Title

Understanding the process of adolescent assent for Voluntary medical male circumcision in Zimbabwe: findings from a cross-sectional study

Presenter

Nisa Hurst

Authors

R. West^1,2, S. Sharma¹, N. Hurst¹, W. Bench¹, B. Maponga³, N. Nhando³, L. Bullock¹, S. Xaba⁴, K. Hatzold⁵, S. Gumede-Moyo^1,6

Institutions

¹Ipsos, London, United Kingdom, ²Boston University, Department of Global Health, Boston, United States, ³Population Services for Health, Harare, Zimbabwe, ⁴Ministry of Health and Childcare, Harare, Zimbabwe, ⁵Population Services International, Cape Town, South Africa, ⁶London School of Hygiene and Tropical Medicine, Department of Population Health, London, United Kingdom

BACKGROUND: Voluntary medical male circumcision (VMMC) is a key HIV prevention option within combination prevention for adolescents >15 years in settings with generalized HIV epidemics. In Zimbabwe, policy currently allows the use of VMMC devices in adolescents >15 years, and there are considerations to lower the threshold to the age of 13 years. There is a need to understand young adolescents’ ability to provide informed assent, current practices in assent/consent, and parents’ requirements for assent/consent to inform policy recommendations for use of VMMC devices and the VMMC programme.
METHODS: Cross-sectional surveys were conducted in Zimbabwe among three groups in September 2022: uncircumcised adolescents/young men (AYM) aged 13-16 (n=881), circumcised AYM aged 13-20 (n=247), and parents (n=443) of uncircumcised adolescents aged 13-16. Surveys asked about VMMC knowledge, experiences with mobilisers, circumcised AYM’s assent/consent experiences, and parents’ preferences for assent/consent processes.
RESULTS: Detailed knowledge of VMMC was similar among 13-14 and 15-16 uncircumcised AYM and parents. However, 64% (150/247) of older circumcised AYM retrospectively felt they would not have been mature enough to make the decision about VMMC at age 13-14. 57% (142/247) of circumcised AYM had a one-to-one discussion with their provider before VMMC; 32% (80/247) said they were not fully informed prior to the procedure, and 54% (134/247) wanted more information about procedure-related pain. 56% (42/75) of uncircumcised AYM whose parents had not provided consent in-person reported that actual consent giving had not been verified with parents.
CONCLUSIONS: There are gaps in the current assent/consent process for VMMC. All providers should be trained to provide balanced information on risks and benefits of the procedure, including potential for pain. One-on-one discussions between providers and adolescents prior to the procedure, age-appropriate counselling, and tools for providers to ascertain the adolescent’s understanding and ability to provide assent are essential processes, especially for younger adolescents who may be less mature than adolescents 15+ that providers have more experience conducting VMMC counselling with. There is also a need to standardise confirmation of parental consent for minors when their parents do not accompany their child to the clinic (e.g., a follow-up phone call).

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