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Skip to 0 minutes and 9 seconds DAVID ROSS: Another health priority in adolescence 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 2010, HIV ranked third of all causes in 10- to 14-year-olds and was responsible for over 8% of total deaths in that age range. And it ranked eighth in 15- to 19-year-olds and responsible for over 3% of total deaths. HIV also ranks fourth globally as a cause of disability adjusted life years lost in adolescence. HIV is only in the top five causes of death in adolescents in one WHO region– Africa– where it ranks number one by a long way.

Skip to 1 minute and 3 seconds Most deaths in these 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 adolescence become sexually active, especially in girls and 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 older male sexual partners.

Skip to 1 minute and 45 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 prevalence in females taking off in older adolescents, with the prevalence in males taking off five to 10 years later. 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 34 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. 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 adolescent’s access to HIV testing, combination ART, and subsequent retention in and adherence to treatment and care are lower than in other age groups.

Skip to 3 minutes and 28 seconds So what are the HIV interventions that are useful to do among adolescents? And it’s important to realise that a multisectoral approach is needed. This should include youth-friendly health services, sexual and reproductive health education in schools and higher education institutions, community interventions, such as through youth clubs or by holding youth health weeks, work with groups at high risk, such a 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 to just do one of these things. Experience has shown that a combination, prevention, treatment, and care approach, is needed.

Skip to 4 minutes and 20 seconds So what do we mean by youth-friendly services? For health services to be youth-friendly, they must be accessible and attractive to youths, they must offer a safe, supportive, nonjudgmental, 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.

Skip to 5 minutes and 8 seconds A review by Sue Napierala Mavedzenge and colleagues published in 2014 showed that there was strong evidence of the effectiveness of a wide range of interventions to prevent HIV among adolescents. 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 affected populations, such as young sex workers, men who have sex with men, and people who inject drugs, are essential in all three contexts but population wide interventions assumed increased importance in generalised epidemic situations.

Skip to 6 minutes and 3 seconds So, in summary, HIV ranks number four in the burden of disease among adolescents globally and number one in Sub-Saharan Africa. 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

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.

Many, but not all countries, have turned a corner in terms of HIV incidence in the past decade. However, adolescence is the only age group with increasing HIV mortality. One reason for this is that adolescents’ access to testing, treatment, and subsequent adherence to it is relatively low in adolescents for a number of reasons. There are many ways in which these barriers can be reduced, but experience has shown that a combined, multisectoral, youth-friendly approach is needed when developing HIV programmes for adolescents, some of which are introduced in the next step.

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Improving the Health of Women, Children and Adolescents: from Evidence to Action

London School of Hygiene & Tropical Medicine