Introduction Access to Health Services for Young People for Preventing HIV and Improving Sexual and Reproductive Health

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1 Introduction Access to Health Services for Young People for Preventing HIV and Improving Sexual and Reproductive Health HIV infections among young men and women (aged years old 1 ) accounted for 4% of all new infections in 26 (1). Ensuring access to health services that address HIV 2 and sexual and reproductive health issues, continues to be an important component of the national response to meet the needs of young people, the majority of whom lack access to effective prevention programmes, including condoms (2). The Declaration of Commitment on HIV/AIDS, adopted by the United Nations General Assembly Special Session (UNGASS) on HIV in 21, included a specific goal for the coverage of interventions for young people: UNGASS on HIV/AIDS GOAL for YOUNG PEOPLE: By 25: ensure that at least 9% and by 21 at least 95% of young men and women,15 24, have access to information, education including peer and youth-specific HIV education and services necessary to develop the life skills required to reduce their vulnerability to HIV infection. In addition, the UNGASS Declaration on Children in 22 included the same goal as the International Conference on Population and Development (ICPD) at its 5th anniversary in In its 1 WHO defines young people as 1 24 years old. The currently available data that is provided in this document is for years olds, who are defined as youth. However, for advocacy reasons, in keeping with the UNGASS Declaration of Commitment where the wording used is young men and women all indicators reported for year olds in this documents will be reported for young people. 2 This essential package identified at an international consultation in Montreux in 23, includes the following: information and counselling, to contribute to young people s acquisition of knowledge and skills condoms for sexually active young people sexually transmitted infection (STI) treatment and care harm reduction measures to decrease transmission through injecting drug use access to HIV testing, care and support. five-year review and appraisal of the implementation of the ICPD Programme of Action, the UN General Assembly stated that: governments should... provide appropriate, specific, user-friendly and accessible services to address effectively their reproductive and sexual health needs, including reproductive health education, information, counselling and health promotion strategies. 3 In order to report on progress in achieving these combined goals, consensus on indicators was needed. The Department of Child and Adolescent Health and Development, World Health Organization (CAH/WHO), organized a technical consultation on Measuring Coverage of Health Services for Young people, in April 26, in Geneva. Participants (UN and international technical partners) proposed that 3 indicators be used at the global level and 6 indicators at the national level to measure the coverage of health services for young people. The global-level indicators are for monitoring in all countries, while the national-level indicators are proposed for use within countries in order to provide more comprehensive information on the coverage achieved. A prime consideration in the selection of indicators was that they coincide with those that are already being collected by Demographic and Health Surveys (DHS), and other multi-country surveys (see Table 1 for the indicators proposed). Two of the global indicators (Indicators 2 and 3) are included in the list for monitoring the UNGASS Declaration of Commitment on HIV/AIDS. WHO will also use these two indicators for monitoring the health sector response to scaling up efforts towards universal access (UA) to HIV prevention, treatment and care, in line with its commitment at the 59th World Health Assembly in 26, to report annually on progress 4. For most-at-risk populations of young people (MARYP), most of the nine indicators identified for general populations also apply, as noted where relevant in Tables 1a b. However, three additional indicators (nos 1 to 12) were also selected for monitoring the coverage of services specifically for MARYP, as noted in Table 1c. 3 UNGA 24, Para 73a 4 WHO s commitment to the World Health Assembly, May 26. 1

2 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH Indicators 11 and 12 are also included in the list for monitoring the UNGASS Declaration of Commitment on HIV/AIDS. Indicators 1 to 12 were selected for monitoring the access of young people to health services, principally for preventing HIV. However, four additional indicators (nos 13 to 16) have also been recently included for measuring universal access to reproductive health. These indicators were identified as a follow-up to the UN General Assembly s adoption in 26 of the Secretary General s report recommending the inclusion of a target to achieve universal access to reproductive health under Millennium Development Goal 5, aimed at improving maternal health. The WHO Department of Reproductive Health and Research, World Health Organization (RHR/WHO), organized a technical consultation with the United Nations Population Fund (UNFPA), to identify indicators critical for measuring the achievement of universal access to reproductive health in March 27. This resulted in the identification of indicators 13 to 16, for measuring universal access to reproductive health, which were subsequently approved by the UN General Assembly in its 27 session (3). This set of 16 indicators and the available data for them are presented as fact sheets to summarize the information currently retrievable electronically from internationally comparable data on access to health services for young people. These indicators have been classified according to the Tanahashi Framework in order to describe varying stages of service coverage (4). The Tanahashi Framework (see Figure 1) defines the stages of measuring coverage of health services as: availability, accessibility, acceptability, contact and effectiveness of client services. 1. Availability: The percentage of a population for whom the service or intervention is available. 2. Accessibility: The percentage of a population who can reach and use the service. 3. Acceptability: The percentage of a population who are willing to use the service. 4. Contact: The percentage of a population who actually use the service. 5. Effectiveness: The percentage of a population who receive effective services. (Data on effectiveness coverage are currently not available for young people, and are not included in this document). Figure 1: The Tanahashi Framework Tanahashi framework for measuring coverage of health services Effective Contact Acceptable Accessible Available SOURCE REF. Tanahashi 1978 (4) DEFINITION OF COVERAGE Coverage of health services for HIV prevention for young people: The number of young people aged years for whom services are available/ accessible/acceptable or being used by them, of all young people aged years, surveyed. The number of respondents aged years who know about health services they could use, are willing and able to use them, and have used them The total number of respondents aged years. 2

3 Methodology used to prepare accompanying fact sheets A search was conducted for internationally comparable data from 2 to 25 for the 16 indicators. The principal data sources were AIDS Indicator Surveys (AIS) and DHS, with Behavioural Surveillance Surveys (BSS) and other sources being identified where available and relevant. For AIS/DHS data, the STATcompiler database was used. Additional data for these indicators are available for specific countries from other international data sources (e.g. Pan Arab Project for Family Health) which we were not able to access in the time available, but that will be included in subsequent updates. Moreover, data from nationally representative surveys that countries may have undertaken were not included unless they were available in the electronic data sources for AIS, BSS, DHS or Joint United Nations Programme on HIV/AIDS (UNAIDS) publications. Most of the data compiled corresponds to all young men and women, unless otherwise noted. For example, data for Indicator 16 (Unmet need for family planning) includes only currently married women, while Indicator 13 (Contraceptive prevalence) includes currently married and unmarried sexually active women. Data from the monitoring of UNGASS targets were also included when available. The accompanying fact sheets are for use by advocates and programme managers in countries, for planning and monitoring implementation of programmes to improve access to health services and reproductive health for adolescents and young people. Tables 1a-d provide brief summaries of the 16 indicators presented in the fact sheets, organized according to the Tanahashi stages of coverage and whether they are recommended for global- or national-level assessment. The tables also indicate whether given indicators are recommended for use in settings with generalized and/or concentrated epidemic. Table 1c lists the additional indicators for concentrated epidemics while Table 1d lists the four indicators approved for monitoring universal access to reproductive health. Global Indicators Table 1a summarizes the information currently available (for 2 25) for Indicators 1, 2 and 3, which were selected as global indicators for monitoring in all countries. The selection of these three global indicators was based on consideration of the Expanded Programme on Immunization (EPI) model of coverage assessment, which focuses on immunization coverage (contact coverage) and the availability of vaccines (availability coverage). Using similar logic, and in the interest of keeping a minimum number of indicators for global comparisons, one availability coverage indicator and two contact coverage indicators were selected. The global availability coverage indicator was selected from among two such indicators included among the nine indicators recommended for use in settings with generalized HIV epidemics. These are: a) the availability of youth-friendly health services (YFHS); and, b) the availability of condoms. The term YFHS denotes efforts to improve the access to and quality of health service delivery to young people. The choice of a global indicator from these two options was made on the basis of their likelihood to promote or increase access to health services for young people. While condom availability is considered important to monitor in countries, in order to ensure a sufficient supply of essential condoms, it is not clearly linked to increased condom use, particularly by young people. On the other hand, emerging data suggests that the availability of YFHS could result in increased utilization of health services by young people. Therefore, for global monitoring of availability coverage, Indicator 1 was selected to indicate the availability of YFHS. The other availability coverage indicator on condom availability, is to be monitored at the national level (as Indicator 4). Indicator 1 is a new indicator for which very little data currently exists, but from an advocacy perspective, its selection as a global indicator also serves to highlight the increased need for collecting such information and consequently for ensuring the availability of such services. The two other global indicators, Indicator 2 (Condom use for the last higher-risk sex) and Indicator 3 (Use of testing and counselling services for HIV), were selected as the contact coverage indicators to monitor in all countries. Indicator 2 (condom use) was selected as an important global indicator of dual protection against HIV/ STIs and unwanted pregnancies, and is the one for which data is available from the largest subset of countries (approximately 45 countries) when compared with the other 15 indicators for the time period Monitoring the condom use rate data for young people is increasingly possible from countries, following ICPD +5 in 1999 and the HIV/AIDS UNGASS in 21. Data on use of testing and counselling services for HIV (HTC; Indicator 3) is scarce. The HTC use was nevertheless selected as a global indicator of access because it is a relatively new but important intervention in the context of generalized epidemics, and one for which coverage needs to be scaled up, particularly for young people in sub-saharan Africa. The health sector should be responsible for promoting, supporting and providing condoms and HTC services to young people, although health facilities are not the only appropriate location for their provision. Indicators 2 and 3 are also to be reported on annually by all countries to UNAIDS and WHO, starting in January 28, towards monitoring the 21 UNGASS and other universal access global targets. National Indicators Table 1b summarizes the information available (for 2 25) for the six additional indicators identified for national-level coverage monitoring (Indicators 4 to 9). In accordance with the Tanahashi Framework, Indicators 4 to 7 are for monitoring condom availability, knowledge of their availability, their accessibility, as well as HTC accessibility for young people. These indicators complement global contact coverage indicators 2 and 3 (described above) 3

4 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH by providing additional information for programme managers on some of the determinants of condom and HTC service use by young people. Finally, two other contact coverage indicators were also selected for national-level monitoring: Indicator 8 monitors the use of specified health services; and Indicator 9 assesses STI treatment as reported by young people with symptoms of STIs. HIV prevention services The nine indicators summarized in Tables 1a and b include several indicators for monitoring HIV prevention services for all young people. These services are: information and counselling, to contribute to young people s acquisition of knowledge and skills condoms for sexually active young people STI treatment and care access to HIV testing, care and support harm reduction measures to decrease transmission through injecting drug use (IDU). Although the provision of information and counselling services for young people is not primarily the responsibility of the health sector, provision of youth-friendly health services (Indicator 1) also provides potential access for young people to service providers who are trained to present health-related information, as well as counselling, regarding specific behaviours and health needs. Indicators 2, 4, 5 and 7 track condom use, availability, knowledge of sources of condoms and the reported ability to get condoms. Indicators 3 and 6 provide information on HTC service use and knowledge about the availability of such services. Indicator 9 tracks young people who report seeking treatment for symptoms of STIs. Most-at-risk young people (MARYP) Data for particularly vulnerable groups, including injecting drug users (IDUs), sex workers and men who have sex with men (MSM), are scarce and, where they are available, are mostly not disaggregated by age. There are more data related to most-atrisk young people than this review has been able to document. This has been collated through specific country-level surveys of behaviours, through the mapping of hotzones and hotspots by Population Services International (PSI) and by the PLACE method (Priorities for Local AIDS Control Efforts) protocol developed by MEASURE Evaluation. Thus, as listed in Tables 1a and b, data on condom use among MSM and IDUs are documented as Indicators 2a and 2b respectively. In the case of IDUs, data are only available for those younger than (or older than) 25. Table 1c, which contains some additional data for MARYP, notes that data availability on safe injecting practices (Indicator 12) is combined with Indicator 2a on condom use. Where data are available for coverage of prevention services among MARYP (Indicator 11), it is not age-disaggregated. Reproductive health indicators Table 1d summarizes the data available for the four indicators (13 to 16) that monitor universal access to reproductive health services. For all four indicators, data are available for about 33 countries. These reproductive health indicators are routinely collected in DHS surveys and provide data on young women. For this review, other data sources (e.g. PAPFAM) were not specifically reviewed unless they were included in the STATcomplier database of Macro International Inc. Concluding comments This fact sheet brings together the secondary data available for selected coverage indicators from multiple countries, principally from DHS/AIS data available through the STATcompiler database and the HIV/AIDS indicators database, which have the advantage of using a standardized methodology for data collection. The coverage indicators and their corresponding data presented in summary here and in further detail in the accompanying fact sheets, represent consensus among partners on the important factors to monitor in order to estimate the coverage of health services for young people. This is important for young people not only for HIV prevention and treatment, but also to prevent too early and unwanted pregnancies, unsafe abortions and maternal mortality. This is a step in the process of improving services for young people, including availability, quality and accessibility. But until each of these steps can be tracked with relevant age and sex disaggregation, opportunities to improve the lives of a significant proportion of the population will continue to be missed. The coverage indicators presented here according to availability, accessibility, acceptability and contact with health services provide a progressive picture of the stages of service provision that are intended to improve utilization (contact) of health services. The results presented in the fact sheets are for the time period 2 25, including HIV-related indicators from UNGASS reports prepared by countries in collaboration with UNAIDS. With this scope, it is not surprising that data for the reproductive health indicators were available from countries and for the condom use indicator from 45 countries. In order to improve data availability, in 28, countries are asked to report on data for selected indicators for the UNGASS reporting process supported by UNAIDS, the WHO-supported reporting process on universal access to prevention, treatment, care and support for HIV and UNFPA/WHO-supported reporting on universal access to reproductive health. For this report, the review and documentation of data (albeit incomplete) demonstrated that for the time period 2 25: Internationally comparative data for young people are quite scarce, with data for only 5 of the 16 indicators available for more than 3 countries. Data for the reproductive health indicators (nos ) are more prevalent across countries than for the HIV prevention indicators (other than for condom use for last higher-risk sex, no. 2). 4

5 Table 1a. List of global indicators for monitoring access to health services for young people GLOBAL INDICATORS for GENERALIZED HIV EPIDEMIC GLOBAL INDICATORS for CONCENTRATED HIV EPIDEMICS Indicator No. Indicator Tanahashi classification Data availability Indicator No. Indicator Tanahashi classification Data availability 1. INSTITUTIONALIZING YOUTH-FRIENDLY HEALTH SERVICES AVAILABILITY COVERAGE 12 countries Data from Service Availability Mapping (SAM) not yet available for dissemination, but in process of clearance in countries; Additional data sources from Service Provision Assessments undertaken in 1 countries (SPA, undertaken by Macro International) have not been reviewed. 2. CONDOM USE BY YOUNG PEOPLE AT LAST HIGHER-RISK SEX CONTACT COVERAGE 43 countries: Males : 16 85% Females : % Data from UNGASS & DHS. Males : 2 89% Females : 2 68% Males 2 24 : 15 86%. Females 2 24 : 4 68% Data from DHS/AIS/BSS and other 2A 2B 2C CONDOM USE AMONG YOUNG INJECTING DRUG USERS (IDUs) WHO HAD SEX IN THE PAST ONE MONTH CONDOM USE DURING ANAL SEX AMONG YOUNG MEN WHO HAVE SEX WITH MEN (MSM) CONDOM USE AMONG YOUNG SEX WORKERS CONTACT COVERAGE (See indicator 12 below) 11 countries: Males <25 : % Data are available from UNGASS for all these three groups of most at risk populations but as they have not been disaggregated by age, and could not be quoted here 3. HIV TESTING BEHAVIOUR AMONG YOUNG PEOPLE CONTACT COVERAGE 23 countries: Males : 1 13% Females : 1 27% Males 2 24 : % Females 2 24 : 1 22% 3A 3B 3C HIV TESTING BEHAVIOUR OF IDUs HIV TESTING BEHAVIOUR OF MSM HIV TESTING BEHAVIOUR OF SEX WORKERS CONTACT COVERAGE Data are available from UNGASS for all these three groups of most at risk populations, but not disaggregated by age and therefore are not presented here. 5

6 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH Table 1b. List of national indicators for monitoring access to health services for young people GLOBAL INDICATORS for GENERALIZED HIV EPIDEMIC GLOBAL INDICATORS for CONCENTRATED HIV EPIDEMICS Indicator No. Indicator Tanahashi classification Data availability Indicator No. Indicator Tanahashi classification Data availability 4. CONDOM AVAILABILITY FOR YOUNG PEOPLE AVAILABILITY COVERAGE PSI has been mapping condom availability in 36 countries. The data will be available soon. 4A 4B 4C CONDOM AVAILABILITY FOR YOUNG PEOPLE MOST AT RISK: IDUs MSM SEX WORKERS AVAILABILITY COVERAGE 5. KNOWLEDGE OF A FORMAL SOURCE OF CONDOMS AMONG YOUNG PEOPLE ACCESSIBILITY COVERAGE 29 countries: Males : 14 97% Females : 6 92% Males 2 24 : 5 92% Females 2 24 : 8 94% 6. ACCESSIBILITY TO HTC SERVICES BY YOUNG PEOPLE ACCESSIBILITY COVERAGE 6 countries: Males and Females : 51 72% 6A 6B 6C ACCESSIBILITY OF HTC BY YOUNG IDU ACCESSIBILITY OF HTC SERVICES BY YOUNG MSM ACCESSIBILITY OF HTC SERVICES BY YOUNG SEX WORKERS ACCESSIBILITY COVERAGE 7. ACCESSIBILITY TO CONDOMS BY YOUNG PEOPLE ACCESSIBILITY COVERAGE 17 countries: Males : 27 95% Females : % Males 2 24 : % Females 2 24 : % 8. USE OF SPECIFIED HEALTH SERVICES BY YOUNG PEOPLE CONTACT COVERAGE Data currently not available 8A 8B 8C USE OF SPECIFIED HEALTH SERVICES BY MOST AT RISK YOUNG PEOPLE: IDUs MSM SEX WORKERS 9. YOUTH SEEKING TREATMENT FOR STIs CONTACT COVERAGE 18 countries: Males : 9 68% Females : 26 64% Males 2 24 : 32 65% Females 2 24 : 17 73% 9A 9B 9C MOST AT RISK YOUNG PEOPLE SEEKING TREATMENT FOR STIs: IDUs MSM SEX WORKERS 6

7 Table 1c. List of additional indicators for monitoring access to health services for most-at-risk young people (MARYP) Indicator No. Indicator Tanahashi classification Data availability 1. INTERVENTION SITES WITH MINIMUM PACKAGE OF HIV PREVENTION SERVICES IN HOTSPOTS WHERE MARYP CONCENTRATE AVAILABILITY COVERAGE Data currently not available 11. MARYP REACHED BY HIV PREVENTION SERVICES CONTACT COVERAGE Data are available from UNGASS for all three groups of most-atrisk populations, but not disaggregated by age, and therefore are not presented here. 12. NO SHARING OF NEEDLES BY YOUNG IDUs CONTACT COVERAGE Data combined with indicator 2a 5 countries: Males <25 : % Females <25 : % Table 1d. List of reproductive health indicators for monitoring access to health services for young people Indicator No. Indicator Tanahashi classification Data availability 13. CURRENT USE OF MODERN CONTRACEPTIVES BY YOUNG WOMEN (currently married as well as those unmarried but sexually active) CONTACT COVERAGE 34 countries: Females : % Females 2 24 : % 14. ANTENATAL CARE AT AGE LESS THAN 2 YEARS CONTACT COVERAGE 33 countries: Females <2 : Visit doctor: % Visit other health professional: % Visit traditional birth attendant:.1 7.4% Visit other:.1 6.7% No antenatal care: % Missing:.1.7% 15. AGE-SPECIFIC FERTILITY RATE FOR YOUNG WOMEN OUTCOME INDICATOR 34 countries: Females : births Females 2 24 : births 16. UNMET NEED FOR FAMILY PLANNING AMONG YOUNG WOMEN CURRENTLY MARRIED ACCESSIBILITY COVERAGE 34 countries: Females spacing: % Females limiting: % Females 2 24 spacing: % Females 2 24 limiting: % For especially vulnerable groups of IDUs, sex workers and MSM, though data is available, it has not been disaggregated by age. For this review it was therefore not possible to report substantively on the access of these vulnerable groups of young people to prevention services or their risk and protective behaviours. For global Indicator 1, data is scarce on the availability of youthfriendly health services; but there is increasing attention towards the scaling up of prevention services provided by skilled workers towards achieving universal access. For the other two global indicators, condom use at last high risk sex (no. 2, with data from 43 countries) and use of HTC services (no. 3, with data from 23 countries), the contrast between data availability is not surprising since new guidance on scaling up HTC services has just been provided (May 27) by WHO and UNAIDS. 7

8 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH Knowledge of HTC services is only one among various determinants of HTC service use (including stigma associated with and the cost of services), and comparison of young people s knowledge of and their reported use of HTC (data available for six Caribbean countries; see Indicator 6) shows that less than a fifth of those who knew about the service used it. For condoms, there is some persuasive evidence for the importance of reported self-efficacy for young people to access condoms, as shown in Table 2 below. Thus the prevalence of condom use during higher-risk sex is reported by about half the proportion of young people who report knowing about a formal source of condoms, when such data is available in the same survey by country. Furthermore, the percentage of young people who report being able to access condoms (if they wanted to) is between these two values, as is illustrated for Bolivia, Ghana and Mali in Table 2. Even when the prevalence of knowledge of a formal source of condoms is low to start with, a lower percentage report being able to access condoms, and an even lower percentage report using condoms at last higher-risk sex. The pattern is consistent whether for males or females, suggesting confirmation of the logical sequence of the need to improve the self-efficacy of young people to access condoms even when their knowledge of an available source of condoms is high. For countries in the situation of Mali, for example, efforts are needed to improve the prevalence of all three factors, knowledge, self-efficacy and ultimately the use of condoms. Table 2 illustrates the utility of collecting information according to the Tanahashi Framework stages, which provide insight for programme managers on the typically observed drop-off between the reported prevalence of knowledge compared with the use of condoms or HTC. Table 2. Access to and utilization of condoms in Bolivia, Ghana and Mali Knowledge of condom source Able to access condoms Use of condoms Bolivia, DHS 23 Ghana, DHS 23 Mali, DHS 21 Bolivia, DHS 23 Ghana, DHS 23 Mali, DHS 21 Bolivia, DHS 23 Ghana, DHS 23 Mali, DHS 21 Males % 76% 38% 68% 6.9% 31.7% 37% 46% 23% Females % 59% 23% 4% 37.6% 16.3% 21% 34% 14% Males % 88% 59% 82% 81.6% 53.5% 36% 55% 35% Females % 7% 26% 53% 52.8% 2.5% 2% 32% 16% The confluence of the 21 Declaration of Commitment on HIV/AIDS for increasing access to services for young people, the recent movement towards universal access to prevention, treatment, care and support for HIV prevention, and universal access to reproductive health services for the prevention of maternal mortality, provide an important opportunity for monitoring progress at national levels. Tracking the coverage of services is central to building accountability and transparency towards monitoring the achievement of these goals. The compilation of these fact sheets suggests that much needs to be done even to have monitoring data at facility and population level. With the advent of reporting for UNGASS to UNAIDS, and universal access in 28, both for HIV and maternal mortality prevention and control, as well as the tracking of the Millennium Development Goals, more country-level data will become available for several indicators and should help to better identify if interventions are reaching a significant percentage of young people. References 26 report on the global aids epidemic, Joint United Nations Programme on HIV/AIDS, ANN3_en.pdf At the Crossroads: Accelerating Youth Access to HIV/AIDS Interventions, Joint United Nations Programme on HIV/AIDS, 24. Report of the Secretary-General on the work of the organization, 66, , Annex II, Revised Millennium Development Goal monitoring framework, including new targets and indicators, as recommended by the Inter-agency and Expert Group on Millennium Development Goal Indicators. United Nations, New York, 27. Tanahashi. Health service coverage and its evaluation. Bulletin of the World Health Organization, 1978, 56(2): National AIDS programmes A guide to indicators for monitoring and evaluating national HIV/AIDS prevention programmes for young people, World Health Organization, 24. Service Availability Mapping serviceavailabilitymapping/en/ Major source for data on indicators : Macro International Inc. HIV/AIDS Survey Indicators Database, STATcompiler &CFTOKEN= Behavioural Surveillance Surveys (BSS) in Six Countries of the Organization of Eastern Caribbean States (OECS) Round 1: 25, Antigua and Barbuda, Grenada, St Lucia, Dominica, St Kitts and Nevis, St Vincent and the Grenadines, PAHO, For further information please contact: Department of Child and Adolescent Health and Development (CAH) World Health Organization 2 Avenue Appia, 1211 Geneva 27, Switzerland Tel Fax cah@who.int Web site

9 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH GLOBAL INDICATOR # 1 DATA ON COVERAGE INDICATORS FOR HIV EPIDEMICS Indicator 1 is a new indicator for which very little data currently exists. Its selection as a global indicator is also intended to highlight the critical need to collect such information, and consequently the importance of ensuring that such services are provided. Indicator 1: AVAILABILITY INDICATOR INSTITUTIONALIZING YOUTH-FRIENDLY HEALTH SERVICES Original definition : The estimated number of health facilities with arrangements in place to provide youth-friendly services. : The number of health facilities with at least one health-care provider trained in the provision of youth-friendly services. New definition : The number of health workers trained to provide adolescent/youth-friendly health services, nationally/ sub-nationally. : The number of health-care providers trained in the provision of adolescent/youth-friendly services, nationally/ sub-nationally. : The number of health facilities surveyed. In recent discussions with United Nations (UN) partners within the Indicator Harmonization and Registry Technical Working Group 1 (IHRTWG), it was acknowledged that facility-level information is desirable but not always available. Therefore, a simpler definition of this indicator has been proposed (see box above). This simpler definition is yet to be tested, but can be based on key interview data or centrally available statistics on the training of health-care providers, without having to conduct facility surveys. However, this new definition, while easier to collect, is likely to be a weak proxy for the extent to which adolescent- and youth-friendly health services are institutionalized. WHO has collected data at facility level in 12 countries related to the original definition of this indicator through the Service Availability Mapping (SAM) survey. 2 The SAM survey collects facility-level information on staff trained in the provision of 1 The Indicator Harmonization and Registry Technical Working Group (IHRTWG) was established in 26 by the Monitoring and Evaluation Reference Group (MERG); a group of international experts in monitoring and evaluation of HIV, which is coordinated by the Joint United Nation s Programme on HIV/AIDS (UNAIDS). adolescent sexual and reproductive health (ASRH). The figure below is an example of the data that is available from SAM surveys, in this case applied to the Mwanza region in the United Republic of Tanzania in 25. Macro International Inc. has also supported the collection of facility-level data from about 1 countries since 1998; an initiative called Service Provision Assessment (SPA). More surveys are currently under way and include a wealth of data. SPAs are nationally representative and provide a picture of the strengths and weaknesses of a country s public and private health-care delivery systems. SPAs assess basic infrastructure, maternal and child health, family planning, infectious disease and HIV services. While both SAM and SPA provide facility-level data, such surveys are still rare. If this indicator was included in the Health Management Information Systems (HMIS) at a country level, data would be more readily available. 2 Albania, Ghana, Honduras, Kenya, Maldives, Nigeria, Rwanda, Swaziland, Uganda, the United Republic of Tanzania, Viet Nam and Zambia 1

10 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH Figure 1: Indicator 1 This figure was prepared from preliminary data collected for eight districts in the Mwanza region of the United Republic of Tanzania, for all the public health facilities for the time period Each of the dots represents a health facility. The larger dots denote facilities with 1 3 staff trained in ASRH, while the large red dot is for the Magu district hospital that has 1 or more staff trained in ASRH. NOTES 2

11 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH GLOBAL INDICATOR # 2 DATA ON COVERAGE INDICATORS FOR HIV EPIDEMICS Indicator 2: CONTACT COVERAGE CONDOM USE BY YOUNG PEOPLE AT LAST HIGHER RISK SEX (also UNGASS Indicator 17 and WHO Universal Access Indicator 21) Original definition (August 22 and July 25) New definition : of young people aged years reporting the use of condom during sexual intercourse with a non-regular sex partner : The number of respondents aged years, who report that they used a condom the last time they had sex with a non-regular partner in the last 12 months. : The number of respondents aged years, who reported having had a non-regular sexual partner in the last 12 months. : of women and men aged years who have had more than one sexual partner in the past 12 months reporting the use of a condom during their last sexual intercourse. : The number of the respondents aged years who reported having had more than one sexual partner in the last 12 months who also reported that a condom was used the last time they had sex : The number of respondents aged years who reported having had more than one sexual partner in the last 12 months This indicator was redefined and simplified in consultation with Demographic and Health Surveys (DHS), and UN partners within The Indicator Harmonization and Registry Technical Working Group (IHRTWG), 1 as experience suggested that respondents were confused by all the qualifiers (i.e. nonmarital, non-cohabitating). The currently available data presented in this fact sheet from DHS and the United Nations General Assembly Special Session on HIV/AIDS (UNGASS), are based on the more complex original definition (see text box above). However, DHS has 1 The Indicator Harmonization and Registry Technical Working Group (IHRTWG) established in 26 by the Monitoring and Evaluation Reference Group (MERG), a group of international experts in monitoring and evaluation of HIV/AIDS, which is coordinated by UNAIDS. recently begun collecting and compiling data on the simpler definition from previous surveys (e.g. use of condoms among those who had multiple partners in the last year). While the data for the new definition of the indicator has not been calculated as a percentage for past surveys, it will now be calculated routinely and will be included in the HIV/AIDS Survey Indicators Database for future surveys. Table 1 below lists all the available data for the original definition of Indicator 2 (from 2 to 25), for reporting on UNGASS, as compiled by the Joint United Nations Programme on HIV/AIDS (UNAIDS) and DHS. Data disaggregated by age and sex are available for 43 countries, when UNGASS reporting and DHS data availability is combined. Note that the UNGASS data is aggregated for ages years and not disaggregated by and 2 24, as in 1

12 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH Figure 1: Indicator 2 Condom use at last higher risk sex among young men and women Antigua & Barbuda Dominica Grenada St. Kitts & Nevis St. Lucia St. Vincent & the Grenadines age years Six countries from the organization of Eastern Caribbean States (Source: BSS in Six Countries of the Organization of Eastern Caribbean States [OECS], PAHO 27) DHS. In addition, data from six more Caribbean countries was available from behavioural surveillance surveys (BSS) for year-olds, though not disaggregated by sex (see Figure 1). For condom use among most-at-risk young people (MARYP), Figure 2 shows condom use rates for 11 countries, for men who have sex with men (MSM). Age-disaggregated data were not readily available for condom use among young commercial sex workers, though UNGASS reports include data for adults among this MARYP target group. For condom use among injecting drug users, the data are combined with that for safe injecting practices (Indicator 12) and are presented with the corresponding fact sheet. In general, the search for data on MARYPs will require a more in-depth review of specific studies than was possible in the time frame available for the preparation of this fact sheet. Figure 1 illustrates a condom use rate higher than 5% (combined for males and females) for six Eastern Caribbean countries. The lack of sex disaggregated data can mask important variations. For instance for the African region: in Table 1 data for year old males and females for 2 countries are included, from DHS and UNGASS. For the African region, for five countries (Angola, Benin, Botswana, Burkina Faso and the Central African Republic), both males and females among year olds report greater than 5% prevalence of condom use. In addition, for three other countries (Cameroon, Senegal and Zimbabwe), the reported prevalence among males is higher than 5% but not for females. For Uganda, although data was not available for the combined year old age category, the prevalence rates for males and 2 24, the rate is higher than 5%, and for females it is likely to be similarly high. Interestingly, year old Ugandan females report higher condom use rates for last higher risk sex than their male counterparts (56% vs 5%). For year-olds in Burundi, the condom use rates for females are higher than for males (5.6% vs 46%) while in Lesotho and Mozambique it is similar (49.8% vs 48.6% for year olds and 3% each for year olds, respectively). For other countries, males report consistently higher condom use rates than females for both age brackets (15 19 and 2 24 years old). These condom use rates for the last higher risk sex have to be put in the context of the nature of the current epidemic where year olds account for 4% of all new infections (UNAIDS 26). Also, throughout sub-saharan Africa, girls and young women (15 24 years) are now three times more likely to be HIV positive than young men, with this trend continuing in the Caribbean, where young women are up to 2.5 times more likely to be infected. 2 To date, consistent and correct condom use is the only effective method for preventing HIV infection in sexually active people. The 43-country data reported in Table 1 do not include all nationally representative surveys that governments have undertaken. With increased emphasis from UNAIDS and the World Health Organization (WHO) for reporting and collation of selected indicators for young people (this indicator being one of them), more country-level data should become available for 28. In general, Table 1 shows that there appears to be good concurrence between UNGASS reporting to UNAIDS and DHS data when available for the same countries, except for Benin and Zambia. For Benin, the UNGASS report rates 2 The Global Coalition on Women and AIDS: United Nations Population Fund (UNFPA), Joint United Nations Programme on HIV/AIDS (UNAIDS) and United Nations Development Fund for Women (UNIFEM) publication on women and HIV. 2

13 # 2 GLOBAL INDICATOR HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH for condom use are about two-fold higher than from DHS. For Zambia, the UNGASS report rates are considerably lower than for those reported by DHS. Further review and consultation with national programme managers is needed to explain these discrepancies. For Cameroon, Ghana, Kenya, Lesotho, and Malawi these two sources provide almost identical data. Table 1: Indicator 2: Condom use at last higher risk sex Countries UNGASS 25 country report (Data collection varied between 2 and 25) DHS/AIS/BSS/SBS (Collected between 21 and 25) DHS/AIS/BSS/SBS (Collected between 2 and 25) Males years of age Females years of age All young people Males years of age Females years of age Males years of age Females years of age Males 2 24 years of age Females 2 24 years of age Sub-Saharan Africa Angola Benin Botswana Burkina Faso Burundi Cameroon Central African Republic Chad Côte D Ivoire Eritrea 81. Ethiopia Ghana Guinea Kenya Madagascar Malawi Mali Mozambique Nigeria Rwanda Senegal Uganda AIDS impact survey (AIS) 4 Sexual behavioural survey (SBS) Continued 3

14 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH Countries UNGASS 25 country report (Data collection varied between 2 and 25) DHS/AIS/BSS/SBS (Collected between 21 and 25) DHS/AIS/BSS/SBS (Collected between 2 and 25) Males years of age Females years of age All young people Males years of age Females years of age Males years of age Females years of age Males 2 24 years of age Females 2 24 years of age United Republic of Tanzania Zambia Zimbabwe East Asia and Pacific Mongolia South and South-East Asia Cambodia India Philippines Viet Nam Eastern Europe and Central Asia Czech Republic Republic of Moldova Russian Federation 78.8 Ukraine Uzbekistan Caribbean Barbados Dominican Republic Guyana Latin America Argentina 46. Bolivia Brazil 74.1 Colombia 39. Honduras Nicaragua Behavioural surveillance survey (BSS) 6 Population and AIDS indicator survey 7 Health examination survey 4

15 # 2 GLOBAL INDICATOR HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH DATA ON COVERAGE INDICATORS FOR MOST-AT-RISK YOUNG PEOPLE Data is not readily available for most of the indicators (Nos. 2 9). However some data is available for the age groups <>25 for Indicator 2 as shown below. As noted further above, the available data for Indicator 2A is combined with that for safe injecting practices (Indicator 12) and is presented with that fact sheet. Indicator 2A: CONTACT COVERAGE CONDOM USE AMONG YOUNG INJECTING DRUG USERS WHO HAD SEX IN THE PAST MONTH (also UNGASS Indicator 2) The percentages of young injecting drug users (IDUs) aged years who report that a condom was used the last time they had sex in the past one month The number of young IDUs who report that a condom was used the last time they had sex during the last month. The number of young IDUs who report injecting drugs and having sexual intercourse during the preceding month. Indicator 2B: CONTACT COVERAGE CONDOM USE DURING ANAL SEX AMONG YOUNG MEN WHO HAVE SEX WITH MEN (MSM) (also UNGASS Indicator 19) The proportion of young men aged years who report using a condom on the last occasion when they had anal sex with a male partner in the preceding six months. The number of MSM aged years who report using a condom on the last occasion when they had anal sex with a male partner in the preceding six months All MSM aged years who have had anal sex with a man in the preceding six months. Figure 2. Indicator 2B Men less than 25 years old, who reported using condoms the last time they had anal sex with a male partner age less than 25 years Congo Mongolia Bangladesh Indonesia Pakistan Armenia Belarus Republic of Moldova Ukraine Panama Peru Countries (Source: UNGASS country reporting 25 [UNAIDS Report 26]; 5) For condom use among MSM, Figure 2 shows the distribution for selected countries. Comparing this with data in Table 1 for the general population of year olds: 5

16 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH Indicator 2C: CONTACT COVERAGE CONDOM USE AMONG YOUNG COMMERCIAL SEX WORKERS (also UNGASS Indicator 18) The percentage of young commercial sex workers who used a condom the last time they had sex with a client. The number of commercial sex workers aged years who used a condom the last time they had sex with a client. All commercial sex workers aged years As noted above, the data for this indicator, available through UNGASS reporting, is not available with appropriate age disaggregation and hence is not presented in this fact sheet. 6

17 # 2 GLOBAL INDICATOR HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH NOTES 7

18 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH NOTES 8 For further information please contact: Department of Child and Adolescent Health and Development (CAH) World Health Organization 2 Avenue Appia, 1211 Geneva 27, Switzerland Tel Fax cah@who.int Web site

19 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH GLOBAL INDICATOR # 2A &12 DATA ON COVERAGE INDICATORS FOR MOST-AT-RISK YOUNG PEOPLE Data are not readily available for most indicators for concentrated epidemics. However some data are available for the age groups <>25 for some of the indicators, as shown below. (Note: Data for indicators 2a and 12 were combined in reporting; see Fig. 1 below) Indicator 2A: CONTACT COVERAGE CONDOM USE AMONG YOUNG INJECTING DRUG USERS (IDU) WHO HAD SEX IN THE PAST ONE MONTH The percentage of young IDUs (15 24 years) who report that a condom was used the last time they had sex in the past month. The number of young IDUs who report injecting drugs and having sexual intercourse during the preceding month. The number of young IDUs who report injecting drugs and having sexual intercourse during the preceding month. New Indicator 2A: CONTACT COVERAGE (also UNGASS Indicator 2; to be disaggregated by <>25 for 28 reporting) The percentage of IDUs reporting the use of a condom the last time they had sexual intercourse, disaggregated by sex and age (<>25) The number of respondents who reported that a condom was used the last time they had sex. The number of respondents who report having had sexual intercourse in the last month. Figure 1: Indicators 2A & 12 Safe injecting and safer sex practices among young injecting drug users less than Bangladesh Indonesia Thailand Viet Nam Various countries Armenia Moldova Ukraine Males < 25 Females < 25 Source: UNGASS country reporting for 2 25; UNAIDS Report 26) 1

20 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH Indicator 12: CONTACT COVERAGE SAFE INJECTING PRACTICES AMONG YOUNG INJECTING DRUG USERS The percentage of young IDUs who report having never used non-sterile injecting equipment during the last month. The number of IDUs who report having never used non-sterile injecting equipment during the last month. All young IDUs aged years who report injecting drugs during the last month. New Indicator 12: CONTACT COVERAGE (also UNGASS Indicator 21; to be disaggregated by <>25 for 28 reporting) The percentage of IDUs reporting the use of sterile injecting equipment the last time they injected, Disaggregated by sex and age (<25, 25+). The number of respondents who report using sterile injecting equipment the last time they injected drugs. The number of respondents who report injecting drugs in the last month. For UNGASS 28 reporting Indicators 2A and 12 will be reported on separately. But the previous data was combined as shown in Figure 1. The data presented in Figure 1, indicate significant public health challenges for these countries though the figures from Armenia, Moldova and Viet Nam are encouraging. In this group of countries (other than Thailand), HIV transmission is still driven by IDUs and unsafe injecting drug practices, as well as sexual contacts. Having a combination of Indicators 2A and 12 leaves it unclear as to what proportion of the data represents safe/unsafe injecting drug practices and/or use/ non-use of condoms, which is unhelpful programmatically for focusing action. For Viet Nam, the rates of safe injecting and sex practices among males are encouraging but the lack of data for females is a cause for concern, as a significant percentage of female sex workers reportedly inject drugs and appear to have a low rate of condom use. As for other countries in Asia, in Thailand for example, unsafe injecting practices among IDUs continues to be a problem, as the data suggests. It is not clear if the higher rates of safer sex and injecting practices for young women represent condom use or higher use of sterile equipment than among men. In Indonesia, risk-associated practices of unsafe injecting and frequent unprotected sex have been noted. In Eastern Europe, the data is alarming for the Ukraine, with its low rate of safer practices. In Ukraine, the HIV prevalence exceeds 5% among IDUs and shows no signs of decline. Non-sterile injecting equipment remains a serious risk factor. Additionally, heterosexual transmission has increased dramatically, illustrating how the epidemic can rapidly spread from vulnerable groups to the general population. In Moldova and Armenia the relatively higher use of protective practices is encouraging, though HIV incidence has doubled during the period in question. From the 28 UNGASS report, receiving data separately for each indicator and age disaggregated (<> 25 years) will be very helpful, particularly when young people are a significant proportion of the most-at-risk populations. 2

21 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH GLOBAL INDICATOR # 3 DATA ON COVERAGE INDICATORS FOR HIV EPIDEMICS The data provided below were kindly extracted by Macro International Inc. from the HIV/AIDS database, specifically for sexually active young people. Indicator 3: CONTACT COVERAGE HIV TESTING BEHAVIOUR AMONG YOUNG PEOPLE (also UNAIDS Indicator 38 and WHO Universal Access Indicator 5) The proportion of sexually active young people who had an HIV test in the preceding 12 months and know the result. The number of respondents aged years who had an HIV test in the preceding 12 months and who know the result. Respondents aged years who have had sex in the preceding 12 months. HIV testing and counselling (HTC) is a relatively new intervention and the current utilization rates are low. The three figures below provide the data available from 23 countries for this indicator, which is a subset of the data collected on HTC. Thus the surveys collected data on HTC prevalence among all young people, which was then further categorized for those who are sexually active. This is particularly important in the context of sub-saharan Africa where HTC is encouraged to facilitate primary and secondary HIV prevention. Among the African countries with data available, only one (Rwanda) shows HTC rates of more than 12% for males and females of both age ranges, and 2 24 years. In general, where data is available for both sexes, the female rates are at par with or slightly higher than males of the same age range. This is encouraging in a region where HIV infections in females years are much higher than for males of the same age cohort. The exceptions are the lower rates of female testing in Chad and Ethiopia and for 2 24 year olds in Nigeria. In Lesotho, the prevalence rates for HTC for 2 24 year old females are double that of the males for that age range and of year olds, but nevertheless are low considering that it has one of the highest HIV prevalence rates in the world. Figure 1: Indicator 3 Young people aged years who have had an HIV test and know the result Burkina Faso DHS Cameroon DHS Chad DHS Congo DHS 25 Ethiopia DHS 25 Ghana DHS Guinea DHS Lesotho DHS Madagascar DHS Males Females Males 2 24 Females 2 24 Sub-Saharan African countries (Source: Macro International Inc., HIV/AIDS Survey Indicators Database) 1

22 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH Figure 2: Indicator 3 Young people aged years who have had an HIV test and know the result Malawi DHS 24 Mozambique DHS 23 Nigeria DHS Rwanda DHS Senegal DHS United Republic of Tanzania DHS Uganda HIV/ AIDS SBS Zimbabwe DHS 25 6 Males Females Males 2 24 Females 2 24 Sub-Saharan African countries (cont.) (Source: Macro International Inc., HIV/AIDS Survey Indicators Database) For the other countries listed in Figure 3 below, though Guyana and Haiti have similar HIV prevalence, the HTC levels for Guyana are not only double those of Haiti, but among the highest reported for all the 23 countries other than the Republic of Moldova and Rwanda (see Figure 2 above). The Republic of Moldova s HTC rates, which are among the three highest reported for the 23 countries shown in these figures, are encouraging given the two-fold increase reported in new HIV infections in the most recent data available from UNAIDS. Figure 3: Indicator 3 Young people aged years who have had an HIV test and know the result Republic of Moldova DHS 25 1 Philippines DHS Viet Nam Population and AIS 3 Bolivia DHS Guyana AIS Haiti DHS 25 6 Males Females Males 2 24 Females 2 24 Various region countries (Source: Macro International Inc., HIV/AIDS Survey Indicators Database) The current emphasis on reporting on Universal Access in 28, should also make facility-level data available for HTC, which would allow more detailed analyses of sex- and agedisaggregated testing behaviours of young people. 2

23 GLOBAL INDICATOR HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH # 3 DATA ON COVERAGE INDICATORS FOR MOST-AT-RISK YOUNG PEOPLE (MARYP) Data for Indicator 3 is not age disaggregated for MARYPs in UNGASS reporting and hence not presented here. Indicator 3A: CONTACT COVERAGE HIV TESTING BEHAVIOUR AMONG INJECTING DRUG USERS (IDUs) The proportion of sexually active young IDUs who have had an HIV test in the preceding 12 months and know the result. The number of sexually active IDUs aged years who have had an HIV test in the preceding 12 months and know the result. IDUs aged years who have had sex in the preceding 12 months. ALTERNATIVE INDICATOR 3A: CONTACT COVERAGE This is the suggested modification of this indicator at the UNAIDS Monitoring and Evaluation Reference Group (MERG) meeting on Indicator Harmonization & Registry Technical Working Group, January 27. The proportion of IDUs who have had an HIV test in the preceding 12 months and know the result. The number of IDUs aged years who have had an HIV test in the preceding 12 months and who know the result. All IDUs aged years. Indicator 3B: CONTACT COVERAGE HIV TESTING BEHAVIOUR AMONG MEN WHO HAVE SEX WITH MEN (MSM) The proportion of young MSM who have had an HIV test in the preceding 12 months and know the result. The number of MSM aged years who have had an HIV test in the preceding 12 months and who know the result. All MSM aged years. Indicator 3C: CONTACT COVERAGE HIV TESTING BEHAVIOUR AMONG COMMERCIAL SEX WORKERS The proportion of young commercial sex workers who have had an HIV test in the preceding 12 months and know the result. The number of commercial sex workers aged years who have had an HIV test in the preceding 12 months and who know the result. All commercial sex workers aged years. 3

24 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH NOTES 4 For further information please contact: Department of Child and Adolescent Health and Development (CAH) World Health Organization 2 Avenue Appia, 1211 Geneva 27, Switzerland Tel Fax cah@who.int Web site

25 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH NATIONAL INDICATOR # 4 DATA ON COVERAGE INDICATORS FOR HIV EPIDEMICS Data disaggregated by type of venue frequented by young people were not available for Indicator 4. Indicator 4: AVAILABILITY COVERAGE CONDOM AVAILABILITY FOR YOUNG PEOPLE Original definition : The percentage of randomly selected retail outlets and service delivery points typically accessed by young people that have condoms in stock at the time of the survey. : The number of retail outlets and service delivery points that are typically accessed by young people and have condoms in stock at the time of the survey. : The number of retail outlets and service delivery points typically accessed by young people aged years. Indicator 4 has also been redefined and simplified in consultation with Demographic and Health Surveys (DHS) and UN partners within IHRTWG. 1 Information using this new definition of the indicator can be collected at the national level through key informant interviews without the necessity for facility mapping and population-based surveys. This will include data from manufacturers and major commercial distributors as well as major donors, condom storage facilities and government, parastatal and nongovernmental bodies involved in acquiring and distributing condoms. However, this new definition does not represent the indicator as defined above; condom availability for young people. Data for the original definition of this indicator is being collected by Population Services International (PSI) in randomly selected outlets in selected geographic areas of 36 countries, where risk-associated activity among young people is known to take place. In addition, geographic accessibility is also measured by population-based surveys conducted by PSI with targeted groups in hot zones, including migrant youth who come to urban areas to study in universities or join factories. While the data is soon to be made available on the PSI website, currently, only the list of countries (36 in all) that have recently completed this phase of the mapping is available. These New definition : The total number of condoms distributed nationwide during the last 12 months, divided by the total population aged years. : The total number of condoms (male, female) distributed nation-wide during the last 12 months. : The total population aged years. include: Cambodia, China, India, the Lao People s Democratic Republic, Nepal, Thailand and Viet Nam, in Asia. In East Africa, the countries where this mapping has been completed include: Ethiopia, Malawi, Mozambique, the United Republic of Tanzania and Uganda. In West and Central Africa, the countries where mapping has been completed are: Burkina Faso, Burundi, Guinea, Haiti, Mali, Nigeria, Rwanda and Togo. In southern Africa, the countries where the mapping has been completed are: Botswana, Lesotho, Madagascar, Namibia, South Africa, Swaziland, Zambia, and Zimbabwe. Finally, in Latin America and the Caribbean, the countries that have completed the mapping include: Belize, Costa Rica, the Dominican Republic, El Salvador, Guatemala, Honduras, Mexico, Nicaragua and Panama. In Chiang Mai and Lamphun in Thailand, PSI has mapped condom outlet availability in hot zones accessed by men who have sex with men (MSM) and sex workers. In Kazakhstan, this was combined with population-based surveys to assess access. Unfortunately the data for these studies are also not currently available on the PSI website. 2 2 Presentation by Dr Varja Lipovsek at the Technical Consultation on Measuring Coverage of Health Services for Young people, in April 26, in Geneva, organized by the Department of Child and Adolescent Health and Development, World Health Organization. 1 The Indicator Harmonization and Registry Technical Working Group (IHRTWG) 1

26 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH Indicator 4A: AVAILABILITY COVERAGE CONDOM AVAILABILITY FOR YOUNG INJECTING DRUG USERS The percentage of randomly selected retail outlets and service delivery points typically accessed by young injecting drug users (IDUs) that have condoms in stock at the time of the survey. The number of retail outlets and service delivery points that are typically accessed by IDUs aged years that have condoms in stock at the time of the survey. Sites and venues that are typically accessed by young IDUs should be identified either through key informants or from survey responses concerning the places where young IDUs obtain or prefer to obtain condoms. The number of retail outlets and service delivery points typically accessed by IDUs aged years. Indicator 4B: AVAILABILITY COVERAGE CONDOM AVAILABILITY FOR YOUNG MEN WHO HAVE SEX WITH MEN The percentage of randomly selected retail outlets and service delivery points typically accessed by young men who have sex with men (MSM) that had condoms in stock at the time of the survey. The number of retail outlets and service delivery points that are typically accessed by MSM aged years that had condoms in stock at the time of the survey. Sites and venues that are typically accessed by young MSM should be identified either through key informants or from survey responses concerning the places where young MSM obtain or prefer to obtain condoms. The number of retail outlets and service delivery points typically accessed by MSM aged years. Indicator 4C: AVAILABILITY COVERAGE CONDOM AVAILABILITY FOR YOUNG SEX WORKERS The percentage of randomly selected retail outlets and service delivery points typically accessed by young sex workers that had condoms in stock at the time of the survey. The number of retail outlets and service delivery points that are typically accessed by sex workers aged years that had condoms in stock at the time of the survey. Sites and venues that are typically accessed by young sex workers should be identified either through key informants or from survey responses concerning the places where young sex workers obtain or prefer to obtain condoms. The number of retail outlets and service delivery points typically accessed by sex workers aged years. 2 For further information please contact: Department of Child and Adolescent Health and Development (CAH) World Health Organization 2 Avenue Appia, 1211 Geneva 27, Switzerland Tel Fax cah@who.int Web site

27 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH NATIONAL INDICATOR # 5 DATA ON COVERAGE INDICATORS FOR HIV EPIDEMICS Indicator 5: ACCESSIBILITY COVERAGE KNOWLEDGE OF A FORMAL SOURCE OF CONDOMS AMONG YOUNG PEOPLE The percentage of young people aged years who know of at least one formal source of condoms. All young people aged years who can name at least one formal source of condoms. All young people aged years. Figures 1a to 1d illustrate the data that is currently available for this indicator from Demographic and Health Surveys (DHS) for 3 countries. As shown below, young men aged 2 24 years appear to be the most knowledgeable about a formal source of condoms (except in the Philippines, Uganda and Zimbabwe) while per country, young women aged years seem to be the least knowledgeable. In general, this is to be expected as this data on knowledge among young people about of a formal source of male condoms is fairly high. In general, it appears that at least 3% of young people know of a formal source of condoms, other than in Chad, in Mali (for young women), and in Nigeria (15 19 year old women). In almost all countries all year old young men and women were surveyed except in Cameroon, Colombia, Honduras, Jordan and Nicaragua. In Jordan only ever married young women were the respondents. Figure 1a: Indicator 5 Knowledge of a formal source of condoms among young men and women aged years Burkina Faso DHS Cameroon DHS Tchad DHS Congo DHS Ethiopia DHS Ghana DHS Guinea DHS 25 Males Females Males 2 24 Females 2 24 Sub-Saharan African countries (Source: Macro International Inc., HIV/AIDS Survey Indicators Database) 1

28 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH Figure 1b: Indicator 5 Knowledge of a formal source of condoms among young men and women aged years Lesotho DHS Madagascar DHS Malawi DHS Mali DHS 21, ENDSM-III Mozambique DHS 23 Namibia DHS Nigeria DHS 23 Males Females Males 2 24 Females 2 24 Sub-Saharan African countries (cont.) (Source: Macro International Inc., HIV/AIDS Survey Indicators Database) Figure 1c: Indicator 5 Knowledge of a formal source of condoms among young men and women aged years Rwanda DHS Senegal DHS United Republic of Tanzania DHS Uganda DHS Zambia DHS 21 2 Zimbabwe DHS 25 6 Males Females Males 2 24 Females 2 24 Sub-Saharan African countries (cont.) (Source: Macro International Inc., HIV/AIDS Survey Indicators Database) Figure 1d: Indicator 5 Knowledge of a formal source of condoms among young men and women aged years Bolivia DHS Colombia SRH & DHS 25 Honduras DHS 25 6 Jordan Republic Population of Moldava and Family DHS 25 Health Survey 22 (Source: Macro International Inc., HIV/AIDS Survey Indicators Database) Please note, for Indicator 5: Knowledge of a formal source of condoms among young people, was not included in the list of indicators to monitor for most-at-risk young people, at the Technical Consultation on Measuring Coverage of Health Various countries Nepal DHS Nicaragua DHS Philippines DHS 23 Viet Nam Population and AIS Males Females Males 2 24 Females 2 24 Services for Young People, in April 26, in Geneva, organized by the Department of Child and Adolescent Health and Development, World Health Organization (WHO). 2 For further information please contact: Department of Child and Adolescent Health and Development (CAH) World Health Organization 2 Avenue Appia, 1211 Geneva 27, Switzerland Tel Fax cah@who.int Web site

29 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH NATIONAL INDICATOR # 6 DATA ON COVERAGE INDICATORS FOR HIV EPIDEMICS Indicator 6: ACCESSIBILITY COVERAGE ACCESSIBILITY TO HIV TESTING AND COUNSELLING (HTC) SERVICES BY YOUNG PEOPLE of young people aged years who know a place to get HTC. Number of young women and men aged years who know a place to get HTC. All young women and men aged years. This indicator provides data on the knowledge of young people regarding the availability of HIV testing and counselling (HTC) services and is classified as accessibility coverage. While knowledge of where HTC services are available is just one of several factors that affect accessibility to HTC (including associated stigma and the cost of the service), it is also the information that is more readily collected in surveys. The data presented for indicator 6 in this fact sheet, underrepresent the extent of information currently available. Macro International s HIV/AIDS database has data for this indicator from several countries, which it was not possible to access in time for this review. The limited data presented here are from a behavioural surveillance survey (BSS) from six countries of the Caribbean, for young men and women aged years. It is not further age- or sex-disaggregated. It provides information on the knowledge of young people about where to obtain HTC, showing that over half of those surveyed knew where to get confidential HIV testing and counselling services. (Note: The BSS questionnaire specifically included the term confidential in the question for this indicator, which is just one of factors affecting accessibility.) As discussed above, knowing where HTC services are available does not predict their use. Further data from the same respondents from the six countries of the Caribbean showed that only about 1% of young people reported getting tested and knowing the results (Figure 2, further below). 1

30 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH Figure 1: Indicator 6 Accessibility of HIV testing and counselling services by young men and women aged years Antigua & Barbuda 72 Dominica 51 Grenada 6 St. Kitts & Nevis 65 St. Lucia 5 St. Vincent & the Grenadines Young men and women aged years Six countries of the Organization of Eastern Caribbean States in 25/26 (Source: BSS in Six Countries of the Organization of Eastern Caribbean States (OECS), PAHO 27) Figure 2: Indicator 3 Young respondents aged years who received HIV testing in the last 12 months and know the result Antigua & Barbuda 9 9 Dominica Grenada St. Kitts & Nevis 6 12 St. Lucia 9 St. Vincent & the Grenadines Young men and women aged years Six countries of the Organization of Eastern Caribbean States in 25/26 (Source: BSS in Six Countries of the Organization of Eastern Caribbean States (OECS), PAHO 27) Data for most-at-risk young people for Indicators 6a 6c is not readily available. Indicator 6A: ACCESSIBILITY COVERAGE ACCESSIBILITY OF HTC SERVICES BY YOUNG INJECTING DRUG USERS (IDU) : of young IDUs who know a place to get HTC. Number of IDUs aged years who know a place to get HTC. All IDUs aged years. Indicator 6B: ACCESSIBILITY COVERAGE ACCESSIBILITY OF HTC SERVICES BY YOUNG MEN WHO HAVE SEX WITH MEN (MSM) of young MSM who know a place to get HTC. Number of MSM aged years who know a place to get HTC. All MSM aged years. Indicator 6C: ACCESSIBILITY COVERAGE ACCESSIBILITY OF HTC SERVICES BY YOUNG SEX WORKERS : of young sex workers who know a place to get HTC. Number of sex workers aged years who know a place to get HTC. All sex workers aged years. 2 For further information please contact: Department of Child and Adolescent Health and Development (CAH) World Health Organization 2 Avenue Appia, 1211 Geneva 27, Switzerland Tel Fax cah@who.int Web site

31 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH NATIONAL INDICATOR # 7 DATA ON COVERAGE INDICATORS FOR HIV EPIDEMICS Indicator 7 is a relatively new indicator which has been included in recent Demographic and Health Surveys (DHS)/AIDS Indicator Surveys (AIS). The figures below have been prepared from data kindly provided by Macro International Inc. Indicator 7: ACCESSIBILITY COVERAGE PERCEPTION OF ACCESS TO CONDOMS BY YOUNG PEOPLE (also UNAIDS Indicator Harmonization and Registry Technical Working Group Indicator 35) The percentage of young people who report they could get condoms on their own. The number of young women and men aged years who know a place to get condoms and who report that they could get condoms on their own if they wanted. All young people aged years. Indicator 7, describing the perceptions of young people on access to condoms, will be included in future DHS/AIS surveys for all countries that undertake these surveys. This indicator of reported prevalence of perceived access to condoms was considered important to monitor as a determinant of condom use, as it assesses the reported self-efficacy of young people for getting condoms when they want to use one. Typically more males than females report perceived access to condoms for the same age cohorts, and 2 24 years, as would be expected. The exceptions are in the Dominican Republic and Zimbabwe among 2 24 year olds. Among both age groups in the Dominican Republic, a higher percentage of females report that they can get condoms if they want, but this is particularly divergent for the year olds (3.9% of males reporting they could get a condom if they wanted to versus 71% of females). It is not clear why this is so, particularly since reported condom use at last higher risk sex (Indicator 2) among 2 24 year old males in the same survey is 53% and for 2 24 year old females it is 3%,and these condom use rates are consistent with expected trends from the previous DHS surveys undertaken in the Dominican Republic. For Zimbabwe, it is interesting that the prevalence rates reported here for Indicator 7 for year-olds of both sexes is the same as the reported prevalence of condom use at last higher risk sex (see Indicator 2). But for 2 24 year-olds, though the perceived access to condoms is almost the same for both sexes, the condom use rates for Indicator 2 are reported to be 73% for males and 44% for females. In general, as expected, the prevalence rates for Indicator 7 are higher than reported condom use, where data are available for the same countries (for Bolivia, Ethiopia, Ghana, Guinea, Mali, the Philippines and Rwanda). For Madagascar, Mali, the Philippines and Rwanda, the relatively lower percentage of prevalence for indicator 7 is also mirrored in the relatively low condom use rate reported for Indicator 2 (see fact sheet for Indicator 2). For Cambodia, Colombia, Honduras, Rwanda and Senegal, Indicator 7 data for male youth were not available. 1

32 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH Figure 1a: Indicator 7 Young people aged years who report they could get condoms on their own Ethiopia DHS Ghana DHS Lesotho DHS Mali Madagascar DHS 21 DHS Namibia DHS Rwanda DHS 25 Senegal DHS Zimbabwe DHS 25 6 Males Females Males 2 24 Females 2 24 Sub-Saharan African countries (2 26) (Source: Macro International Inc., HIV/AIDS Survey Indicators Database) Figure 1b: Indicator 7 Young people aged years who report they could get condoms on their own Armenia Bolivia DHS Cambodia DHS Colombia DHS Dominican Republic DHS Honduras DHS Nepal DHS Philippines DHS 23 Males Females Males 2 24 Females 2 24 Various countries (2 26) (Source: Macro International Inc., HIV/AIDS Survey Indicators Database) NOTES 2 For further information please contact: Department of Child and Adolescent Health and Development (CAH) World Health Organization 2 Avenue Appia, 1211 Geneva 27, Switzerland Tel Fax cah@who.int Web site

33 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH NATIONAL INDICATOR # 8 DATA ON COVERAGE INDICATORS FOR HIV EPIDEMICS Data for Indicator 8, for population-based assessment, is available from Demographic and Health Surveys (DHS) data sources, for components of the services included in the definition (use of HIV testing and counselling services [Indicator 3]; sexually transmitted infection (STI) treatment [Indicator 9]; and contraceptive provision from Service Provision Assessment (SPA) and prevalence [Indicator 13] from the household surveys). Indicator 8: CONTACT COVERAGE USE OF SPECIFIED HEALTH SERVICES BY YOUNG PEOPLE The use of specified health services by young people can be measured through either facility-based records (measuring service utilization only) or population-based methods such as surveys (which can give an estimate of the coverage of health services). Facility-based assessment: The number of young people using a specified health service in a defined period. Health services of particular interest include those concerned with HIV testing, STI diagnosis and treatment, and family planning/ contraceptive provision. All clients using a specified health service in a defined period. Population-based assessment: The number of young people who report receiving any of the specified health services (HIV testing, STI diagnosis and treatment, and family planning/contraceptive provision) in the preceding 12 months. Young people surveyed who report being sexually active (have ever had sex). This indicator is intended for tracking the number of young people seeking health services as an indication of care-seeking behaviour, since such utilization appears to be low compared to the need. Facility-based assessment The facility-based assessment would provide valuable information that is currently difficult to retrieve as the data recording formats in countries mostly do not include the relevant age categories (as a minimum, 1 14, and 2 24 years). However, the current definition of this indicator leaves it unclear as to what the facility-level data collection and compilation steps should be, in addition to the age categorization already mentioned, for the following reasons: STI diagnosis can be undertaken through laboratory tests and/or a syndromic approach and treatment may not be licensed for nurses providing services; scoring this requires careful specification. Contraceptive provision is part of family planning, though the latter includes more than just contraceptive provision; again scoring this requires further specification on what is being counted. 1

34 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH Population-based assessment The same challenges noted above for facility-based assessments would apply to population-based assessments, in addition to which specification is needed on whether the services reported to be received by young people are from public and/or private facilities (including pharmacies) as well as traditional healers. With the current push to record data for monitoring progress towards Universal Access, information on the provision of these services will begin to be collected. But without the specifications noted above, the data collected may be difficult to interpret. Please note: For most-at-risk young people (MARYP), Indicator 8, use of specified health services by young people, was not considered relevant as service statistics are not likely to record the status of a client as a MARYP, and neither are MARYP likely to access such services. This was the decision taken at the Technical Consultation on Measuring Coverage of Health Services for Young People, in April 26, in Geneva, organized by the Department of Child and Adolescent Health and Development, World Health Organization (WHO). NOTES 2 For further information please contact: Department of Child and Adolescent Health and Development (CAH) World Health Organization 2 Avenue Appia, 1211 Geneva 27, Switzerland Tel Fax cah@who.int Web site

35 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH NATIONAL INDICATOR # 9 DATA ON COVERAGE INDICATORS FOR HIV EPIDEMICS Indicator 9: CONTACT COVERAGE YOUNG PEOPLE SEEKING TREATMENT FOR SEXUALLY TRANSMITTED INFECTIONS (STIs) The percentage of young people reporting symptoms of STIs in the last 12 months who sought care from a service provider with personnel trained in STI care. The number of young men and women aged years reporting symptoms of STIs in the last 12 months who sought care from service providers trained to national standards in STI care. The total number of young people aged years who reported symptoms suggestive of STIs in the last 12 months. The data for Indicator 9 in Figs 1a and 1b, suggest that young women are more likely to seek treatment for STIs than young men. Overall, among those who report symptoms of STIs, those reporting seeking treatment ranged from 7% in Nicaragua for 2 24 year old women to 73% in the Dominican Republic and Mozambique. For several of the reporting countries this appears to be clustered around 3 5%, suggesting the need for further information to explain and decrease this gap with programmatic action as well. STIs impose an enormous burden of morbidity and mortality, both directly through their impact on reproductive and child health, and indirectly through their role in facilitating the sexual transmission of HIV infection. There are problems in the effective implementation of control programmes because STIs are not just biological and medical problems, but also behavioural, social, political and economic problems many facets that have not been adequately addressed in the past. Please note that only the data for Egypt, in Fig. 1b, was for ever married young women, instead of all young women. Figure 1a: Indicator 9 Young men and women seeking treatment for STIs (15 24 ) Benin DHS 21 (3) Burkina Faso DHS 23 (3) Cameroon DHS 24 (3) Ghana DHS 23 (3) Kenya DHS 23 (3) Mali DHS 21, ENDSM-III (3) Mozambique DHS 23 (3) Nigeria DHS 23 (3) Uganda HIV/AIDS SBS 24 5 (3) Sub-Saharan Africa United Republic of Tanzania DHS Zambia DHS 21 2 (3) Males Females Males 2 24 Females 2 24 (Source: Macro International Inc., HIV/AIDS Survey Indicators Database) 1

36 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH Data for most-at-risk young people for Indicators 9a 9c is not readily available. Figure 1b: Indicator 9 STI treatment-seeking behaviour among young people aged years Uzbekistan Health Examination Survey 22 (1, 3) 17 Viet Nam Population and AIDS Survey (3) Dominican Republic Demographic and Health Survey 22 (3) Côte d Ivoire Young People (15 19) Egypt Demographic Health Survey Honduras (BSS) Nicaragua 21 young people DHS 15 19, 21 Males Females Males 2 24 Females 2 24 (Source: Macro International Inc., HIV/AIDS Survey Indicators Database) Indicator 9A: CONTACT COVERAGE YOUNG INJECTING DRUG USERS (IDUs) SEEKING TREATMENT FOR SEXUALLY TRANSMITTED INFECTIONS The percentage of young IDUs reporting symptoms of STIs in the last 12 months who sought care at a service provider with personnel trained in STI care, of all young IDU respondents in a population-based or targeted survey aged years. The number of young IDUs (men and women) who sought care from service providers trained to national standards in STI care. All young IDUs aged years who reported symptoms suggestive of STIs. Indicator 9B: CONTACT COVERAGE YOUNG MEN WHO HAVE SEX WITH MEN (MSM) SEEKING TREATMENT FOR SEXUALLY TRANSMITTED INFECTIONS The percentage of young MSM reporting symptoms of STIs in the last 12 months who sought care at a service provider with personnel trained in STI care, of all young MSM respondents aged years in a population-based or targeted survey. The number of young MSM who sought care from service providers trained to national standards in STI care. All young MSM aged years who reported symptoms suggestive of STIs. Indicator 9C: CONTACT COVERAGE YOUNG SEX WORKERS SEEKING TREATMENT FOR SEXUALLY TRANSMITTED INFECTIONS The percentage of young sex workers reporting symptoms of STIs in the last 12 months who sought care at a service provider with personnel trained in STI care, of all young sex worker respondents aged years in a population-based or targeted survey. The number of young sex workers who sought care from service providers trained to national standards in STI care. All young sex workers aged years who reported symptoms suggestive of STIs. 2 For further information please contact: Department of Child and Adolescent Health and Development (CAH) World Health Organization 2 Avenue Appia, 1211 Geneva 27, Switzerland Tel Fax cah@who.int Web site

37 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH ADDITIONAL INDICATORS # 1 &11 DATA ON COVERAGE INDICATORS FOR MOST-AT-RISK YOUNG PEOPLE Some preliminary data for Indicator 1 is available from the Prevention Service Availability Mapping (P-SAM) undertaken by the people were not specifically targeted but hotspots were identified by key informants, where risk-associated behaviours were known to take place. The data has not yet been published. Indicator 1 INTERVENTION SITES WITH A MINIMUM PACKAGE OF HIV PREVENTION SERVICES IN HOTSPOTS WHERE MOST-AT-RISK YOUNG PEOPLE (MARYP) ARE PRESENT IN GREATER NUMBERS The percentage of intervention sites with a minimum package of HIV prevention services in hot spots where MARYP are present in greater numbers. The number of intervention sites with a minimum package of HIV prevention services in place. The package of services should include all of the following only in the context of face to face encounters with MARYP (injecting drug users (IDUs), men who have sex with men (MSM) and sex workers): For IDUs in addition to the above: The total number of intervention sites assessed. United Nations General Assembly Special Session on HIV/AIDS (UNGASS) data on most-at-risk populations (sex workers, IDUs and MSM) reached with HIV prevention programmes is available but is not age-disaggregated to provide data for Indicator 11. 1

38 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH Indicator 11 MOST-AT-RISK YOUNG PEOPLE REACHED BY HIV PREVENTION SERVICES (also UNGASS Indicator 9 to be disaggregated by <>25) The package of services should include all of the following only in the context of face to face encounters with a young IDUs, MSM or sexworkers. For IDUs in addition to the above: NOTES 2 For further information please contact: Tel cah@who.int Web site

39 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH REPRODUCTIVE HEALTH INDICATOR # 13 DATA ON UNIVERSAL ACCESS TO REPRODUCTIVE HEALTH FOR YOUNG PEOPLE Indicator 13: CONTACT COVERAGE CONTRACEPTIVE PREVALENCE The proportion of women of reproductive age who are using (or whose partner is using) a contraceptive method at a given point in time. The number of women of reproductive age at risk of pregnancy who are using (or whose partner is using) a contraceptive method at a given point in time. The number of women of reproductive age at risk of pregnancy at the same point in time. The data available in Demographic and Health Surveys (DHS) on contraceptive use has a slightly modified definition as noted in the box below. Indicator 13: CONTACT COVERAGE CURRENT USE OF CONTRACEPTION The percentage of distribution of all women, of currently married women and of sexually active unmarried women by contraceptive method currently used, according to age. The number of women of reproductive age at risk of pregnancy who are married or are sexually active unmarried women, and using (or whose partner is using) a contraceptive method at a given point in time. The number of women of reproductive age at risk of pregnancy at the same point in time. One in three deaths related to pregnancy and childbirth could be avoided if all women had access to contraceptive services. That means some 175, women each year could be saved, and many more could avoid severe or long-lasting injuries (United Nations Population Fund (UNFPA) Population Issues: Contraception). As many as 5% of pregnancies are unplanned, and 25% are unwanted. The unwanted pregnancies are disproportionately among young, unmarried girls who often lack access to contraception. Figures 1a to 1f below provide data from 34 countries on the use of modern contraceptives by young women, which has generally increased rapidly over the past 3 years. However, progress has stalled in many lowincome countries and notably in sub-saharan Africa. Figures 1a. to 1c. show the rates for sub-saharan Africa, where in only 5 out of 2 countries, unmarried, sexually active year-old women report a contraceptive use rate greater than 45%, while for year old unmarried, sexually active women, this is the case for four countries. Furthermore, in 7 out of the 2 countries, year old unmarried, sexually active women report a contraceptive use rate of less than 25%. 1

40 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH Figure 1a: Indicator 13 Current use of modern contraception among young women aged years Benin Burkina Faso Cameroon Chad 24 Sub-Saharan Africa Congo (Brazzaville) Eritrea Ethiopia 25 Currently married Unmarried sexually active years of age Currently married 2 24 Unmarried sexually active 2 24 years of age Sub-Saharan Africa, (Source: Macro International Inc., STATcompiler) Among these countries with a low prevalence, for Benin, Chad (Figure 1a) and Mali (Figure 1b), young women also report low use of condoms for last higher-risk sex, according to DHS data (less than 2% for year-old women, Indicator 2). In addition, in Mali, knowledge of a formal source of condoms is also low among young women, ranging from 23 26% (Indicator 5). Data is not available however for Benin and Chad for Indicator 5, so it is not clear if (lack of) knowledge of a formal source of condoms is one of the barriers for their use (i.e. accessibility) or not. Figure 1b: Indicator 13 Current use of modern contraceptives by young women aged years Ghana Guinea Kenya Lesotho Madagascar 23/24 Malawi 24 Mali Currently married Unmarried sexually active years of age Currently married 2 24 Unmarried sexually active 2 24 years of age Sub-Saharan Africa, (cont.) (Source: Macro International Inc., STATcompiler) Figure 1c: Indicator 13 Current use of modern contraceptives among young women aged years Mozambique Nigeria Rwanda 25 Senegal 25 Sub-Saharan Africa, (cont.) United Republic of Tanzania Zambia 21/2 (1) Currently married Unmarried sexually active years of age Currently married 2 24 Unmarried sexually active 2 24 years of age (Source: Macro International Inc., STATcompiler) 2

41 REPRODUCTIVE HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH # 13 HEALTH INDICATOR The data currently available from DHS for Latin American countries shows consistently higher prevalence rates than for sub-saharan Africa (Figure 1d below). Figure 1d: Indicator 13 Current use of modern contraceptives by young women aged years Bolivia Colombia Dominican Republic Honduras Nicaragua 21 Currently married Unmarried sexually active Currently married 2 24 Unmarried sexually active 2 24 Latin America and the Caribbean, (Source: Macro International Inc., STATcompiler) Note that for Figures 1e & f for the regions shown below, DHS data was not disaggregated by marital status. Figure 1d shows that the contraceptive prevalence rate in North Africa is relatively low, regardless of marital status. Figure 1f, for South and South-East Asia, shows low prevalence for Nepal and the Philippines. Unfortunately, for the countries represented in each of these examples, condom use data is not available (Indicator 2), as a comparison. Figure 1e: Indicator 13 Current use of modern contraceptives by sexually active young women aged years Figure 1f: Indicator 13 Current use of modern contraceptives by sexually active young women aged years years of age 2 24 years of age years of age 2 24 years of age Egypt 25 Jordan 22 Moldova Republic of 25 Morocco (2) Bangladesh 24 (3) Indonesia 22/23 Philippines 23 Viet Nam Nepal 21 North Africa/West Asia/Europe, (Source: Macro International Inc., STATcompiler) South and South-East Asia, (Source: Macro International Inc., STATcompiler) 3

42 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH NOTES 4 For further information please contact: Department of Child and Adolescent Health and Development (CAH) World Health Organization 2 Avenue Appia, 1211 Geneva 27, Switzerland Tel Fax cah@who.int Web site

43 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH REPRODUCTIVE HEALTH INDICATOR # 14 DATA ON UNIVERSAL ACCESS TO REPRODUCTIVE HEALTH FOR YOUNG PEOPLE Indicator 14: CONTACT COVERAGE ANTENATAL CARE COVERAGE (Original definition) The proportion of women attended, at least once during their pregnancy, by skilled health personnel for reasons relating to pregnancy. The number of pregnant women attended, at least once during their pregnancy, by skilled personnel for reasons related to pregnancy during a fixed period. The total number of live births during the same period. Indicator 14: CONTACT COVERAGE ANTENATAL CARE COVERAGE (New definition) The percentage of distribution of live births in the five years preceding the survey by source of antenatal care during pregnancy, according to maternal and background characteristics. The number of live births in the five years preceding the survey by source of antenatal care during pregnancy. The total number of live births during the same period. Data for this indicator is available from 33 countries, from Demographic and Health Surveys (DHS). The data for sub-saharan Africa (Figures 1a c) shows that a high percentage of women <2, go for at least one antenatal check up, but with a health professional other than a doctor. WHO is currently compiling the database for four antenatal care visits (which is the recommended frequency). 1

44 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH In Figure 1d below, Egypt, Jordan and Moldova have high rates of at least one antenatal care visit with a doctor. However, Egypt and Morocco have similar rates of no antenatal care as well, though for the latter, other health professionals provide antenatal care to the same extent as doctors. Egypt shows two extremes: no antenatal care for one-third of its population, and at least one antenatal visit with a doctor for 72% of deliveries. Figure 1a: Antenatal care at age less than 2 years, sub-saharan Africa (21 25) Antenatal care at age less than 2 years Benin 21 Burkina Faso Cameroon Chad Congo (Brazzaville) Eritrea Ethiopia 25.2 Doctor Other health professional Traditional birth attendant Other No antenatal care Missing Sub-Saharan Africa (Source: Macro International Inc., STATcompiler) Figure 1b: Antenatal care at age less than 2 years, sub-saharan Africa (21 25) Antenatal care at less than 2 years Ghana Guinea Kenya Lesotho Madagascar 23/ Malawi 22 Mali 21 Doctor Other health professional Traditional birth attendant Other No antenatal care Missing Sub-Saharan Africa (cont.) (Source: Macro International Inc., STATcompiler) Figure 1c: Antenatal care at age less than 2 years, sub-saharan Africa (21 25) Antenatal care at age less than 2 years Mozambique Nigeria Rwanda Senegal United Republic of Tanzania Zambia 21/2 Doctor Other health professional Traditional birth attendant Other No antenatal care Missing Sub-Saharan Africa (cont.) (Source: Macro International Inc., STATcompiler) 2

45 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH REPRODUCTIVE HEALTH INDICATOR # 14 Figure 1d: Antenatal care at age less than 2 years, North Africa, West Asia, Europe (22 25) Antenatal care at age less than 2 years Doctor Other health professional Traditional birth attendant Other No antenatal care Missing Egypt 25 Jordan 22 Republic of Moldova 25 Morocco North Africa/West Asia/Europe (Source: Macro International Inc., STATcompiler) In Figure 1e, more antenatal care visits in South/South-East Asia are with other health professionals rather than doctors. Indonesia reports that 88% of women less than 2 have at least one visit with a health nurse. Figure 1e: Antenatal care at age less than 2 years, South and South-East Asia, (21 24) Antenatal care at age less than 2 years Doctor Other health professional Traditional birth attendant Other No antenatal care Missing Bangladesh 24 (3) Indonesia 22/23 Nepal 21 Philippines 23 South and South-East Asia (Source: Macro International Inc., STATcompiler) 3

46 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH In contrast in Figure 1f, showing data for for Latin America and the Caribbean countries, a medical doctor appears to be the preferred health-care personnel for antenatal care visits, which in general appear to be well attended. Figure 1f: Antenatal care at age less than 2 years, Latin America and the Caribbean (21 25) Antenatal care at age less than 2 years Doctor Other health professional Traditional birth attendant Other No antenatal care Missing Bolivia 23 Colombia 25 Dominican Republic 22 Honduras 25 Nicaragua 21 Latin America and the Caribbean (Source: Macro International Inc., STATcompiler) NOTES 4 For further information please contact: Department of Child and Adolescent Health and Development (CAH) World Health Organization 2 Avenue Appia, 1211 Geneva 27, Switzerland Tel Fax cah@who.int Web site

47 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH REPRODUCTIVE HEALTH INDICATOR # 15 DATA ON UNIVERSAL ACCESS TO REPRODUCTIVE HEALTH for young people Indicator 15 AGE-SPECIFIC FERTILITY RATE FOR YOUNG WOMEN An age-specific fertility rate (ASFR) is the ratio of the number of births in women of particular age group to the number of women of the same age at mid-year (often expressed per 1 women). The number of births in a year to mothers of a specific age. The number of women of the same age at mid-year. Note: Rates are for the period 1 36 months preceding the survey. Demographic and Health Surveys (DHS) data are available for this indicator from 34 countries (see figures 1a 1h). Agespecific fertility rate is an outcome indicator rather than a coverage indicator. However, it is included in the list of access indicators as it is considered to reflect the access to/lack of contraceptives for young people. Data for sub-saharan Africa (Figure 1a) show fertility rates that are similar to that of South/South-East Asia (Figure 1c). The next highest prevalence appears to be in the Latin American/ Caribbean region (Figure 1d) for 2 24 year-olds, where the year-olds also have a relatively high fertility rate, followed by data for the Middle East and North Africa (Figure 1b). Figure 1a: Indicator 15 Age-specific fertility rate among young women aged years Number of births Benin Burkina Faso Cameroon Chad Congo (Brazzaville) Eritrea Ethiopia Sub-Saharan Africa, (Source: Macro International Inc., STATcompiler) 1

48 HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH Figure 1b: Indicator 15 Age-specific fertility rate among young women aged years Number of births Ghana Guinea Kenya Lesotho Madagascar Malawi Mali Sub-Saharan Africa, (cont.) (Source: Macro International Inc., STATcompiler) Figure 1c: Indicator 15 Age-specific fertility rate among young women aged years Number of births Mozambique Nigeria Rwanda Senegal 25 Sub-Saharan Africa, (cont.) United Republic of Tanzania Zambia 21 2 (1) (Source: Macro International Inc., STATcompiler) Figure 1d: Indicator 15 Age-specific fertility rate among young women aged years Number of births Egypt Jordan Republic of Moldova Morocco North Africa/West Asia/Europe, (Source: Macro International Inc., STATcompiler) 2

49 REPRODUCTIVE HIV AND IMPROVING SEXUAL AND REPRODUCTIVE HEALTH HEALTH INDICATOR # 15 Figure 1e: Indicator 15 Age-specific fertility rate among young women aged years Number of births Bangladesh 24 (3) Indonesia Nepal Philippines Viet Nam South and South-East Asia, (Source: Macro International Inc., STATcompiler) Figure 1f: Indicator 15 Age-specific fertility rate among young women aged years Number of births Bolivia Colombia Dominican Republic Honduras Nicaragua Latin America and the Caribbean, (Source: Macro International Inc., STATcompiler) 3