention: Wearing condoms correctly and consistently^ | 100 | 100 | 76.9 (63.2–90.7) | χ2 = 13.1, p = 0.068 | 92.0 (87.1–96.8) |
Prevention: Condom demonstration | 77.7 (13.9–100) | 69.7 (43.7–95.7) | 47.8 (32.5–63.0) | χ2 = 4.42, p = 0.161 | 62.9 (43.4–82.5) |
Prevention: Gave client condoms* | 27.2 (1.6–52.8) | 12.9 (3.1–22.8) | 2.4 (0–8.2) | χ2 = 4.69, p = 0.045 | 10.8 (2.8–18.8) |
Prevention: Talk with partner about HIV prevention* | 14.3 (0–55.1) | 29.6 (8.1–51.2) | 3.3 (0–11.1) | χ2 = 7.87, p = 0.041 | 18.8 (5.5–32.1) |
Prevention: Talk with partner about HIV testing* | 24.8 (0–95.5) | 59.7 (40.0–79.4) | 19.8 (3.9–35.6) | χ2 = 12.30, p = 0.048 | 42.0 (26.9–57.1) |
Explained that for HIV–positive men, MC does NOT prevent them from transmitting the virus | 57.0 (0–100) | 52.8 (28.9–76.7) | 42.0 (21.0–63.1) | χ2 = 1.01, p = 0.551 | 49.5 (32.8–66.2) |
Explained the importance of sexual abstinence for 6 weeks after circumcision | 89.8 (50.2–100) | 94.5 (86.3–100) | 84.6 (65.1–100) | χ2 = 1.96, p = 0.519 | 90.6 (84.6–96.6) |
Message Exposure During Individual Counseling (Including Pre- and Post-test, Post-operative, and 48-h Follow-up Counseling)
Message | 15–17 (adolescents) | 20 + (adults) | ||
---|---|---|---|---|
Unadjusted OR (95 % CI) | Adjusted OR∇
(95 % CI) | Unadjusted OR (95 % CI) | Adjusted OR∇
(95 % CI) | |
Explained that the test is confidential, meaning they will not tell anyone else client results (n = 315) | 2.2 (0.5–9.0) t = 1.23, p = 0.246 | 0.9 (0.5–1.6) t = −0.58, p = 0.576 | 0.9 (0.5–1.7) t = −0.33, p = 0.746 |
0.3** (0.1–0.6)
t = −3.56, p = 0.005
|
Explained that the test will be performed unless client declined (test is optional) (n = 313) | 0.7 (0.2–3.4) t = −0.47, p = 0.650 | 0.8 (0.3–2.2) t = −0.53, p = 0.610 | 0.7 (0.2–2.8) t = −0.56, p = 0.588 | 0.8 (0.3–2.2) t = −0.49, p = 0.632 |
Prevention: Abstinence | 2.4 (0.6–10.1) t = 1.32, p = 0.217 | 1.7 (0.4–7.7) t = 0.83, p = 0.428 | 0.8 (0.5–1.4) t = −0.84, p = 0.421 |
0.6* (0.4–0.9)
t = −2.74, p = 0.021
|
Prevention: Being faithful to one sexual partner | 1.6 (0.5–5.2) t = 0.88, p = 0.400 | 1.0 (0.2–4.1) t = −0.04, p = 0.970 | 1.1 (0.5–2.4) t = 0.20, p = 0.848 | 0.6 (0.4–1.1) t = −1.78, p = 0.105 |
Prevention: Reducing the number of sexual partners | 1.1 (0.4–2.8) t = 0.15, p = 0.881 | 0.6 (0.2–1.9) t = −0.94, p = 0.367 | 1.7 (0.6–5.0) t = 1.07, p = 0.310 | 1.0 (0.5–2.3) t = 0.11, p = 0.916 |
Prevention: Wearing condoms correctly and consistently |
0.2* (0.1–0.8)
t = −2.69, p = 0.023
|
0.2** (0.1–0.5)
t = −3.53, p = 0.005
| 0.4 (0.2–1.2) t = −1.76, p = 0.110 |
0.4** (0.2–0.6)
t = −4.02, p = 0.002
|
Prevention: Condom demonstration | 0.2^ (0.–1.1) t = −2.10, p = 0.063 |
0.1* (0–0.8)
t = −2.49, p = 0.032
| 1.2 (0.2–6.9) t = 0.29, p = 0.781 | 0.9 (0.2–3.4) t = −0.19, p = 0.856 |
Prevention: Gave client condoms |
0.1** (0–0.4)
t = −3.88, p = 0.003
|
0.2** (0.1–0.5)
t = −4.20, p = 0.002
| 0.5 (0.1–2.3) t = −1.05, p = 0.320 | 1.0(0.5–2.2) t = 0.13, p = 0.900 |
Prevention: Talk with partner about HIV prevention |
0.2** (0.1–0.5)
t = −3.71, p = 0.004
|
0.3** (0.1–0.6)
t = −3.70, p = 0.004
| 0.5 (0.2–1.3) t = −1.74, p = 0.113 | 0.6 (0.3–1.4) t = −1.31, p = 0.219 |
Prevention: Talk with partner about HIV testing |
0.3* (0.1–0.9)
t = −2.33, p = 0.042
|
0.3* (0.1–0.9)
t = −2.44, p = 0.035
|
0.5** (0.4–0.8)
t = −3.94, p = 0.003
| 0.7 (0.4–1.4) t = −1.08, p = 0.306 |
Explained that for HIV-positive men, MC does NOT prevent them from transmitting the virus to others | 1.1 (0.3–4.7) t = 0.15, p = 0.882 | 1.0 (0.3–3.1) t = −0.05, p = 0.962 |
4.0** (2.1–7.7)
t = 4.84, p = 0.001
|
3.1* (1.4–7.0)
t = 3.13, p = 0.011
|
Explained the importance of sexual abstinence for 6 weeks after circumcision |
0.1* (0–0.6)
t = −3.05, p = 0.012
|
0.1* (0–0.6)
t = −2.89, p = 0.016
| 1.2 (0.2–7.8) t = 0.20, p = 0.849 | 1.5 (0.2–10.3) t = 0.52, p = 0.618 |
Discussion
-
Address counselors’ discomfort with giving messages to adolescents in the group education session by giving them skills in segmenting their clients by age, and training them to provide age-sensitive messages in individual counseling rather than group education.
-
Create job aids that guide counselors in providing comprehensive messages, appropriately tailored to age and working with mixed age groups. These job aides should address both the messages and the suggestions on providing them to the different aged clients in a group setting.
-
Individual counseling should be strengthened as a best-approach for providing key sexual and reproductive health messages to adolescents, given that young VMMC clients as well as counselors appeared to be more comfortable receiving and providing messages perceived as age-sensitive during individual counseling.
Conclusion
“Generally, the low level of [HIV] testing among adolescents could partly be the reason for increased AIDS-related mortality among them. Adolescents who do not know that they are infected with HIV are unlikely to seek ART, and their diagnosis may be substantially delayed until they experience symptoms of advanced HIV disease, in many cases it will be too late for treatment” [1].