Increasing Access to Services

Gaps in Research

1.: Interventions are needed to increase community involvement and investment in programs that promote the introduction and utilization of youth-friendly services.
2.: Laws and practices that obstruct adolescents’ access to services, such as parental consent requirements, age, and marital status requirements, must be aligned with the actual behavior of adolescents.
3.: Adolescents living with HIV need information and services through adolescent-friendly HIV services on a number of topics, including disclosure, safer sex, contraception, safe motherhood and gender-based violence.
4.: Increased efforts are needed to reduce stigma against adolescents living with HIV, particularly young key populations.
5.: Mandatory pre-marital HIV testing may increase HIV stigma.
6.: Actions are needed to increase young people’s knowledge of when and where to access health services, including access to contraception and condoms.
7.: Increased efforts are needed to address the needs of adolescents living with HIV who are pregnant and to create linkages between HIV centers and maternal health clinics.
8.: Increased training is needed for providers to discuss sexuality and pleasure with adolescent youth who need reproductive health services.
9.: Evaluated guidelines are needed to manage the transition from pediatric to adult care
10.: Sex and age disaggregated data is critical to assess which ages are falling through the cracks in data collection.
11.: Further evaluation of the potential use of Pre-exposure Prophylaxis for adolescent women is needed.
12.: Successful strategies are needed to increase adherence to ART among adolescents and reduce loss to follow up.
13.: Evidence-based interventions are needed for adolescents who inject drugs.
14.: Concerted efforts are needed to enable adolescents at risk to test confidentially for HIV and be immediately linked to services, with information on where and how to access services.
15.: Additional research is needed on disease progression among children and adolescents who acquired HIV as infants.
16.: Youth-friendly services are needed within schools to increase access to condoms and/or HIV testing for those who are sexually active.

1. Interventions are needed to increase community involvement and investment in programs that promote the introduction and utilization of youth-friendly services. A literature review found that in order to increase utilization of youth friendly services, efforts to change community attitudes on adolescent sexuality were needed

Gap noted, for example, in a literature review of youth-friendly service programs (Gay et al., 2015; Speizer et al., 2003); Kenya (Hagey et al., 2015).

2. Laws and practices that obstruct adolescents’ access to services, such as parental consent requirements, age, and marital status requirements, must be aligned with the actual behavior of adolescents. Studies found that legal requirements restricted adolescents from getting tested for HIV even if they were sexually active and at risk for HIV. "There is a strong evidence base that the stigma, discrimination and criminalization affecting adolescent key populations aged 10 to 17 is intensified due to domestic and international legal constructs that rely on law-enforcement based interventions dependent upon arrests, pre-trial detention, incarceration and compulsory ‘rehabilitation’ in institutional placements," particularly among adolescents who sell sex or inject drugs (Conner, 2015: para 1).

Gap noted, for example, in Eastern and Southern Africa (UNESCO, 2013); Rwanda (Binagwaho et al., 2012); Swaziland (All in to End Adolescent AIDS, 2015a); Albania, Moldova, Romania and Serbia (Busza et al., 2013); Kenya (Agbemenu and Schlenk, 2011); Zimbabwe (Ferrand et al., 2011; Shroufi et al., 2013); Tanzania (Ferrand et al., 2010); India, Botswana, Kenya, Malawi, Mozambique, Rwanda, Tanzania, Thailand, Trinidad, Uganda, Zambia and Zimbabwe (McCauley, 2004) and South Africa (HRW, 2003a); Thailand (Tulloch et al., 2014).

3. Adolescents living with HIV need information and services through adolescent-friendly HIV services on a number of topics, including disclosure, safer sex, contraception, safe motherhood and gender-based violence. Studies found that health providers were unprepared to discuss HIV and contraception with adolescents who acquired HIV through perinatal transmission, despite the fact that significant numbers of these adolescents were already sexually active. Another study found that these adolescents need skills to disclose their serostatus to sexual partner. WHO recommends that perinatally infected adolescents be advised of their positive serostatus by age 6 (WHO, 2013) but there is little guidance on disclosure for adolescents. Facilitated disclosure by parents and providers to adolescents living with HIV may lead to higher retention in HIV care (Arrive et al., 2012). Parents living with HIV whose adolescents may be living with HIV also need assistance to disclose to their adolescents, as parents fear rejection from their children. Positive health dignity and prevention interventions can help people living with HIV lead healthy lives and reduce HIV transmission, but tailored interventions for adolescents and their parents have not been evaluated for effectiveness, although a trial is currently ongoing (Cunningham, 2015; Mofeson and Cotton, 2013). One study found that 29% of young women aged 16 to 24 living with HIV reported being forced to have sex. No validated curriculum that was shown to be effective for reducing unsafe sex among adolescents living with HIV was found, although some manuals have been developed (Parker et al., 2013c; UNESCO and GNP+, 2012).

Gap noted globally (Denno et al., 2015; Lowenthal et al., 2014; Pettifor et al., 2013; Evangeli and Foster, 2014); and for example, in South Africa (Hill et al., 2015; Fatti et al., 2014); Zambia (Stangl et al., 2015; FHI360, 2013; Hodgson et al., 2012; Baryamutuma and Baingana, 2011; Birungi et al., 2011b; Obare et al., 2009); Ghana (Gyamfi et al., 2015); Kenya, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe (Pitorak et al., 2013); Uganda, Malawi, Zambia and India (Kenny et al., 2012); China (Mu et al., 2015; Zhou et al., 2012); Rwanda (Test et al., 2012); DRC (Parker et al., 2013a and b); Kenya (Hagey et al., 2015; Obare et al., 2012); Nigeria (Folayan et al., 2014); Brazil (Cruz et al., 2015); Uganda (Lowenthal et al., 2014); and Uganda and Kenya (Birungi et al., 2009a; Birungi et al., 2009b; Birungi et al., 2009c).

4. Increased efforts are needed to reduce stigma against adolescents living with HIV, particularly young key populations. A study found that adolescents living with HIV kept silent about their HIV status to schools, friends and family so as to not experience stigma and discrimination.

Gap noted, for example, globally (Mutumba and Harper, 2015); in Zambia (Stangl et al., 2015); Botswana (Thupaygale-Tshweneagae, 2010:262) and Uganda (Birungi et al., 2011b; Obare et al., 2009).

5. Mandatory pre-marital HIV testing may increase HIV stigma. A study found youth believed that mandatory pre-marital HIV testing would increase stigma against those who test HIV-positive with significant numbers believing that they were not personally at risk of acquiring HIV.

Gap noted, for example, in Nigeria (Arulogun and Adefioye, 2010).

6. Actions are needed to increase young people’s knowledge of when and where to access health services, including access to contraception and condoms. A UNESCO review found that young people lacked knowledge of where to access health services to meet their needs. Adolescents in numerous countries are sexually active, yet have low rates of contraceptive use. Adolescents need accurate detailed information about the level of risk of different sex acts (oral, genital and anal). Studies found that youth aged 15 to 24 were at high risk of either acquiring HIV or testing HIV-positive, yet less likely to report having been tested for HIV. Increased knowledge that HIV-positive infants can survive to adolescence is also needed so that these young people can get tested for HIV and access services. In some countries, HIV prevalence among both female and male adolescents who tested for HIV was as high as 16%. [See also Meeting the Meeting the Sexual and Reproductive Health Needs of Women Living With HIV]

Gap noted in Sub-Saharan Africa (Fatusi and Hindin, 2010); Ethiopia (Lindstrom et al., 2010); West Africa (Arrive et al., 2012); Zimbabwe (Ferrand et al., 2011); South Africa (Ramirez-Avila et al., 2012; Khasany et al., 2012; Venkatesh et al., 2011a) and Nigeria (Yahaya et al., 2010); globally (UNESCO, 2009b).

7. Increased efforts are needed to address the needs of adolescents living with HIV who are pregnant and to create linkages between HIV centers and maternal health clinics. A study showed that use of maternal health services to prevent vertical transmission was lower than the proportion who attended prenatal care. In this study, less than half of pregnant adolescents attended four antenatal care visits. In addition, use of skilled attendance during or after abortion or miscarriage was low.[See also Safe Motherhood and Prevention of Vertical Transmission and Structuring Health Services to Meet Women’s Needs]

Gap noted in Kenya (Birungi et al., 2011a).

8. Increased training is needed for providers to discuss sexuality and pleasure with adolescent youth who need reproductive health services. A analysis of fictional narratives written by young people aged ten to 24 concerning HIV found that young people criticized the lack of skills by providers to discuss issues of sex and pleasure as well as conceptualizing rape as a punishment for girls who do not abstain from sex.

Gap noted, for example, in Eastern and Southern Africa (UNESCO, 2013); Senegal, Burkina Faso, Nigeria, Kenya, Namibia and Swaziland (Winskell et al., 2011a).

9. Evaluated guidelines are needed to manage the transition from pediatric to adult care

10. Sex and age disaggregated data is critical to assess which ages are falling through the cracks in data collection. Current HIV data collection masks critically needed data on adolescents ages 10 to 19. For example, a study that disaggregated ages found that loss to follow up for patients aged 10 to 24 was twice as high for ages 15 to 19 than for ages 10 to 14 (Koech et al., 2014).

Gap noted globally (Lowenthal et al., 2014; Sohn and Hazra, 2013) and for example, in Zambia (Denison et al., 2015); Swaziland (All in to End Adolescent AIDS, 2015a) and Kenya, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe (Pitorak et al., 2013).

11. Further evaluation of the potential use of Pre-exposure Prophylaxis for adolescent women is needed. PrEP has been successfully used by people who inject drugs (Choopanya et al., 2013 cited in Pettitfor et al., 2015), but no studies were found among adolescents who inject drugs. ART is being formulated in vaginal rings (Baeten et al., 2016) which may increase use by adolescents without requiring daily pill taking (Brady et al., 2013 and Tolley et al., 2013 cited in Pettitfor et al., 2015); however, the initial pilot trial showed no effcicacy for those under age 21 but efficacy for those over age 21. One study of qualitative interviews with young women found that if given the option of PrEP, they would not use condoms (Corneli et al., 2015).

Gap noted globally (Celum et al., 2015; Pettifor et al., 2015).

12. Successful strategies are needed to increase adherence to ART among adolescents and reduce loss to follow up. A study found that adolescents and young adults aged 15 to 24 living with HIV were more likely, following treatment initiation, to have higher viral loads, higher rates of virological failure and greater low to follow up from services. Another study found that adolescents (ages 9 to 19) had poorer virological outcomes compared to young adults (ages 20 to 28). A review found few estimates on viral suppression among ages 10 to 19 (All in End Adolescent AIDS, 2015c). A specialized HIV management program could not retain a substantial proportion of those who tested positive for HIV in care. A review of studies of adherence among adolescents and children in Lower and Middle Income countries found that most studies were cross-sectional with age data ranging from six months to 21, limiting the ability to define which strategies are key to increasing adherence among ages 10 to 19. Cognitive behavioral therapy can be further explored as a strategy to increase adherence in adolescent populations.

Gap noted, globally (Pettifor et al., 2013; WHO, 2013; Hudelson and Cluver, 2015; MacPherson et al., 2015; Parsons et al., 2014 cited in Celum et al., 2015); in Rwanda (Mutwa et al., 2013); Zambia (FHI360, 2013; Denison et al., 2015); Kenya (Koech et al., 2014); Kenya, Mozambique, Tanzania and Rwanda (Lamb et al., 2014); Kenya, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe (Pitorak et al., 2013); South Africa (Evans et al., 2013; Nkala et al., 2015; Naik et al., 2015; Nglazi et al., 2011); Uganda (Wiens et al., 2012 cited in Denison et al., 2015).

13. Evidence-based interventions are needed for adolescents who inject drugs. "There is a pronounced lack of data on young women who use or inject drugs, a key subpopulation with complex needs" (Larney et al., 2015: S106), despite high rates of HIV. In addition, “it is imperative that interventions not rely on law enforcement, but instead provide low-threshold, voluntary services, shelter and support..." (Conner, 2015: para 1).

Gap noted, globally (Larney et al., 2014, Conner, 2015); and in India (Armstrong et al., 2014); Poland (Czerwinski et al., 2013); Estonia (Vorobjov et al., 2013).

14. Concerted efforts are needed to enable adolescents at risk to test confidentially for HIV and be immediately linked to services, with information on where and how to access services. Access to and update of HIV testing and counseling (HTC) by adolescents is significantly lower than for adults. One study found that adolescents who were tested through provider-initiated testing (the WHO standard) had higher loss to follow up if they tested HIV-positive than adolescents who were tested through voluntary testing and counseling (Lamb et al., 2014). HTC must, according to WHO, include consent, confidentiality, counseling, correct test results and connections to treatment, care and prevention services. A recent report found that no data exists for HTC among ages 10 to 14 (All in to End Adolescent AIDS, 2015c). Access to HTC for adolescents who inject drugs is particularly challenging. HTC clients also need counseling on contraception and referral to services.

Gap noted globally (Pettitfor et al., 2013; WHO, 2013) and for example, for Kenya, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe (Pitorak et al., 2013); Myanmar (Saw et al., 2014); Kenya (Baumgartner et al., 2012); South Africa (Otwombe et al., 2015); Ethiopia (Feleke et al., 2013); Uganda (Graffy et al., 2012); Jamaica (All in to End Adolescent AIDS, 2015c).

15. Additional research is needed on disease progression among children and adolescents who acquired HIV as infants.

Gap noted globally (Idele et al., 2014).

16. Youth-friendly services are needed within schools to increase access to condoms and/or HIV testing for those who are sexually active. A study found that youth in numerous countries do not have information or access to condoms within school systems.

Gap noted, for example, globally (Todesco and Gay, forthcoming 2016); in Rwanda (Michielsen et al., 2014); Zimbabwe (Ferrand et al., 2011); South Africa (Kharsany et al., 2012; Venkatesh et al., 2011a) Nigeria (Yahaya et al., 2010) and Antigua and Barbuda; Bahamas; Bolivia; Columbia: Costa Rica; Chile; Dominica; Ecuador; El Salvador; Guyana; Haiti; Honduras; Jamaica; Mexico; Nicaragua; Panama; Paraguay; Peru; Venezuela; Dominican Republic; Santa Lucia; Suriname; Trinidad y Tobago; and Uruguay (DeMaria et al., 2009).