Dr Sinead Delany-Moretlwe (Wits RHI, Johannesburg) made the first presentation on the EMPOWER project, which examined the potential for young women to use oral pre-exposure prophylaxis (PrEP) to prevent HIV infection in South Africa and Tanzania. The study also explored whether intimate partner violence (IPV) will be a barrier to PrEP and whether services are able to tackle it. IPV has been experienced in some form by around one-third of ESA women by the age of 19,
The project confirmed that young women were at high risk of HIV and violence. However, contrary to some perceptions, young women do recognise their risk, and they are very receptive to youth friendly health services (YFHS) that include PrEP, and are also confidential, respectful and non-judgmental. Furthermore, empowerment interventions do have potential to affect IPV risk within programmatic timeframes, not just in the long term. Other key lessons included the importance of youth engagement in service design and the need for effective partnerships for cross-sectoral referrals.
The P-ART-Y study was conducted by the Desmond Tutu Centre, Stellenbosch University and Zambart, Zambia, to investigate the acceptability of a community-based youth prevention package in Zambia and South Africa. It reported that high levels of acceptance of household testing and prevention packages among youth facilitated progress towards the first and second UNAIDS 90-90-90 targets among adolescents. Key success factors of the intervention included active adolescent community advisory boards and community youth work workers.
Adults’ attitudes to young people’s sexuality can present important barriers to testing, openness and protection from HIV. Adolescents reported sex as an "unavoidable reality", but many adults were in denial about adolescent sexual activity, norms and knowledge, and discouraged disclosure and open discussion. The rapid rise in HIV prevalence in young women from around 2% at age 17 years to 5% at age 19 years underscored the importance of effective interventions for adolescents around those ages.
The Mzantsi Wakho study (University of Cape Town and Oxford University) looked at socio-economic drivers of vulnerability in HIV-positive South African youth. It spoke of the lived experiences of youth with HIV, and what can be done to tackle vulnerability to non-adherence and unsafe behaviour. Poor levels of adherence and viral suppression, as well as substantial mortality during the study period, revealed the severe pressures on these young people.
As in other EHPSA studies, adult behaviours were critical to adolescent outcomes. Disclosure of adolescents’ HIV status to them increased ART adherence three-fold, and disclosure before the age of 12 years doubled adherence again. On the other hand, exposure to physical abuse, violence at home or by teachers, and verbal abuse in clinics severely reduce adherence. Adolescent girls who are pregnant are particularly vulnerable to negative outcomes, as are adolescent boys who are scolded by adults.
Encouragingly, access to welfare grants, food security, support groups, schooling and parental supervision all increase adherence and safe behaviours. Also health services measurably boost adherence when they provide components of “STACK”: reliable medication Stocks; staff Time to interact with teens; Accompaniment or Cash to help with transport to the clinics; or Kind staff - who simply do not shout at clients.
The GIRL POWER study (University of North Carolina and Desmond Tutu Centre, Cape Town) made findings on the importance of youth-friendly health services (YFHS) and combination prevention for young women. It reported that YFHS can increase uptake of HCT, condoms and contraception, through adapting variables such as: the attitude and age of providers; private, non-stigmatising clinical environments; shorter waiting times, longer opening hours and provision of more integrated services.
The final presentation was on evaluations of the impact of adolescent and HIV interventions (co-funded by EHPSA and the World Bank and implemented by host governments), that have been using implementation science to explore whether innovations are effective under real-world, imperfect but scalable conditions. Among their key results to date are that: transport vouchers have increased male circumcision uptake by seven-fold in Malawi; smartphone notification systems have some effectiveness in improving linkage to care among young PLWHIV in South Africa, but face some implementation challenges; and that cash transfer incentives can lead to more condom use (Swaziland).
Presentations were followed by discussion of numerous comments and questions from an engaged audience. What is needed to take the interventions to scale? What are the root causes of destructive adult and health worker attitudes, and how can they best be addressed? How can adults start to see youth as part of the solution, not just the problem? How can systems actually overcome the lack of integration and coordination within services and between sectors at all levels? Participants noted that this can be challenging to get right in practice, and can have unintended adverse effects such as reducing privacy and other features required to improve accessibility to young women.
One key question was why have previous generations of YFHS not been effectively scaled up and sustained. Several participants noted that EHPSA studies distinguished themselves by identifying essential building blocks for impact that could be added incrementally, while previous efforts had tried to do everything. Previously, complex norms and standards had been developed when some simpler inputs might be more robust. Examples would be: providing basic information for young people; having a youth service champion in each facility; and providing better data on the scale and types of adolescent problems. In addition, some clinics seem to no longer provide basic youth friendly service components simply because they are not aware of their importance or certain of their impact.
There was also commentary on what could be learned from EHPSA’s focused attention to using research results to influence policy change. This had included dissemination to HIV authorities and Ministries of Health in 15 countries, and active engagement of researchers in a range of policy and planning processes at national levels.
In closing, Dr Charlotte Watts, DFID Chief Scientific advisor, said it was pleasing to see how the EHPSA research teams had really delivered, with quality research and important findings. Several ideas stood out for her. Firstly, our thinking must be framed by the recognition that most adolescents are not infected, a challenge and reason for hope. But we must also see urgency in the fact that adolescents are dying from HIV. Secondly, EHPSA has shown a clearly defined, actionable set of structural risks, behaviours and barriers which can be targeted to reduce risk of HIV infection and to improve adherence. This is an important contribution to more effective combination programming, and strong evidence of the effectiveness of multisectoral involvement. Thirdly, EHPSA has shown ways to “keep it simple” and avoid overly complex and abstract approaches: each study has highlighted a few important, basic things. Finally, the research has shown that we are often not acting on common sense. For example, it is obvious that we need to support health workers better if we want them to provide client friendly services in challenging circumstances.
Read the presentations here...
More about EHPSA’s adolescent portfolio here...