Skip to 0 minutes and 10 seconds SPEAKER 1: Another health priority in adolescents is HIV. Where do you think that HIV mortality ranks among the causes of death in 10- to 14-year-olds and in 15- to 19-year-olds globally? Well, in 2013, HIV ranked first of all causes in 10- to 14-year-olds and was responsible for over 10.4% of total deaths in that age range. And it ranked third in 15- to 19-year-olds and responsible for over 6.2% percent of total deaths. HIV also ranks third globally as a cause of disability-adjusted life years lost in early adolescence. HIV is only in the top five causes of death in adolescents and one WHO region, Africa, where it ranks number one by a long way.
Skip to 1 minute and 0 seconds Most deaths in this age group occur in long-term survivors of perinatal HIV infection, that’s young children who’ve been infected either in pregnancy at birth or during infancy. HIV incidence, that’s the number of new infections with HIV, is extremely low in young adolescents but it escalates rapidly after adolescents become sexually active, especially in girls in young women. And the difference between girls and boys in terms of when HIV takes off is mainly due to girls and young women tending to have all their male sexual partners.
Skip to 1 minute and 39 seconds This slide is taken from a recent paper prepared by UNICEF. And it shows the HIV prevalence by age and sex in four sub-Saharan African countries, three from southern Africa with a very high HIV burden, that’s Swaziland, Botswana, and South Africa, and the fourth is Uganda from East Africa, which has a much lower but still considerable HIV burden. As you can see from studying these four graphs, all four countries show the problems in females taking off in adolescence– sorry, in older adolescents, with the prevalence in males taking off 5 to 10 years later.
Skip to 2 minutes and 18 seconds The good news is that many, but not all, countries have turned the corner in the past decade in terms of HIV incidence.
Skip to 2 minutes and 29 seconds Here we can see that the incidence rate of HIV in 15- to 49-year-olds has declined by at least 25% in a large number of countries in the decade between 2001 and 2011 with the incidence increasing in a far smaller number of countries over the same period.
Skip to 2 minutes and 49 seconds On the other hand, adolescence is the only age group with increasing HIV mortality globally. This is for two main reasons. Antiretrovirals for prevention of mother to child transmission of HIV were not widely available when today’s adolescents were being born and, secondly, because adolescents access to HIV testing, combination ART and the subsequent retention in, and adherence to, treatment and care are lower than in other age groups. So what are the HIV interventions that are useful to do among adolescents? And it’s important to realise that a multi-sectoral approach is needed.
Skip to 3 minutes and 28 seconds This should include youth friendly health services, sexual and reproductive health education in schools, and higher education institutions, community interventions such as youth clubs or by holding youth health weeks, work with groups at high risk such as sex workers, men who have sex with men, and people who inject drugs, mass media approaches, and structural interventions such as changing laws and policies to create a supportive environment. It’s not enough just to do one of these things. Experience has shown that a combination prevention treatment and care approach is needed. So what do we mean by h-friendly services? For health services to be youth-friendly, they must be accessible and attractive to youths.
Skip to 4 minutes and 13 seconds They must offer a safe, supportive, non-judgmental and confidential environment for young people to discuss their health problems with the health workers. And providers must be trained in how to deal effectively with issues that are specific to young people and to offer them relevant information and skills. Studies have shown that training in providing supportive supervision to health workers to help them to be more youth-friendly can be effective in improving youth friendliness. And they can also increase attendances by young people seeking health care. A review published in 2014 showed that there was strong evidence of the effectiveness of a wide range of interventions to prevent HIV among adolescents.
Skip to 4 minutes and 56 seconds The correct choice of the effective interventions that should be included in the adolescent health control programme for HIV should depend on the type of epidemic and the specific local context. There are three main types of HIV epidemics that have been described, low level epidemics, concentrated epidemics, and generalised epidemics. Interventions for key effected populations such as young sex workers, men who have sex with men, and people who inject drugs are essentially in all three countries. But population-wide interventions assumed increased importance in generalised epidemics situations. So, in summary, HIV ranks number three in the burden of disease among young adolescents globally and number one in sub-Saharan Africa.
Skip to 5 minutes and 43 seconds There are a wide range of effective interventions for HIV prevention, treatment, and care in adolescents. And the choice of which should be included in a multi-sectoral HIV control programme should depend on the type of epidemic and the specific context.
Health priorities: HIV testing, treatment and care
The next few steps focus on programming for the health of adolescents and young people, considering why, as a demographic group, they’re special or different, and what we can do when developing programmes and interventions to better address their needs. To illustrate these points we’ll use the example of HIV, which ranks highly as a cause of death among adolescents globally, and is the top cause in Africa by a long way.
Where are we now?
An estimated 2.1 million adolescents were living with HIV in 2016; with 71% of these living in just 10 countries – 9 in sub-Saharan Africa, and India. This number is expected to increase in coming decades due to improved survival for people living with HIV and an increasing number of adolescents in this region.
Girls and young women are disproportionately affected by HIV, with 61% of older ALHIV (aged 15-19) being female, and 2/3 of new infections in this age group among girls. There are multiple reasons for this, including biological vulnerability (the risk of male-to-female HIV transmission is twice that of female-to-male), and gender power dynamics making it harder for young women to negotiate safe sex.
Despite the scale-up of treatment for HIV (antiretroviral therapy (ART), HIV remains an important cause of death among adolescents, and in 2015 was estimated to be the 8th leading cause of death among all adolescents globally, but the fourth leading cause in Africa. Moreover, adolescence is the only age group in which mortality from HIV is not decreasing. The video discusses why this is, and the strategies that are proving effective to improve uptake of HIV testing, and access to appropriate treatment and care. These include increased use of oral HIV self-testing kits, and availability of trained people in the community to help young people adhere to treatment.
© London School of Hygiene & Tropical Medicine 2019