Achieving the Global Goals: Access to Services

This 81-page technical report is one outcome of a global World Health Organization (WHO) consultation on the health services response to the prevention and care of HIV among young people, worldwide. Organised in collaboration with UNAIDS, UNFPA, UNICEF, and YouthNet, this March 2003 consultation in Montreux, Switzerland "sought to obtain consensus around evidence-based health service interventions for the prevention and care of HIV among young people; effective strategies for delivering these interventions, the essential characteristics of successful programmes; and the strategic partnerships and actions at global and regional levels that will be required to stimulate and support action in countries."

The consultation's focus on the role of young people was motivated by evidence that "young people are at the heart of the HIV/AIDS pandemic in terms of transmission, impact and potential for change. Available data indicate that more than half of those newly infected with HIV are young people aged 15-24 years, which amounts to 6000 new infections among young people every day, and nearly 12 million of the HIV infected people globally are 15-24 years old, of whom approximately 7.3 million are female."

In this context, participants in the consultation sought to establish how different partners might help to increase young people's access to the interventions known to be most effective, focusing on information and counselling; condoms; testing, treatment and care for sexually transmitted infections (STIs) and HIV; and harm reduction, through trained providers in a variety of settings. There is an emphasis on youth participation, and on the use of communication (such as social marketing) to mobilise youth to use services. Each strategy is analysed with reference to particular examples of programmes in practice, and with a bullet-point list of recommendations gleaned from the evaluation/consultation.

The consultation itself drew on a range of methods such as plenary presentations and discussions, visualisation in participatory programmes (VIPP) techniques, and group discussion with feedback to plenary that aimed to take advantage of the wide technical and operational experiences of the participants and facilitate their full participation. Background papers commissioned specifically for the meeting set out to examine the available evidence, organised into one of 5 levels of strength. The primary outcome that was examined in all of the reviews was the incidence of HIV infection among young people. However, behavioural outcomes such as condom use at last sex, reported numbers of partners, and frequency of partner change or the incidence of other STIs were used as proxy indicators for the likely effect upon HIV transmission.

Excerpts from the Executive Summary follow

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"Participants attending the consultation emphasized the important role that the health sector has to play, and stressed that to date there has been inadequate attention and insufficient resources directed to developing and strengthening this. The interventions that are provided through health services need to be seen within the context of other priority activities of the health system, such as collecting, analysing and using the data necessary for programmes, policies, and advocacy, and contributing to and disseminating the evidence base that needs to underpin supportive policies for effective programmes. They also need to be seen within the context of the activities of other sectors, for some of which the health sector will need to play a mobilizing and supportive role.

Based on background papers that were prepared for the meeting and the subsequent discussions, it was agreed that there was evidence for effectiveness for a number of interventions that could be delivered though a range of different service providers. These included information and counselling, to contribute to young people's acquisition of knowledge and skills; condoms for sexually active young people; STI treatment and care; harm reduction measures to decrease transmission through IDU [injecting drug use]; and access to HIV testing, care and support. All of these interventions have been demonstrated to have an effective role in reducing HIV transmission and meeting the needs of young people for prevention and care, in a variety of settings. Participants agreed that young people have a right to, and need for equitable access to these interventions, regardless of sex, age, marital status or other socio-culturally-defined variables, and regardless of the prevalence of HIV. Although the precise intervention mix is likely to vary depending on a range of factors including the epidemiology of HIV and the priority target groups (based on behavioural, developmental or socio-economic and demographic characteristics), services for young people should at a minimum comprise some or all of the above interventions.

In addition to agreeing on the core evidence-based health service interventions, the consultation outlined effective strategies for delivering these interventions, that consider the diversity of young people and their needs, different settings, different target groups and different scenarios in terms of the phase of the epidemic and the available infrastructures and resources. These delivery strategies included strengthening existing health facilities, the use of peer and non-peer outreach, social marketing, social franchising, voucher schemes, and greater involvement of the private sector.

The key characteristics required to ensure that services are more responsive to the specific needs of adolescents, or 'adolescent friendly', were reviewed and endorsed by participants. Guiding principles for the effective delivery of priority interventions include attention to health system issues, for example giving adequate attention to improving the skills of service providers, and making sure that facilities are accessible to, and used by young people, based on their health seeking behaviours; the meaningful participation of young people, parents and other community members in providing and supporting the services; and giving adequate attention to supervision and supplies as a basis for taking effective interventions to scale. Participants emphasized that when talking about adolescent or youth-friendly services, this was not a call for parallel services, but for the services that are being provided to be more responsive to the specific needs of young people.

The priority health services for the prevention and care of HIV/AIDS among young people need to build on and contribute to other on-going health services for young people directed to their health and development, including sexual and reproductive health. It will be important to link these interventions to efforts to achieve the MDGs on maternal and child mortality, both of which have important implications for adolescents, dual protection, and related problems such as drug and alcohol use and gender-based violence. Because there is a sense of urgency and political commitment to responding to HIV/AIDS in many countries and globally, including the 3-by-5 commitment made by WHO and partners, it is likely to provide an important entry point for developing services for young people, both for the general population of young people and for neglected and particularly vulnerable groups.

If the activities of the range of partners who need to contribute to the prevention and care of HIV/AIDS among young people are to be mobilized and coordinated at national level, it will be important to transform the global goals into more specific and operational national targets. This will not only provide focus for the various partners who need to be involved, but will also help mobilize resources and provide local and national pressure for accelerated action. Such targets can only be determined at country level, but participants were able to develop indicative targets during the consultation, in order to provide a focus for the discussions, and these can be further developed as a basis for accelerated action in countries....Policy makers, planners and programme managers need to ensure that service providers and facilities operating at district and national level are equipped, and have the capacity to deliver effective interventions to reduce new HIV infections among young people, and better respond to the needs of those already HIV infected.

Specific recommendations were made for global and regional activities that would support the implementation of the priority evidence-based interventions outlined during the consultation (prevention and decreasing risk through information and counselling, condoms and harm reduction; and the testing and treatment of STIs and HIV/AIDS). These ranged from advocacy and resource mobilization, through the development of specific programme support tools and capacity development, to the need to support on-going evaluations and operations research. Health and development partners now need to focus their resources around these priority interventions, taking into consideration both the available evidence base and the growing experiences of people charged with developing the health sector response to HIV among young people. Improving overall collaboration and focus among key UN partners and international donors to assist countries accelerate focused action will remain a challenge..."