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Men diagnosed with HIV face gender-related barriers to initiating and adhering to antiretroviral therapy (ART). This qualitative study (73 in-depth interviews; 28 focus group discussions), conducted with men in three urban sites in Côte d'Ivoire in 2016, examined perceptions of ART, including benefits and challenges, to explore how ART mitigates HIV's threats to men's sexuality, economic success, family roles, social status, and health. Participants perceived that adhering to ART would reduce risk of transmitting HIV to others, minimize job loss and lost productivity, and help maintain men's roles as decision makers and providers. ART adherence was thought to help reduce the threat of HIV-related stigma, despite concerns about unintentional disclosure. While ART was perceived to improve health directly, it restricted men's schedules. Side effects were also a major challenge. Social and behavior change approaches building on these insights may improve male engagement across the HIV care continuum.

Background Historically, men in sub-Saharan Africa have worse outcomes along the HIV care continuum than women. Brothers for Life (BFL) is a community-based behavior change intervention for men, adapted for Cote d'Ivoire, involving group discussions that address salient gender norms and promote HIV prevention, testing, and linkage to care with support from peer navigators. The goal of this study was to describe the BFL program as implemented in Cote d'Ivoire, evaluate program implementation, and report uptake of HIV testing and treatment among BFL participants. Setting Three urban and periurban sites in Cote d'Ivoire. Methods The implementation evaluation assessed the fidelity and acceptability of the BFL program and the reach of program completion, testing and peer navigation using qualitative and quantitative approaches. Results BFL facilitation fidelity and content fidelity were high. Semi-structured interviews with BFL participants indicated that men appreciated the format and content and that the BFL program helped some participants overcome their fears and adopt more positive attitudes and behaviors around testing and treatment. Assessments of reach showed that, of the 7,187 BFL participants, 81% tested for HIV as part of BFL and 2.3% (135) tested HIV positive. Of those, 102 (76%) accepted peer navigator support and 97% (131) initiated treatment. After six months, 100% of the 131 men who initiated treatment remained in care. Conclusion The implementation of BFL in Cote d'Ivoire successfully achieved the goals of engaging participants in discussions around HIV prevention, encouraging HIV testing, and achieving linkage to care, treatment initiation, and retention.

Background While female involvement in voluntary medical male circumcision (VMMC) has been studied among adults, little is known about the influence of adolescent females on their male counterparts. This study explored adolescent females’ involvement in VMMC decision making and the postoperative wound healing process in South Africa, Tanzania, and Zimbabwe. Methods Across 3 countries, 12 focus group discussions were conducted with a total of 90 adolescent females (aged 16–19 years). Individual in-depth interviews were conducted 6–10 weeks post-VMMC with 92 adolescent males (aged 10–19 years). Transcribed and translated qualitative data were coded into categories and subcategories by 2 independent coders. Results Adolescent female participants reported being supportive of male peers’ decisions to seek VMMC, with the caveat that some thought VMMC gives males a chance to be promiscuous. Regardless, females from all countries expressed preference for circumcised over uncircumcised sexual partners. Adolescent females believed VMMC to be beneficial for the sexual health of both partners, viewed males with a circumcised penis as more attractive than uncircumcised males, used their romantic relationships with males or the potential for sex as leveraging points to convince males to become circumcised, and demonstrated supportive attitudes in the wound-healing period. Interviews with males confirmed that encouragement from females was a motivating factor in seeking VMMC. Conclusions Adolescent female participants played a role in convincing young males to seek VMMC and remained supportive of the decision postprocedure. Programs aiming to increase uptake of VMMC and other health-related initiatives for adolescent males should consider the perspective and influence of adolescent females.

Background The 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. Methods Quantitative 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. Results Although 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. Conclusions Moving 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.

Background Voluntary medical male circumcision (VMMC) is one of few opportunities in sub-Saharan Africa to engage male adolescents in the healthcare system. Limited data are available on the level of parental communication, engagement, and support adolescents receive during the VMMC experience. Methods We conducted 24 focus group discussions with parents/guardians of adolescents (N = 192) who agreed to be circumcised or were recently circumcised in South Africa, Tanzania, and Zimbabwe. In addition, male adolescents (N = 1293) in South Africa (n = 299), Tanzania (n = 498), and Zimbabwe (n = 496) were interviewed about their VMMC experience within 7–10 days postprocedure. We estimated adjusted prevalence ratios (aPRs) using multivariable Poisson regression with generalized estimating equations and robust standard errors. Results Parents/guardians noted challenges and gaps in communicating with their sons about VMMC, especially when they did not accompany them to the clinic. Adolescents aged 10–14 years were significantly more likely than 15- to 19-year-olds to report that their parent accompanied them to a preprocedure counseling session (56.5% vs 12.5%; P < .001). Among adolescents, younger age (aPR, 0.86; 95% confidence interval [CI], .76–.99) and rural setting (aPR, 0.34; 95% CI, .13–.89) were less likely to be associated with parental–adolescent communication barriers, while lower socioeconomic status (aPR, 1.37; 95% CI, 1.00–1.87), being agnostic (or of a nondominant religion; aPR, 2.87; 95% CI, 2.21–3.72), and living in South Africa (aPR, 2.63; 95% CI, 1.29–4.73) were associated with greater perceived barriers to parental–adolescent communication about VMMC. Parents/guardians found it more difficult to be involved in wound care for older adolescents than for adolescents

Background Little is known regarding the impact of counseling delivered during voluntary medical male circumcision (VMMC) services on adolescents’ human immunodeficiency virus (HIV) knowledge, VMMC knowledge, or post-VMMC preventive sexual intentions. This study assessed the effect of counseling on knowledge and intentions. Methods Surveys were conducted with 1293 adolescent clients in 3 countries (South Africa, n = 299; Tanzania, n = 498; Zimbabwe, n = 496). Adolescents were assessed on HIV and VMMC knowledge-based items before receiving VMMC preprocedure counseling and at a follow-up survey approximately 10 days postprocedure. Sexually active adolescents were asked about their sexual intentions in the follow-up survey. Prevalence ratios (PRs) and 95% confidence intervals (CIs) were calculated by modified Poisson regression models with generalized estimating equations and robust variance estimators. Results Regarding post-VMMC HIV prevention knowledge, older adolescents were significantly more likely than younger adolescents to know that a male should use condoms (age 10–14 years, 41.1%; 15–19 years, 84.2%; aPR, 1.38 [95% CI, 1.19–1.60]), have fewer sex partners (age 10–14 years, 8.1%; age 15–19 years, 24.5%; aPR, 2.10 [95% CI, 1.30–3.39]), and be faithful to one partner (age 10–14 years, 5.7%; age 15–19 years, 23.2%; aPR, 2.79 [95% CI, 1.97–3.97]) to further protect himself from HIV. Older adolescents demonstrated greater improvement in knowledge in most categories, differences that were significant for questions regarding number of sex partners (aPR, 2.01 [95% CI, 1.18–3.44]) and faithfulness to one partner post-VMMC (aPR, 3.28 [95% CI, 2.22–4.86]). However, prevention knowledge levels overall and HIV risk reduction sexual intentions among sexually active adolescents were notably low, especially given that adolescents had been counseled only 7–10 days prior. Conclusions Adolescent VMMC counseling needs to be improved to increase knowledge and postprocedure preventive sexual intentions.

Background Experience with providers shapes the quality of adolescent health services, including voluntary medical male circumcision (VMMC). This study examined the perceived quality of in-service communication and counseling during adolescent VMMC services. Methods A postprocedure quantitative survey measuring overall satisfaction, comfort, perceived quality of in-service communication and counseling, and perceived quality of facility-level factors was administered across 14 VMMC sites in South Africa, Tanzania, and Zimbabwe. Participants were adolescent male clients aged 10–14 years (n = 836) and 15–19 years (n = 457) and completed the survey 7 to 10 days following VMMC. Adjusted prevalence ratios (aPRs) were estimated by multivariable modified Poisson regression with generalized estimating equations and robust variance estimation to account for site-level clustering. Results Of 10- to 14-year-olds and 15- to 19-year-olds, 97.7% and 98.7%, respectively, reported they were either satisfied or very satisfied with their VMMC counseling experience. Most were also very likely or somewhat likely (93.6% of 10- to 14-year olds and 94.7% of 15- to 19-year olds) to recommend VMMC to their peers. On a 9-point scale, the median perceived quality of in-service (counselor) communication was 9 (interquartile range [IQR], 8–9) among 15- to 19-year-olds and 8 (IQR, 7–9) among 10- to 14-year-olds. The 10- to 14-year-olds were more likely than 15- to 19-year-olds to perceive a lower quality of in-service (counselor) communication (score

Background The World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) have set a Fast-Track goal to achieve 90% coverage of voluntary medical male circumcision (VMMC) among boys and men aged 10–29 years in priority settings by 2021. We aimed to identify age-specific facilitators of VMMC uptake among adolescents. Methods Younger (aged 10–14 years; n = 967) and older (aged 15–19 years; n = 559) male adolescents completed structured interviews about perceptions of and motivations for VMMC before receiving VMMC counseling at 14 service provision sites across South Africa, Tanzania, and Zimbabwe. Adjusted prevalence ratios (aPRs) were estimated using multivariable modified Poisson regression models with generalized estimating equations and robust standard errors. Results The majority of adolescents reported a strong desire for VMMC. Compared with older adolescents, younger adolescents were less likely to cite protection against human immunodeficiency virus (HIV) or other sexually transmitted infections (aPR, 0.77; 95% confidence interval [CI], .66–.91) and hygienic reasons (aPR, 0.55; 95% CI, .39–.77) as their motivation to undergo VMMC but were more likely to report being motivated by advice from others (aPR, 1.88; 95% CI, 1.54–2.29). Although most adolescents believed that undergoing VMMC was a normative behavior, younger adolescents were less likely to perceive higher descriptive norms (aPR, 0.79; .71–.89), injunctive norms (aPR, 0.86; 95% CI, .73–1.00), or anticipated stigma for being uncircumcised (aPR, 0.79; 95% CI, .68–.90). Younger adolescents were also less likely than older adolescents to correctly cite that VMMC offers men and boys partial HIV protection (aPR, 0.73; 95% CI, .65–.82). Irrespective of age, adolescents’ main concern about undergoing VMMC was pain (aPR, 0.95; 95% CI, .87–1.04). Among younger adolescents, fear of pain was negatively associated with desire for VMMC (aPR, 0.89; 95% CI, .83–.96). Conclusions Age-specific strategies are important to consider to generate sustainable demand for VMMC. Programmatic efforts should consider building on the social norms surrounding VMMC and aim to alleviate fears about pain.

Background The new World Health Organization and Joint United Nations Programme on HIV/AIDS strategic framework for voluntary medical male circumcision (VMMC) aims to increase VMMC coverage among males aged 10-29 years in priority settings to 90% by 2021. We use mathematical modeling to assess the likelihood that selected countries will achieve this objective, given their historical VMMC progress and current implementation options. Methods We use the Decision Makers' Program Planning Toolkit, version 2, to examine 4 ambitious but feasible scenarios for scaling up VMMC coverage from 2017 through 2021, inclusive in Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Tanzania, Uganda, and Zimbabwe. Results Tanzania is the only country that would reach the goal of 90% VMMC coverage in 10- to 29-year-olds by the end of 2021 in the scenarios assessed, and this was true in 3 of the scenarios studied. Mozambique, South Africa, and Lesotho would come close to reaching the objective only in the most ambitious scenario examined. Conclusions Major changes in VMMC implementation in most countries will be required to increase the proportion of circumcised 10- to 29-year-olds to 90% by the end of 2021. Scaling up VMMC coverage in males aged 10-29 years will require significantly increasing the number of circumcisions provided to 10- to 14-year-olds and 15- to 29-year-olds.

Background Adolescent boys (aged 10–19 years) constitute the majority of voluntary medical male circumcision (VMMC) clients in sub-Saharan Africa. They are at higher risk of postoperative infections compared to adults. We explored adolescents’ wound-care knowledge, self-efficacy, and practices after VMMC to inform strategies for reducing the risks of infectious complications postoperatively. Methods Quantitative and qualitative data were collected in South Africa, Tanzania, and Zimbabwe between June 2015 to September 2016. A postprocedure survey was conducted approximately 7–10 days after VMMC among male adolescents (n = 1293) who had completed a preprocedure survey; the postprocedure survey assessed knowledge of proper wound care and wound-care self-efficacy. We also conducted in-depth interviews (n = 92) with male adolescents 6–10 weeks after the VMMC procedure to further explore comprehension of providers’ wound-care instructions as well as wound-care practices, and we held 24 focus group discussions with randomly selected parents/guardians of the adolescents. Results Adolescent VMMC clients face multiple challenges with postcircumcision wound care owing to factors such as forgetting, misinterpreting, and disregarding provider instructions. Although younger adolescents stated that parental intervention helped them overcome potential hindrances to wound care, parents and guardians lacked crucial information on wound care because most had not attended counseling sessions. Some older adolescents reported ignoring symptoms of infection and not returning to the clinic for review when an adverse event had occurred. Conclusions Increased involvement of parents/guardians in wound-care counseling for younger adolescents and in wound-care supervision, alongside the development of age-appropriate materials on wound care, are needed to minimize postoperative complications after VMMC.

Background The majority of individuals who seek voluntary medical male circumcision (VMMC) services in sub-Saharan Africa are adolescents (ages 10–19 years). However, adolescents who obtain VMMC services report receiving little information on human immunodeficiency virus (HIV) prevention and care. In this study, we assessed the perceptions of VMMC facility managers and providers about current training content and their perspectives on age-appropriate adolescent counseling. Methods Semistructured in-depth interviews were conducted with 33 VMMC providers in Tanzania (n = 12), South Africa (n = 9), and Zimbabwe (n = 12) and with 4 key informant facility managers in each country (total 12). Two coders independently coded the data thematically using a 2-step process and Atlas.ti qualitative coding software. Results Providers and facility managers discussed limitations with current VMMC training, noting the need for adolescent-specific guidelines and counseling skills. Providers expressed hesitation in communicating complete sexual health information—including HIV testing, HIV prevention, proper condom usage, the importance of knowing a partner’s HIV status, and abstinence from sex or masturbation during wound healing—with younger males (aged

Objective: Voluntary medical male circumcision (VMMC) is one of the first opportunities for adolescent males in African countries to interact with the healthcare system. This study explored the approaches used during adolescent VMMC counseling and whether these strategies maximize broader HIV prevention opportunities. Methods: Qualitative interviews were conducted with 92 VMMC clients ages 10–19 years in South Africa (n = 36), Tanzania (n = 36), and Zimbabwe (n = 20) and 33 VMMC providers across the three countries. Discussions explored HIV prevention counseling, testing, and disclosure of results. Audio recordings were transcribed, translated into English, and coded thematically by two individuals. Results: Male adolescents in all three countries reported that limited information was provided about HIV prevention and care, and adolescents were rarely provided condoms. Although VMMC protocols require opt-out HIV testing, adolescents recounted having blood taken without knowing the purpose, not receiving results, nor completely understanding the link between VMMC and HIV. Most males interviewed assumed they had tested negative because they were subsequently circumcised without knowing test results. Providers reported spending little time talking about HIV prevention, including condom use. They admitted that younger adolescent clients often receive little information if assumed they are not sexually active or too young to understand and instead discussed nonsexually transmitted routes of HIV. Conclusion: In the sites of the three countries studied, HIV prevention and care messages were inconsistent and sometimes totally absent from VMMC counseling sessions. VMMC appears to be a missed opportunity to engage in further HIV prevention and care with adolescents.

Supplemental Digital Content is Available in the Text., Background: As test and treat rolls out, effective interventions are needed to address the determinants of outcomes across the HIV treatment continuum and ensure that people infected with HIV are promptly tested, initiate treatment early, adhere to treatment, and are virally suppressed. Communication approaches offer viable options for promoting relevant behaviors across the continuum. Conceptual Framework: This article introduces a conceptual framework, which can guide the development of effective health communication interventions and activities that aim to impact behaviors across the HIV treatment continuum in low- and medium-income countries. The framework includes HIV testing and counseling, linkage to care, retention in pre-antiretroviral therapy and antiretroviral therapy initiation in one single-stage linkage to care and treatment, and adherence for viral suppression. The determinants of behaviors vary across the continuum and include both facilitators and barriers with communication interventions designed to focus on specific determinants presented in the model. At each stage, relevant determinants occur at the various levels of the social–ecological model: intrapersonal, interpersonal, health services, community, and policy. Effective health communication interventions have mainly relied on mHealth, interpersonal communication through service providers and peers, community support groups, and treatment supporters. Discussion: The conceptual framework and evidence presented highlight areas across the continuum where health communication can significantly impact treatment outcomes to reach the 90-90-90 goals by strategically addressing key behavioral determinants. As test and treat rolls out, multifaceted health communication approaches will be critical.

Background Zimbabwe aims to increase circumcision coverage to 80% among 13- to 29-year-olds. However, implementation data suggest that high coverage among men ages 20 and older may not be achievable without efforts specifically targeted to these men, incurring additional costs per circumcision. Scale-up scenarios were created based on trends in implementation data in Zimbabwe, and the cost-effectiveness of increasing efforts to recruit clients ages 20–29 was examined. Methods Zimbabwe voluntary medical male circumcision (VMMC) program data were used to project trends in male circumcision coverage by age into the future. The projection informed a base scenario in which, by 2018, the country achieves 80% circumcision coverage among males ages 10–19 and lower levels of coverage among men above age 20. The Zimbabwe DMPPT 2.0 model was used to project costs and impacts, assuming a US$109 VMMC unit cost in the base scenario and a 3% discount rate. Two other scenarios assumed that the program could increase coverage among clients ages 20–29 with a corresponding increase in unit cost for these age groups. Results When circumcision coverage among men ages 20–29 is increased compared with a base scenario reflecting current implementation trends, fewer VMMCs are required to avert one infection. If more than 50% additional effort (reflected as multiplying the unit cost by >1.5) is required to double the increase in coverage among this age group compared with the base scenario, the cost per HIV infection averted is higher than in the base scenario. Conclusions Although increased investment in recruiting VMMC clients ages 20–29 may lead to greater overall impact if recruitment efforts are successful, it may also lead to lower cost-effectiveness, depending on the cost of increasing recruitment. Programs should measure the relationship between increased effort and increased ability to attract this age group.

This article responds to key questions related to health communication that are commonly asked in the HIV/AIDS arena: "What is health communication?"; "What is its role beyond HIV prevention?"; and "How can it be used to achieve better HIV/AIDS outcomes?" We review how communication scientists think about their own discipline and build on a basic definition of communication as a fundamental human process without which most individual, group, organizational, and societal activities could not happen, including how people think about and respond to health issues such as HIV and AIDS. Diverse factors and processes that drive human behavior are reviewed, including the concept of ideation (what people know, think, and feel about particular behaviors) and the influence of communication at multiple levels of a social ecological system. Four main functions of communication-information seeking and delivery, persuasion, social connection and structural/cultural expression and maintenance-are linked to a modified version of the Department of Health and Human Services Continuum of Care and are used to conceptualize ways in which communication can achieve better HIV/AIDS outcomes. The article provides examples of how communication complements other types of interventions across the HIV/AIDS continuum of care and has effects on HIV-related knowledge, attitudes, social norms, risk perceptions, service delivery quality, and behavioral decisions that affect if and when the virus is transmitted, when and where testing and care are sought, and how well adherence to antiretroviral therapy is maintained. We illustrate this approach with a case study of HIV/AIDS communication conducted by the New York City Health Department during 2005-2013.

BACKGROUND AND METHODS By December 2013, it was estimated that close to 6 million men had been circumcised in the 14 priority countries for scaling up voluntary medical male circumcision (VMMC), the majority being adolescents (10-19 years). This article discusses why efforts to scale up VMMC should prioritize adolescent men, drawing from new evidence and experiences at the international, country, and service delivery levels. Furthermore, we review the extent to which VMMC programs have reached adolescents, addressed their specific needs, and can be linked to their sexual and reproductive health and other key services. RESULTS AND DISCUSSION In priority countries, adolescents represent 34%-55% of the target population to be circumcised, whereas program data from these countries show that adolescents represent between 35% and 74% of the circumcised men. VMMC for adolescents has several advantages: uptake of services among adolescents is culturally and socially more acceptable than for adults; there are fewer barriers regarding sexual abstinence during healing or female partner pressures; VMMC performed before the age of sexual debut has maximum long-term impact on reducing HIV risk at the individual level and consequently reduces the risk of transmission in the population. Offered as a comprehensive package, adolescent VMMC can potentially increase public health benefits and offers opportunities for addressing gender norms. Additional research is needed to assess whether current VMMC services address the specific needs of adolescent clients, to test adapted tools, and to assess linkages between VMMC and other adolescent-focused HIV, health, and social services.

Background We conducted quantitative and qualitative studies to explore barriers and motivating factors to VMMC for HIV prevention, and to assess utilization of existing VMMC communication channels. Methods and Findings A population-based survey was conducted with 2350 respondents aged 15–49. Analysis consisted of descriptive statistics and bivariate analysis between circumcision and selected demographics. Logistic regression was used to determine predictors of male circumcision uptake compared to intention to circumcise. Focus group discussions (FGDs) were held with men purposively selected to represent a range of ethnicities. 68% and 53% of female/male respondents, respectively, had heard about VMMC for HIV prevention, mostly through the radio (71%). Among male respondents, 11.3% reported being circumcised and 49% reported willingness to undergo VMMC. Factors which men reported motivated them to undergo VMMC included HIV/STI prevention (44%), improved hygiene (26%), enhanced sexual performance (6%) and cervical cancer prevention for partner (6%). Factors that deterred men from undergoing VMMC included fear of pain (40%), not believing that they were at risk of HIV (18%), lack of partner support (6%). Additionally, there were differences in motivators and barriers by age. FGDs suggested additional barriers including fear of HIV testing, partner refusal, reluctance to abstain from sex and myths and misconceptions. Conclusions VMMC demand-creation messages need to be specifically tailored for different ages and should emphasize non-HIV prevention benefits, such as improved hygiene and sexual appeal, and need to address men's fear of pain. Promoting VMMC among women is crucial as they appear to have considerable influence over men's decision to get circumcised.