On the cutting edge: Improving the informed consent process for adolescents in Zambia undergoing male circumcision for HIV prevention

Abstract

Based on evidence that it can reduce HIV transmission by up to 60%, male circumcision (MC) is being scaled up in high HIV prevalence settings. We present data from operations research into the introduction of MC in Zambia, assessing informed consent (IC) procedures for adolescent MC clients. We administered a comprehension test among adult (n = 311) and adolescent (n = 115) clients at 10 clinics around Lusaka between the counselling and IC process. We conducted semi-structured interviews with adolescent (13–17 years) MC clients 1 week post-surgery (n = 28) and 13 key informants (service providers and stakeholders). We conducted six focus group discussions (FGDs) among 36 parents/guardians; half who had chosen MC for their sons, half who had not. Data reveal complex interactions between adolescent and parent/guardian regarding making and authorizing the decision to circumcise. Although comprehension was generally high, adolescents scored significantly (p < 0.05) lower than adult clients on two questions, reflecting difficulty in understanding the key concepts associated with MC. Adolescent clients were significantly less likely than adult clients to report feeling comfortable with the decision to undergo MC (44% vs. 13%, p < 0.05). Qualitative data indicate that IC procedures for minors are poorly understood and inconsistently implemented at clinic sites, at a time when regulation was changing. The disparity between IC procedures for research and for surgery limits study findings; however, we underscore the absolute importance of creating an environment in which human rights abuses are prevented. We recommend that service providers take steps to strengthen the IC process for minors, including training providers and publicizing consent requirements in community outreach activities.

Keywords:

• adolescents
• circumcision
• HIV
• prevention

Acknowledgements

We express our deepest thanks to clients and their parents/guardians attending male circumcision clinics in Zambia, clinic staff members and community informants, without whom this research study could not have taken place. We are grateful to our research team in Zambia: James Banda, Kolala Chilele, Mulenga Kaemba, Walumweya Mubitana, Patrick Nawa, Shimeo Sakanya, Michael Kabaghe, Lason Kapata, Janet Mulilo, Given Nakalonga, Patrick Nkhata and Nchimunya P. Nkwengele. This study was conducted under a subgrant from Population Services International (PSI) through the Male Circumcision Partnership (MCP), which is sponsored by PSI with support from The Bill and Melinda Gates Foundation. The MCP was established with the support of the Gates Foundation and the President's Emergency Fund for AIDS Relief in collaboration with the Government of Zambia. Thanks to MCP colleagues within the Government of Zambia/Ministry of Health and at the following organizations: Marie Stopes International, Population Services International, Society for Family Health and the Bill and Melinda Gates Foundation.

Notes

This article is based on a presentation delivered on 13 September 2011 at the AIDS Impact Conference in Santa Fe, NM, USA.

1. A child is defined as anyone under the age of 18 (Office of the United Nations High Commissioner for Human Rights [OHCHR], 1989).

2. See Friedland et al. (2011) for further details of comprehension.

3. Similar to comments from adult clients.