Increasing Access to Services
While the literature on access to HIV services by adolescents is limited, the literature on access to sexual and reproductive health services more broadly demonstrates that youth-friendly approaches can increase use of reproductive health care services by female adolescents (Neukom and Ashford, 2003). Young people’s service needs are frequently overlooked in HIV programming that is not specifically for young people. Numerous studies in developing countries show that adolescents under the age of 15 are sexually active. For example, in sub-Saharan Africa, adolescent girls under age 15 are 50% more likely than boys to be sexually active (UNAIDS, 2008). A nationally representative sample of youth in South Africa found that 18% of young men and 8% of young women said they had had sex for the first time at age 14 or younger (Pettifor et al., 2009). As a result of a 2002 study of Zambian secondary school students, Warenius et al. (2007) noted that although “government policy in Zambia states that all sexually active men and women should have access to reproductive healthcare and information…in practice, young people have limited access to such services” (p. 534). Increasing services for adolescents need not reinvent the wheel, however; “strengthening the health care system to better serve adolescents requires taking a strategic look at ways to build capacity within the existing system, rather than creating a parallel structure focused only on adolescents” (Boonstra, 2007). [See also Chapter 13. Structuring Health Services to Meet Women’s Needs]
Policy and Legal Barriers to Access Must be Overcome
Policy and legal barriers often prevent young people from accessing services. Many health services will not provide sexual and reproductive health services to unmarried women. In most countries, young people under the age of 18 need parental consent to obtain medical care, including VCT, despite the fact that counseling and testing can lead young people to change their behavior and many youth are sexually active before age 18. Laws that require providers to seek parental consent before testing minors or to provide test results to parents may make adolescents reluctant to seek services. Adolescents must feel comfortable accessing necessary services in order to protect themselves from HIV. Surveys of nearly 20,000 adolescents in Burkina Faso, Ghana, Malawi and Uganda found that adolescents prefer services from clinics and hospitals rather than traditional healers and pharmacies but are often embarrassed or too shy to seek them out (Biddlecom et al., 2007).
Disaggregated Data Is Needed
Effective programs for young people need to understand how young people use services and what other barriers (e.g., community and provider attitudes) must be overcome. “Effectiveness is hindered by the lack of systematic attention to gender in designing programmes for most-at-risk young people. Most countries do not have accurate data on the population of young men and women, nor do they maintain records by sex of young people’s use of services” (UNFPA Inter-Agency Task Team on HIV and Young People, 2008: 4). To ensure an accurate picture of the sexual and reproductive health needs of young people, basic data on adolescents should be disaggregated by gender with more precise age groups, such as ages 10–11; 12–14; 15–17; and 18–19 (Dixon-Mueller, 2007). In addition, data should be disaggregated by marital status, as access to services and sexual behaviors differ in many countries based on marital status.
Access to HPV Vaccinations May Benefit Girls Who Become HIV-Positive Later in Life
A 2007 meta-analysis found that HPV infection is much more prevalent in women with HIV (De Vuyst and Franceschi, 2007). Clinical trials are underway to assess HPV vaccination in perinatally infected HIV-positive adolescents. Vaccination against HPV strains 16 and 18 is effective and these strains cause approximately 70% of cervical cancers worldwide (The Future II Study Group, 2007). However, HPV vaccines do not protect against all types of HPV strains that cause cancer and therefore, all women, even those who have received the HPV vaccine, should still get regular pap smears or screening for cervical cancer. It is critical to assess if the HPV vaccine will demonstrate efficacy for longer than five years (Kim and Goldie, 2008 cited in Rothman and Rothman, 2009). HPV vaccination for adolescent girls has been rolled out in some countries in the Global North and initial efforts are underway to roll out HPV vaccinations for young girls in some countries in the Global South. Vaccinating young girls against HPV may provide additional protection against cervical cancer, particularly if the young women acquire HIV as they get older. Studies have shown a higher rate of cervical cancer among women living with HIV. Increasing access to HPV vaccinations is therefore an important service for young women. [See also Chapter 8. Meeting the Sexual and Reproductive Health Needs of Women Living With HIV]