Quite rightly, the big focus of the 22nd International AIDS Conference in Amsterdam was on adolescents and key populations: for these are the groups we most need to reach if we are to achieve the ambitious 90-90-90 targets and the goal to end AIDS by 2030.
Adolescents and young people, for example, represent a growing share of people living with HIV worldwide. In 2017 alone, 590,000 young people between the ages of 15 to 24 years were newly infected with HIV. The adolescent HIV crisis is most serious in eastern and southern Africa, where around 1.1 million adolescents living with HIV represent 60% of the world’s adolescent HIV population.
Many presentations at the conference described this challenge. An early satellite by the Evidence for HIV Prevention in Eastern and Southern Africa (EHPSA) programme profiled four studies with different approaches to uptake and retention of adolescents in HIV and sexual health services in eastern and southern Africa.
The GIRL POWER study, which looked at models of combination prevention interventions for adolescent girls in Malawi and South Africa, illustrated the pivotal importance of youth-friendly health services, including health workers that are trained to deal sensitively with adolescent issues. In the Malawi branch of the study, the youth-friendly clinic intervention outperformed the all other interventions such as cash transfers and empowerment groups. Adolescents noted the condemnatory attitudes of health workers to adolescent sexuality in mainstream clinics and particularly valued the non-judgmental and open attitudes, and respectful treatment by health workers in the GIRL POWER intervention clinics.
The Mzantsi Wakho study takes a different approach by following a cohort of over a thousand HIV-positive adolescents in the Eastern Cape Province of South Africa to provide a clear insight into their lived reality. One part of the study focused on the five features of clinics that were most associated with adolescents being retained in care. These were: clinic well stocked with ARVs; staff with sufficient time to see adolescents; having someone with whom to attend the clinic; having enough cash to get to the clinic; and kind staff. Combinations of these five interventions significantly affected retention in care: With access to none, only 3% of adolescents were retained in care, whereas those who said they had access to all five reported a 70% probability of being retained in care. In interviews, young people told researchers them that one of the single greatest deterrents to returning to the clinic was being shouted at by nurses.
For key populations, many of whom are stigmatized and criminalized by society in general, health worker attitudes are also critical barriers to services, and all three of EHPSA’s studies on HIV prevention for men who have sex with men (MSM) made similar findings. Interviewees in Namibia, South Africa and Kenya all said that they avoided visiting mainstream facilities because of the homophobic attitudes of health workers and general lack of an MSM-friendly environment.
Successful models of adolescent-friendly and MSM-friendly facilities abound in the global literature. Many organizations have developed guides and programs for in-service training of health workers. However, this approach is resource heavy and requires ongoing follow-up due to the mobility of health workers and other factors. The demand for tailored training for different groups – adolescents, MSM, sex workers, etc. - is an additional challenge. To date no countries in the ESA region have been able to carry this type of training to scale.
This has led to a growing debate on the need for curriculum change at pre-service level to ensure sustainability. Pre-service training offers the advantage of scale with lower costs than in-service training. In theory, such a curriculum could focus on diversity training, imparting skills and attitudes that may serve a range of populations with special needs. While this may not result in gold-standard services, it would be a start.
Interestingly the Global Fund Technical Review Panel report of 2017 encouraged countries who are applying for funding for human resources for health to include pre-service training. The report noted: “Global Fund support focuses on in-service training rather than on strengthening pre-service training. However, over-reliance on in-service group training is an inefficient use of resources and results in widespread absence of workers from health care facilities. The TRP recommends greater attention to human resources for health investments in pre-service is warranted.”
It is up to influential organisations such as the World Health Organization and UNAIDS to take this forward on a global level. The time is right.
Lesley Lawson is the Knowledge and Communications Manager of the Evidence for HIV Prevention in Eastern and Southern Africa (EHPSA) programme.
Click here for further information on researchers’ presentations and the animated infographic from EHPSA’s satellite session at the 22nd International AIDS Conference in Amsterdam, 23-27 July 2018.