Effective approaches for programming to reduce adolescent vulnerability to HIV infection, HIV risk, and HIV-related morbidity and mortality: a systematic review of systematic reviews

"Not Taking it Will Just be Like a Sin": Young People Living with HIV and the Stigmatization of Less-Than-Perfect Adherence to Antiretroviral Therapy

Global health priorities are being set to address questions on adherence to HIV antiretroviral therapy in adolescence. Few studies have explored young people's perspectives on the complex host of social and relational challenges they face in dealing with their treatment in secret and their condition in silence. In redressing this, we present findings from a longitudinal qualitative study with young people living with HIV in the UK, Ireland, US, and Uganda, embedded within the BREATHER international clinical trial. Drawing from Goffman's notion of stigma, we analyze relational dynamics in HIV clinics, as rare spaces where HIV is "known," and how young people's relationships may be threatened by non-adherence to treatment. Young people's reflections on and strategies for maintaining their reputation as patients raise questions about particular forms of medicalization of HIV and the moralization of treatment adherence that affect them, and how these may restrict opportunities for care across the epidemic.

Neurodevelopment: The Impact of Nutrition and Inflammation During Adolescence in Low-Resource Settings

Approximately 1 out of 5 children worldwide suffers from childhood malnutrition or stunting and associated health conditions, including an increased susceptibility to infections and inflammation. Due to improved early interventions, most children even in low-resource settings now survive early childhood malnutrition, yet exhibit continuing evidence of neurodevelopmental deficits, including poor school achievement and behavioral problems. These conditions are compounded in children who continue to be undernourished throughout the adolescent years. At present, these sequelae of malnutrition and infection are of major concern in the adolescent population, given that young people between the ages of 10 and 24 years represent nearly one-quarter of the world's population. Therefore, there is an urgent need to focus on the well-being of this age group and, in particular, on behavioral, cognitive, and brain disorders of adolescents who experienced malnutrition, infection, and inflammation prenatally, in early childhood, and during adolescence itself. Because one-third of all women globally become pregnant during their adolescent years, brain and behavioral disorders during this period can have an intergenerational impact, affecting the health and well-being of the next generation. This article summarizes the current state of knowledge and evidence gaps regarding childhood and adolescent malnutrition and inflammation and their impact on adolescent neurodevelopment, the limited evidence regarding nutrition and psychosocial interventions, and the role of resilience and protective factors in this age group. This overview should help to inform the development of new strategies to improve the neurodevelopmental outcomes of high risk adolescent populations.

Assessment of a Culturally-Tailored Sexual Health Education Program for African American Youth

African American youth are affected disproportionately by sexually transmitted infections (STIs), human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS), and teenage pregnancy when compared to other racial groups. This paper evaluates the effectiveness of the To Help Young People Establish (2 HYPE) Abstinence Club, a behavioral intervention designed to promote delayed sexual activity among African American youth ages 12-18 in Atlanta, Georgia. The intervention included 20 h of curriculum and creative arts instruction. Pre- and post-intervention survey data collected from 2008-2010 were analyzed to determine the effectiveness of the intervention. Intervention (n = 651) and comparison (n = 112) groups were compared through analysis of variance and multivariate logistic regression models. There was a statistically significant increase in intervention youth who were thinking about being abstinent (p = 0.0005). Those who had not been engaged in sexual activity were two times more likely to plan abstinence compared to participants that had been previously sexually active previously (odds ratio 2.41; 95% confidence interval 1.62, 3.60). Significant results hold implications for subsequent community-based participatory research and practice that broadens the understanding of the relevance of marriage, as just one among other life success milestones that may hold more importance to African American youth in positioning the value of delayed and responsible sexual activity towards effective STIs, HIV/AIDS, and teen pregnancy risk reduction interventions.

School-based sexual health education interventions to prevent STI/HIV in sub-Saharan Africa: a systematic review and meta-analysis

Background

School-based sexual health education has the potential to provide an inclusive and comprehensive approach to promoting sexual health among young people. We reviewed evaluations of school-based sexual health education interventions in sub-Saharan Africa to assess effectiveness in reducing sexually transmitted infections and promoting condom use.

Methods

We searched ten electronic databases, hand-searched key journals, and reference lists of included articles for potential studies. Data were extracted on outcomes, intervention characteristics, methods and study characteristics indicative of methodological quality. Where possible, data were synthesized using random effect meta-analysis. Intervention features found predominantly in effective interventions were noted.

Results

The initial search retrieved 21634 potentially relevant citations. Of these, 51 papers reporting on 31 interventions were included. No evaluation reported statistically significant effects on the incidence or prevalence of Human Immunodeficiency Virus and Herpes Simplex Virus 2 infections. However, intervention participants reported statistically significant greater condom use in both randomised controlled trials and non-randomised trials for short (less than 6 months) follow-up periods (OR = 1.62, 95 % CI = 1.03–2.55 and OR = 2.88, 95 % CI = 1.41–5.90 respectively). For intermediate (6–10 months) and long-term (more than 10 months) follow-up periods, the effect was statistically significant (OR = 1.40, 95 % CI = 1.16–1.68) and marginally significant (OR = 1.22, 95 % CI = 0.99–1.50) among the randomised trials respectively. Only 12 of the 31 interventions reported implementation details, out of which seven reported on fidelity.

Conclusion

School-based sexual health education has the potential to promote condom use among young people in sub-Saharan Africa. However, further work is needed to develop and evaluate interventions that have measurable effects on sexually transmitted infections.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3715-4) contains supplementary material, which is available to authorized users.

Behavioral Interventions for Preventing Sexually Transmitted Infections and Unintended Pregnancies: An Overview of Systematic Reviews

BACKGROUND

Countless sex education programs have been implemented worldwide in recent decades, but epidemiological data show no improvement in rates of sexually transmitted infections or unintended pregnancies.

OBJECTIVE

To summarize the evidence from higher-quality systematic reviews on the efficacy of behavioral interventions for the prevention of sexually transmitted infections and unintended pregnancies.

METHODS

We conducted an overview of reviews by selecting systematic reviews that met minimum quality criteria in terms of the design of the studies reviewed. We compared the results obtained when the effects of interventions were assessed on the basis of objective criteria (biological data) to those obtained when outcomes were assessed on the basis of subjective criteria (self-reports). The results of Cochrane and non-Cochrane reviews were also compared.

RESULTS

We identified 55 systematic reviews. No overall effect on the sexual behavior of program participants was observed in 72.5% of the reviews that used objective criteria and in 48.1% of the reviews based on subjective criteria. In the Cochrane reviews, no evidence of an overall effect was observed in 86% of reviews based on objective variables and in 70.5% of those based on subjective variables.

CONCLUSIONS

There is no evidence that behavioral interventions modify rates of sexually transmitted infections (including human immunodeficiency virus infections) or unintended pregnancies, particularly when effects are assessed using objective, biological data. Primary prevention strategies for sexually transmitted infections and unintended pregnancies need to be re-evaluated.

Addressing Unmet Sexual Health Needs among Black Adolescents with Mental Illnesses

Despite advances in HIV epidemiologic and prevention research, adolescents with mental illnesses remain a historically underserved group with respect to human immunodeficiency virus (HIV)/sexually transmitted infection (STI) prevention resources. Black adolescents with mental illnesses in particular are a relatively underserved, hidden population in the field of sexual health. Strategies and guidelines are needed to account for underlying psychopathology among Black adolescents with mental illnesses in ways that current models have yet to address. In this paper, we propose several actionable mechanisms to better integrate HIV/STI and mental health related services and activities for sexual health promotion.

A critical review of the effectiveness of educational interventions applied in HIV/AIDS prevention

OBJECTIVE

A critical review of issues around the effectiveness of educational approaches applied in the field of HIV/AIDS prevention.

METHODS

Published papers, systematic reviews and technical reports were reviewed.

RESULTS

The review has identified the large gap between the current state of the art and the ultimate goal of the education-based approaches contributing to the reduction of HIV incidence rates. Significant positive impact has been reported mainly on mediating factors to behavioural change (knowledge, attitude, and intentions). The reported impact on actual behaviour change has been weak and short-lived. Biological markers are not used in many studies as outcome measures and follow-up period is too short to facilitate the measurement of impact on behaviour change or biological markers. Several methodological flaws and cultural issues militate against effective programming. A guideline for standardising practice and research in school-based programme is available for use.

CONCLUSION

There is only very modest evidence of the effectiveness of educational interventions as a result of several gaps in project design, implementation and follow-up. There is urgent need to raise practice and research standards.

PRACTICE IMPLICATIONS

Educational interventions should utilise scientifically valid data gathering methods. Follow-up period should be long enough to allow for impact measurement.

Prevalence of Sexual Experience and Initiation of Sexual Intercourse Among Adolescents, Rakai District, Uganda, 1994-2011

PURPOSE

The purpose of the study was to identify risk factors and time trends for sexual experience and sexual debut in rural Uganda.

METHODS

Using population-based, longitudinal data from 15- to 19-year olds in Rakai, Uganda, we examined temporal trends in the prevalence of sexual experience and potential risk factors for sexual experience (n = 31,517 person-round observations) using logistic regression. We then identified factors associated with initiation of sex between survey rounds, using Poisson regression to estimate incidence rate ratios (IRR; n = 5,126 person-year observations).

RESULTS

Sexual experience was more common among adolescent women than men. The prevalence of sexual experience rose for most age-gender groups after 1994 and then declined after 2002. Factors associated with higher prevalence of sexual experience (without adjustment for other factors) included age, not enrolled in school, orphanhood, lower socioeconomic status, and drinking alcohol in the past 30 days; similar factors were associated with initiation of sex. Factors independently associated with initiation of sex included older age, nonenrollment in school (IRR = 1.7 for women and 1.8 for men), alcohol use (IRR = 1.3 for women and men), and being a double orphan among men (IRR = 1.2). Sexual experience began to decline around 2000, whereas increases in school enrollment began as early as 1994 and declines in orphanhood occurred after 2004 (as antiretroviral therapy became available).

CONCLUSIONS

Sexual experience among youth in Rakai was associated with social factors particularly school enrollment. Changes in these social factors also appear to influence change over time in sexual experience.

Rethinking HIV prevention to prepare for oral PrEP implementation for young African women

INTRODUCTION

HIV incidence remains high among young women in sub-Saharan Africa in spite of scale-up of HIV testing, behavioural interventions, antiretroviral treatment and medical male circumcision. There is a critical need to critique past approaches and learn about the most effective implementation of evidence-based HIV prevention strategies, particularly emerging interventions such as pre-exposure prophylaxis (PrEP).

DISCUSSION

Women in sub-Saharan Africa are at increased risk of HIV during adolescence and into their 20s, in part due to contextual factors including gender norms and relationship dynamics, and limited access to reproductive and sexual health services. We reviewed behavioural, behavioural economic and biomedical approaches to HIV prevention for young African women, with a particular focus on the barriers, opportunities and implications for implementing PrEP in this group. Behavioural interventions have had limited impact in part due to not effectively addressing the context, broader sexual norms and expectations, and structural factors that increase risk and vulnerability. Of biomedical HIV prevention strategies that have been tested, daily oral PrEP has the greatest evidence for protection, although adherence was low in two placebo-controlled trials in young African women. Given high efficacy and effectiveness in other populations, demonstration projects of open-label PrEP in young African women are needed to determine the most effective delivery models and whether women at substantial risk are motivated and able to use oral PrEP with sufficient adherence to achieve HIV prevention benefits.

CONCLUSIONS

Social marketing, adherence support and behavioural economic interventions should be evaluated as part of PrEP demonstration projects among young African women in terms of their effectiveness in increasing demand and optimizing uptake and effective use of PrEP. Lessons learned through evaluations of implementation strategies for delivering oral PrEP, a first-generation biomedical HIV prevention product, will inform development of new and less user-dependent PrEP formulations and delivery of an expanding choice of prevention options in HIV prevention programmes for young African women.

HIV testing and linkage to services for youth

Introduction

HIV testing is the portal to serostatus knowledge that can empower linkage to care for HIV treatment and HIV prevention. However, young people's access to HIV testing is uneven worldwide. The objective of this paper is to review the context and concerns faced by youth around HIV testing in low- as well as high-income country settings.

Discussion

HIV testing is a critical entry point for primary and secondary prevention as well as care and treatment for young people including key populations of vulnerable youth. We provide a framework for thinking about the role of testing in the continuum of prevention and care for young people. Brief case study examples from Kenya and the US illustrate some of the common barriers and issues involved for young people.

Conclusions

Young people worldwide need more routine access to HIV testing services that effectively address the developmental, socio-political and other issues faced by young women and men.

Providing comprehensive health services for young key populations: needs, barriers and gaps

INTRODUCTION

Adolescence is a time of physical, emotional and social transitions that have implications for health. In addition to being at high risk for HIV, young key populations (YKP) may experience other health problems attributable to high-risk behaviour or their developmental stage, or a combination of both.

METHODS

We reviewed the needs, barriers and gaps for other non-HIV health services for YKP. We searched PubMed and Google Scholar for articles that provided specific age-related data on sexual and reproductive health; mental health; violence; and substance use problems for adolescent, youth or young sex workers, men who have sex with men, transgender people, and people who inject drugs.

RESULTS

YKP experience more unprotected sex, sexually transmitted infections including HIV, unintended pregnancy, violence, mental health disorders and substance use compared to older members of key populations and youth among the general population. YKP experience significant barriers to accessing care; coverage of services is low, largely because of stigma and discrimination experienced at both the health system and policy levels.

DISCUSSION

YKP require comprehensive, integrated services that respond to their specific developmental needs, including health, educational and social services within the context of a human rights-based approach. The recent WHO Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations are an important first step for a more comprehensive approach to HIV programming for YKP, but there are limited data on the effective delivery of combined interventions for YKP. Significant investments in research and implementation will be required to ensure adequate provision and coverage of services for YKP. In addition, greater commitments to harm reduction and rights-based approaches are needed to address structural barriers to access to care.

HIV infection duration, social support and the level of trauma symptoms in a sample of HIV-positive Polish individuals

The aim of this study was to investigate the relationship between the average HIV infection duration and the level of quantitatively rated post-traumatic stress disorder (PTSD) symptoms and social support dimensions in a sample of 562 Polish HIV+ adults. Possible moderating effects of social support on the relationship between the average HIV infection duration and the level of PTSD symptoms were also analysed. The results of this study suggest that the average HIV infection duration may intensify PTSD symptoms and deteriorate the perceived availability of social support in HIV+ individuals. However, a positive relationship between HIV infection duration and the level of trauma symptoms was observed only in the group of HIV+ individuals with low perceived available social support, but not in the group of HIV-infected individuals with high perceived available social support. This research provided some new insight into the psychological and social aspects of living with HIV. In particular, our results suggest that although HIV infection duration may intensify trauma symptoms and deteriorate social support, perceived available social support may act as a buffer against HIV-related trauma symptoms.

Evidence-based programming for adolescent HIV prevention and care: operational research to inform best practices

BACKGROUND

Globally, a staggering number of adolescents, approximately 2.1 million, were estimated to be living with HIV in 2012. Unique developmental, psychosocial, and environmental considerations make them particularly vulnerable to HIV acquisition and argue for a comprehensive response to address this burgeoning problem.

METHODS

This article explores the current state of the science of HIV prevention, treatment, and care for adolescents and identifies opportunities to address knowledge gaps and improve health outcomes for this age group.

RESULTS

Over the past decade, several important milestones have been achieved in HIV prevention and care among adults, and despite evidence that adherence to care and medications among affected adolescents is significantly compromised, critical research among adolescents and young adults substantially lags behind. Operational research, in particular, is crucial to understanding how to use effective services and interventions for HIV prevention and care safely and effectively for adolescents who are in dire need.

CONCLUSIONS

Operational research among adolescent populations affected by HIV is critically needed to close the knowledge and investment gaps, and scale-up efforts for HIV prevention, treatment, care, and support for this vulnerable age group.

Executive summary: opportunities for action and impact to address HIV and AIDS in adolescents

INTRODUCTION

The global HIV epidemic in adolescents is not controlled, and this group has not received sufficient attention in programming and research efforts addressing HIV prevention, treatment, and care.

METHODS

A global technical consultation on adolescents and HIV addressing services and research gaps was convened by United Nations Children's Fund and the London School of Hygiene and Tropical Medicine in July 2013. Proceedings from this meeting are presented in this issue of the Supplement.

RESULTS

Several reviews highlight poor levels of coverage of critical HIV prevention, treatment, and care interventions for adolescents, disparities in HIV prevalence among adolescent girls, and low-risk perceptions associated with risk behaviors among key risk groups. Others underscore the significance of clear national targets and strengthening data, government involvement, enhanced systems capacity and policy, engagement of community and adolescent social networks, and of mobile and internet technologies to the success of interventions for adolescents. Finally, reviews identified several efficacious interventions for adults that could benefit from operational research to inform optimizing implementation in adolescents and how to do so with maximal cost efficiency and impact on the epidemic.

CONCLUSIONS

Addressing the adolescent gap in the response to the HIV epidemic is essential to a more sustainable and effective response and is critical to overall adolescent health and well-being. The global community has the means and the responsibility to put measures in place to make AIDS-free survival the reality for children in this second decade of life.

The impact and cost of the HIV/AIDS investment framework for adolescents

BACKGROUND

In 2005, the resources needed to support orphans and vulnerable children in sub-Saharan Africa were estimated at US$ 1.1-4.1 billion. Approaches to support vulnerable children have changed considerably since then. This study updates previous estimates by including new types of support and information on support costs.

METHODS

We considered 16 types of support categorized as economic strengthening, education support, social care and community outreach, and program support. The estimates combine the number of children in need of each intervention with unit costs derived from the literature and coverage goals based on current coverage and feasible future improvements.

RESULTS

The number of children affected by AIDS in low- and middle-income countries varies from 58 million to 315 million depending on the definition of need. The resources required to provide support to children living in poor households will grow from US$ 4.2 billion in 2012 to US$ 5-8 billion by 2020. Almost two-thirds of these resources will be needed for Sub-Saharan Africa. The largest needs are for cash transfers, community care workers, early childhood development, block grants for education, M&E monitoring and evaluation, and direct material support.

DISCUSSION

The results show that we can significantly improve the coverage of services for vulnerable children with only modest increases in resources. This results from stable or declining numbers of orphans and children living with HIV plus economic growth that is moving more households out of poverty. The results also reflect an important shift toward providing support to strengthen families and communities that care for children rather than direct material support.

CONCLUSION

More resources are required to support children affected by AIDS, but new approaches to provide that support will be cost effective and have broad social and economic benefits.