Guidelines on Best Practices March 2017
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1 Guidelines n Best Practices fr Adlescent- and Yuth- Friendly HIV Services An Examinatin f 13 Prjects in PEPFAR-Supprted Cuntries March 2017 SR
2 Guidelines n Best Practices fr Adlescent- and Yuth- Friendly HIV Services An Examinatin f 13 Prjects in PEPFAR-Supprted Cuntries Anastasia J. Gage, Mai D, and Dnald Grant MEASURE Evaluatin University f Nrth Carlina at Chapel Hill 400 Meadwmnt Village Circle, 3 rd Flr Chapel Hill, NC USA Phne: measure@unc.edu This publicatin was prduced with the supprt f the United States Agency fr Internatinal Develpment (USAID) under the terms f MEASURE Evaluatin cperative agreement AID- OAA-L MEASURE Evaluatin is implemented by the Carlina Ppulatin Center, University f Nrth Carlina at Chapel Hill in partnership with ICF Internatinal; Jhn Snw, Inc.; Management Sciences fr Health; Palladium; and Tulane University. Views expressed are nt necessarily thse f USAID r the United States gvernment. SR ISBN:
3 ACKNOWLEDGMENTS We thank all thse wh submitted prpsals r helped t finalize the entries that MEASURE Evaluatin cmpiled. We are grateful t technical advisrs Annaliese Limb and Kristen Wares, at the U.S. Agency fr Internatinal Develpment, fr their cntributins t and participatin in the Best Practices Prpsal Review Grup. Cver pht: A grup f yung wmen at SUPPORT Girls Center, in Mumbai, India. SUPPORT prvides vcatinal training and educates street children n STDs, AIDS, and sexual abuse Vijay Sureshkumar, curtesy f Phtshare Guidelines n Best Practices fr Yuth-Friendly HIV Services 3
4 ABBREVIATIONS AYLHIV CATS adlescents and yuth living with HIV cmmunity adlescent treatment supprters HSV2 herpes simplex virus 2 PEPFAR SYMPA USAID VMMC U.S. President s Emergency Plan fr AIDS Relief Supprting Yuth and Mtivating Psitive Actin U.S. Agency fr Internatinal Develpment vluntary medical male circumcisin 4 Guidelines n Best Practices fr Yuth-Friendly HIV Services
5 INTRODUCTION Adlescents (ages 10 19) and yuth (ages 15 24) bear a disprprtinate share f the HIV burden, especially in sub-saharan Africa. Hwever, little is knwn abut what prjects are ding t make their interventins adlescent- and yuth-friendly and what interventins are effective fr changing HIV-related utcmes fr these age grups. Prgram managers and plicymakers have little rigrus evidence n hw best t invest resurces t achieve targets amng adlescents and yung peple. Recgnizing this evidence gap, MEASURE Evaluatin funded by the U.S. Agency fr Internatinal Develpment (USAID) reviewed the evidence n adlescent- and yuth-friendly HIV services as a cntributin t the gal f an AIDS-free generatin that the U.S. President s Emergency Plan fr AIDS Relief (PEPFAR) is pursuing. This review had three bjectives: (1) dcument knwledge f what is wrking and what is nt wrking in terms f delivering adlescent- and yuth-friendly HIV services, and why strategies and prgram activities wrk r d nt wrk; (2) identify useful lessns learned abut key elements f successful adlescent- and yuth-friendly HIV services; and (3) prmte the use and adaptatin f best practices fr adlescent- and yuth-friendly HIV services in rder t imprve the quality f HIV services delivered t yung peple and t attract adlescents and yuth t retain them in thse services. Best Practices fr Adlescent- and Yuth-Friendly HIV Services: A Cmpendium f Selected Prjects in PEPFAR-Supprted Cuntries reflects the results f a call fr best-practices prpsals and an examinatin f peer-reviewed and gray literature in 22 PEPFAR-supprted cuntries. These guidelines are a cmpanin t that dcument. The 13 prjects cvered in the cmpendium are thse we received permissin t summarize. A review grup graded the prjects using well-established criteria. These criteria were adlescent and yuth invlvement, relevance, effectiveness/impact, reach, feasibility, sustainability, replicability r transferability, ethical sundness, and efficiency. Seven best practices, fur prmising practices, and tw emerging practices were identified, f which five prvided strng evidence needed t recmmend pririties fr actin. Best practices are (1) Adlescent-friendly Vluntary Medical Male Circumcisin Prject, in Suth Africa; (2) Futbl para la Vida (Deprtes para la Vida), in Dminican Republic; (3) Mema kwa Vijana, in the United Republic f Tanzania, (4) One2ne Integrated Digital Platfrm, in Kenya; (5) Supprting Yuth and Mtivating Psitive Actin (SYMPA), in the Demcratic Republic f the Cng; (6) Prgram H, in Ethipia and Namibia; and (7) Zvandiri Prject, in Zimbabwe. Prmising practices are (1) Integrated Prject against HIV/AIDS, in Chibmb District, Zambia; (2) Prject Accept, in Suth Africa, United Republic f Tanzania, and Zimbabwe; (3) Sunbursts Prject, in Kenya; and (4) Tlkit and Training Manual fr Transitin f Care and Other Services fr Adlescents with HIV. Emerging practices are (1) Feel the Future, in Malawi; and (2) Yuth Vluntary Cunseling and Testing, in Btswana. (Fr details n all f these, see Table 1). The interventins these prjects prvided were classified int fur grups accrding t cmmn characteristics and chices that prgram managers and plicymakers might have t make when deciding what t d: Clinic-based interventins with r withut a cmmunity cmpnent Clinic-based and schl-based interventins with r withut a cmmunity cmpnent Cmmunity-based interventins Mbile- and web-based interventins Guidelines n Best Practices fr Yuth-Friendly HIV Services 5
6 MAKING PROJECTS ADOLESCENT- AND YOUTH-FRIENDLY At the prgram design and implementatin levels, prjects tk several initiatives t make their interventins adlescent- and yuth-friendly. Meaningful engagement f adlescents and yuth in prgram design and implementatin Increasing accessibility t services, by extending services t after-schl hurs, establishing adlescent centers run by trained adlescents and yuth within health facilities, and prviding mbile HIV testing services in venues easily accessible by yuth Affrdable fees r free services (e.g., free HIV testing, free cndms, and free medical care fr adlescents and yuth living with HIV [AYLHIV]) Linkages between schls, yuth clubs, yuth crners, and ther yuth-friendly institutins Prviding alternative ways t access infrmatin, cunseling, r services (e.g., use f digital technlgies thrugh mbile- r web-based platfrms and cartn vides) Training staff t prvide adlescent- and yuth-friendly services Maintaining privacy and cnfidentiality (e.g., cnducting mck circumcisin fr male adlescents and yuth wh test psitive fr HIV, t maintain cnfidentiality and reduce stigma) Peer cunseling n risk reductin, safer sex, vluntary cunseling and testing fr HIV, and adherence t antiretrviral drugs 6 Guidelines n Best Practices fr Yuth-Friendly HIV Services
7 IMPACT ON ADOLESCENT AND YOUTH HIV-RELATED OUTCOMES Five prjects were categrized as having rigrus evaluatin designs (experimental studies with randm assignment t an interventin r cntrl cnditin r quasi-experimental designs invlving cmparisn grups withut randm assignment): Futbl para la Vida, Mema kwa Vijana, Prgram H, Zvandiri prject, and Prject Accept. Based n the results f the impact evaluatins, prjects were categrized in five nnmutually exclusive grups: Effective fr HIV-related and attitudinal utcmes (e.g., Mema kwa Vijana and Prgram H) Effective fr HIV-related behaviral utcmes Sexual behavir (MEMA kwa Vijana) Cndm use (MEMA kwa Vijana) Intimate partner vilence (Prgram H) HIV testing (Prject Accept) Disclsure and adherence t antiretrviral therapy (Zvandiri prject) Nt effective fr HIV-related behaviral utcmes Sexual behavir (Prject Accept) Effective fr HIV-related bilgical utcmes Clinical symptms and signs f sexually transmitted infectin (STI) (MEMA kwa Vijana) Nt effective fr HIV-related bilgical utcmes HIV incidence and HSV2 prevalence (MEMA kwa Vijana) Eight prjects used nnrigrus r qualitative evaluatin designs. In sme cases, these prjects fund psitive effects n HIV-related knwledge, attitudes, and behaviral utcmes. Nnrigrus designs are ften cst-effective fr establishing the need fr and reach f an interventin and fr building the evidence base. Hwever, prgress in identifying effective strategies t meet the HIV-related needs f adlescents and yuth depends n the use f mre rigrus methds fr determining what wrks, fr hw lng, and fr whm. Guidelines n Best Practices fr Yuth-Friendly HIV Services 7
8 LESSONS LEARNED FROM THESE PROJECTS Clinic-based interventins with r withut a cmmunity cmpnent When implementing curricula amng HIV-psitive yuth, it is t be nted that the educatinal level f participants can vary. Outside f schl-based settings, specific activities requiring written respnses wuld need t be adapted fr adlescents and yuth wh are unable t write (SYMPA prject). T manage the unique needs f adlescents and yuth wh are living with HIV, individualized transitin-t-adult care prgrams must be built (Tlkit and Training Manual) In a cntext where few health facilities ffer HIV services that are tailred t adlescents and yuth, cunselrs are able t reach mre adlescents and yuth during mbile testing as ppsed t fixed-site service delivery (Prject Accept and Yuth VCT [Vluntary Cunseling and Testing] Prject) Clinic-based and schl-based interventins with r withut a cmmunity cmpnent Cmmunity invlvement and cnsultatins are critical fr creating an enabling envirnment fr recruitment f in-schl adlescents fr VMMC services (Adlescent- Friendly VMMC Prject). A single training during scale-up f a schl-based curriculum appears t be insufficient t impart skills required t teach the psychscial aspects f the curriculum. Systematic preservice training f teachers wuld be mre cst-efficient (MEMA kwa Vijana). Cmmunity-based interventins Invlvement f lcal peple and cmmunity-based gvernmental and nngvernmental rganizatins is critical t success in imprving HIV-related knwledge and attitudes amng adlescents and yuth (Futbl para la Vida/Deprtes para la Vida). If HIV-testing services are prvided in cnvenient and accessible lcatins such as markets, churches, cmmunity and shpping centers, and transprtatin hubs, adlescents and yuth will make use f the services and new ppulatins nt serviced by facility-based services can be reached (Prject Accept). There is n magic bullet fr cmmunity mbilizatin. Strategies used in varying cmbinatins are stakehlder buy-in; cmmunity calitin building; direct cmmunity engagement; cmmunity participatin in prject-related activities; raising cmmunity awareness; invlving cmmunity leaders; and creating partnerships with lcal rganizatins (Prject Accept). Mbile and web-based interventins Mbile platfrms are a crucial delivery pint fr adlescents and yuth, because these age grups favr them and als because they are annymus. Annymity makes it easier fr adlescents and yuth t ask questins and seek advice abut health issues (One2One Integrated Digital Platfrm [OIDP]). 8 Guidelines n Best Practices fr Yuth-Friendly HIV Services
9 POTENTIAL FOR SUSTAINABILITY Sustainability was interpreted in terms f sustaining prject activities, transferring best practices t ther prgrams and settings, identifying new funding streams, and maintaining imprved health utcmes fr adlescents and yuth ver time. Prjects identified several factrs that cntribute t the sustainability f their adlescent- and yuth-friendly practices: Integratin f prject activities in existing health systems and gvernment and cmmunity structures Cmmunity buy-in and advcacy fr the prject Cllabrative relatinships and partnerships Crdinating funding frm multiple surces t sustain the prject Evaluatin results demnstrating that the prject is making a difference Hwever, unless partnerships are built with cmmunities, gvernments, and lcal rganizatins right at the prgram design stage, and unless cmmunities are taught hw t secure cntinued funding and ther supprt, even prgrams that rigrus evaluatins have shwn t wrk may nt cntinue beynd the life f the initial interventin. Guidelines n Best Practices fr Yuth-Friendly HIV Services 9
10 ADDITIONAL CONSIDERATIONS Prgrams shuld dcument their activities in detail t clarify what is being dne and the expected utcmes. Mst prgrams need high-quality mnitring and impact evaluatin f interventins amng adlescents and yuth. Where pssible, future evaluatins shuld use randmized r quasiexperimental designs t strengthen the evidence. Mre research is needed n the practices that are best fr engaging adlescents and yuth in planning, implementing, and evaluating HIV preventin, care, treatment, and retentin services. Studies are needed t identify features r characteristics that increase the effectiveness f adlescent- and yuth-friendly HIV prgrams. Prgrams need t make substantial investment in prviding estimates f prgram efficiency and estimates f cst-effectiveness. These data were lacking (r nt in the public dmain) fr mst prjects included in these guidelines. During scale-up f adlescent- and yuth-friendly interventins that have been prven t be effective, attentin must be paid t maintaining an interventin s quality (e.g., prviding a supprtive implementatin infrastructure, nging capacity strengthening activities fr prgram implementers, and increased attentin t supprtive supervisin and mnitring). Assessment f the lng-term impact f prgrams is needed. Adequate funding must be allcated fr rigrus impact evaluatin, fr assessments f prgram efficiency, and t strengthen the methdlgical expertise f implementing partners and research staff in PEPFAR-supprted cuntries. 10 Guidelines n Best Practices fr Yuth-Friendly HIV Services
11 Table 1. Descriptin f interventins included in the Cmpendium Study Lcatin and Prgram Type Target Ppulatin Descriptin BEST PRACTICES Suth Africa: Adlescent-Friendly Vluntary Medical Male Circumcisin (VMMC) Clinic- and schl-based In-schl male adlescents, ages years, in rural areas Cmmunity cnsultatin and engagement In-schl vluntary medical male circumcisin (VMMC) awareness sessins and service-access facilitatin Health facility-based HIV cunseling and testing and VMMC service access Peer recruitment Dminican Republic: Futbl para la Vida (Deprtes para la Vida) Cmmunitybased Mbile and migrant, street, in-schl, and ut-f-schl adlescents and yuth; rphans and vulnerable children in rural and urban areas Bilingual Spanish/Haitian Kreyl sccer camps and curses Training-f-trainers wrkshps fr cmmunity-based peer educatrs (lcal batey sccer players), lcal nngvernmental rganizatin staff, public schls, and health prgrams Supprt fr yuth camps, sccer turnaments, and ther utreach pprtunities United Republic f Tanzania: MEMA kwa Vijana Clinic-, schl-, and cmmunitybased Adlescents, ages years, in rural areas Teacher-led, peer-assisted sexual health educatin curriculum in schls Yuth-friendly health services Cmmunity-based cndm prmtin and distributin by yuth Cmmunity activities (e.g., yuth health weeks) Kenya: One2One Integrated Digital Platfrm (OIDP) Mbile and webbased Adlescents and yuth, ages years, in six cunties with a high burden f HIV Mbile-based services fr sexual and reprductive health, HIV, and genderbased vilence Prvisin f health infrmatin and cunseling thrugh web-based platfrms Engagement f AYLHIV and key ppulatins in message develpment Tll-free htline The Demcratic Republic f the Cng: Supprting Yuth and Mtivating Psitive Actin (SYMPA) Clinic-based Yuth living with HIV (YLWH), ages years, seeking care at a clinic in Kinshasa Develpment and implementatin f a curriculum n psitive preventin Mnthly peer educatin sessins Peer supprt grups Guidelines n Best Practices fr Yuth-Friendly HIV Services 11
12 Ethipia and Namibia: Prgram H Cmmunitybased Yng men, ages years Validated curriculum and educatinal vide t prmte attitude and behavir change amng men Lifestyle scial marketing campaign t prmte changes in cmmunity r scial nrms related t what it means t be a man Grup discussins t prmte critical dialgue and reflectin abut gender nrms amng yung men Zimbabwe: Zvandiri Prject Clinic- and cmmunitybased Adlescents and yuth, ages years Mnthly cmmunity-based supprt grups run by trained facilitatrs (including AYLHIV) Cmmunity utreach cnducted by a multidisciplinary team (an HIV clinician, nurse, cunselrs, a scial wrker, a psychlgist, and a netwrk f cmmunity adlescent treatment supprters (CATS) Peer cunseling by trained ALHIV, ages years, in clinics and thrugh hme visits Establishment f clinic-based adlescent/yuth Zvandiri Centres run by CATS Cmmunity-based HIV cunseling and testing fr children and yung peple Caregiver training by CATS t imprve their understanding f the needs and experiences f the adlescents in their care Multimedia advcacy campaigns and participatin in develpment f plicy and guidelines by Zvandiri adlescents and yuth Prvisin by Zvandiri yuth f training and mentrship fr health wrkers, scial wrkers, and cmmunity rganizatins t strengthen the integratin f psychscial supprt and clinical care PROMISING PRACTICES Zambia: Integrated Prgram Against HIV/AIDS in Chibmb District Cmmunitybased Adlescents and yuth, ages years, in six rural cmmunities Peer-educatr training in life-skills educatin, behavir change cmmunicatin, and psychscial supprt fr rphans and vulnerable children Peer-led scial mbilizatin and awareness raising n preventing HIV and ther sexually transmitted infectins, and gender issues related t child abuse, rape, and early marriage Incme-generating activities fr caregivers Zimbabwe, Tanzania, and Suth Africa: Prject Accept Cmmunitybased Ages years in urban and rural areas Cmmunity mbilizatin (vlunteer recruitment f HIV-psitive and -negative peple and integratin f them arund educatinal, scial, and plitical gals in cmmunity events) Cmmunity-based vluntary cunseling and testing (free HIV testing, pst-test cunseling, free male and female cndms t thse wh test) 12 Guidelines n Best Practices fr Yuth-Friendly HIV Services
13 Cmmunity-based psttest supprt services (infrmatin-sharing grup sessins; psychscial supprt grups; crisis cunseling; cping effectiveness training; and stigma-reductin wrkshps) Kenya Sunbursts Prject Cmmunitybased Children, ages 6 9 years, and adlescents, ages & years, in urban areas Peer-led cmmunity-supprt grup prgram (pen discussin, educatinal lessns, artistic and therapeutic activities, games, and rle-playing) Family scial events Cmmunity utreach fr stigma reductin Summer camp prgram fr children living with life- threatening illnesses Tlkit and Training Manual fr Transitin f Care and Other Services fr Adlescents Living with HIV Clinic-based Healthcare prviders and AYLHIV Develpment f a tlkit and training manual Pilt f the tlkit Cmprehensive training cnducted fr healthcare and cmmunity-care prviders in fur sites Mnthly supprtive supervisin visits Adaptatin f tlkit t lcal cntexts EMERGING PRACTICES Malawi: Feel the Future Btswana: Yuth Vluntary Cunseling and Testing Cmmunitybased Clinic-based AYLHIV Direct cunseling f AYLHIV Dedicatin f physical space at DREAM health centers fr AYLHIV Creatin f age-based supprt grups fr AYLHIV (ages 11 16, 17 20, and years) Cmmunity-based activities t cmbat stigma and discriminatin Adlescents and yuth in the general ppulatin HIV testing and cunseling Supprt fr nging cunseling and scial supprt Referrals fr family planning r CD4+ testing Cntinuus educatin and behavir-change cmmunicatin campaign t increase awareness Pst Test Clubs fr yuth and prmtin f psitive living Guidelines n Best Practices fr Yuth-Friendly HIV Services 13
14 MEASURE Evaluatin University f Nrth Carlina at Chapel Hill 400 Meadwmnt Village Circle, 3 rd Flr Chapel Hill, Nrth Carlina Phne: measure@unc.edu This publicatin was prduced with the supprt f the United States Agency fr Internatinal Develpment (USAID) under the terms f MEASURE Evaluatin cperative agreement AID-OAA-L MEASURE Evaluatin is implemented by the Carlina Ppulatin Center, University f Nrth Carlina at Chapel Hill in partnership with ICF Internatinal; Jhn Snw, Inc.; Management Sciences fr Health; Palladium; and Tulane University. Views expressed are nt necessarily thse f USAID r the United States gvernment. SR
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