Adolescents and HIV epidemic control
Despite years of advocacy and a growing evidence base to reduce vertical programming, progress on integrating services remains limited and, in many countries, HIV prevention and family planning (FP) continue to be offered as isolated services with limited options. Providing individual services in isolation places an unnecessary burden on clients and health workers. In addition, it doesn’t take into consideration the specific needs of adolescent girls and young women (AGYW) who already face numerous challenges to access high-quality care. AGYW report a lack of support from parents and sexual partners for contraceptives and HIV prevention methods[1],[2] and cite negative, judgmental attitudes from providers[3] and frequent stockouts of FP methods as barriers at the health facility level.
To achieve HIV epidemic control, AGYW at high risk of acquiring HIV must have access to comprehensive sexual and reproductive health (SRH) services that address their unique HIV prevention needs alongside their contraceptive and FP needs. The 2023 UNAIDS report confirmed the urgent need to address AGYW HIV prevention and SRH needs, indicating a continued disproportionately high risk of acquiring HIV among AGYW 15–24 years old, with a total of 210,000 women in this age group acquiring HIV in 2022.[4] The report attributes this increased vulnerability among AGYW to insufficient access to information and services to protect their sexual well-being and a lack of decision-making power about sex, contraceptive use, and health care.
Every year, an estimated 21 million AGYW aged 15–19 years in low- and middle-income countries (LMIC) become pregnant, around 50% are unintended; 55% of these pregnancies end in largely unsafe abortions.[5] Although access to modern contraceptive methods has improved, there is still a substantial unmet need for contraception and FP. According to a 2016 study, of the 252 million AGYW living in LMIC, approximately 38 million are sexually active and do not want a child in the next two years; 15 million of these AGYW use a modern contraceptive method, while 23 million do not.[6]
The 2019 Evidence for Contraceptive Options and HIV Outcomes (ECHO) trial,[7] (a large-scale randomized clinical trial of the relationship between hormonal contraception and HIV conducted in Eswatini, Kenya, South Africa, and Zambia), reinforced the need for urgent action. The trial confirmed an unacceptably high incidence of HIV infection and other sexually transmitted infections among AGYW seeking contraception in the study areas and limited choices for HIV prevention and contraception. High HIV incidence was observed among women seeking FP/SRH services who were not necessarily classified or considered to be at risk, emphasizing the importance of integrating HIV prevention and FP/SRH services, especially in high-burden settings. These findings resulted in a renewed call to improve access to a full range of contraceptives and integrate HIV prevention within FP services, including multiple pre-exposure prophylaxis options. The finding informed the development of the 2020 Global Fund Strategic Initiative on Adolescent Girls and Young Women (AGYWSI), a catalytic investment to align national strategies and Global Fund investments with epidemiology and evidence-based interventions that improve HIV prevention outcomes among AGYW.
Experience from five countries
Drawing on our vast experience working across disease areas and services and with our deep understanding of the importance of integrated service delivery for high-quality care, from December 2022 to December 2023, Jhpiego implemented Phase Two of the second component of the AGYWSI with funding from Global Fund and continued strategic aspects of this work until June 2024 with organizational (Jhpiego) funding. We worked in five countries—Kenya, Mozambique, South Africa, Tanzania, and Zimbabwe—supporting government priorities for enhanced SRH/HIV system integration and readiness. This built on work previously done by the World Health Organization in each country that included conducting landscape analysis to assess policy and program gaps and creating country action plans to improve availability, accessibility, uptake, and quality of integrated SRH and HIV services. In each country, Jhpiego worked with governments to identify and support strategic priority activities that could be implemented during the project. Based on our experience, these are the common themes and considerations that should be applied for a sustained, high-quality, integrated approach to SRH/HIV prevention:
- Programs require practical guidance on how to apply principles of integration.
While several global guidance documents emphasize the importance of integration with a focus on “why” and “what,” there is less attention on “how” to operationalize integration and, in the absence of clear step-by-step guidance or an incentive to change, siloed services continue according to the status quo. Insufficient operational guidance and policies that don’t meet the needs of service providers and adolescents can lead to inefficiencies and mistrust in the health system.
What is missing is standardization of approaches at the facility level that inform and shape what is happening at a regional and national level, which should include feedback from providers, engagement and coordination, voices of young people, using human-centered design, tracking of integration indicators, training for implementers, accountability for integration, and a sustainability and planning tool/approach. The result is bi-directional communication to mutually inform each other, supporting a system that is both responsive and well-informed.
2. Governments must lead and prioritize integration of SRH/HIV prevention services for AGYW.
More often, integration initiatives are supported by donors/external agencies using a top-down approach. For ownership and long-term sustainability, integration initiatives require government leadership and political commitment. This may first require demonstrating the value of integration to governments, which includes improved health outcomes, better efficiency of resources, and improved experience of care for individual clients. Engaging with and having governments be at the lead, with targeted support, will enable them to include integration in health policies, strategies, and business processes. The government should also foster collaboration between different health departments and ministries; both central and local (decentralized) levels should be involved. To streamline integrated service delivery efforts and resources, integration scope/activities need to be costed. Donors should include integration as a priority/objective. Jhpiego and other implementing partners should continue to advocate with donors to introduce integration and avoid verticalized programming. Governments can also work to synergize programs at the national level, clearly articulating integration within their strategic plans. Governments then need to reinforce this priority in their discussions with donors. For continuous improvements of integrated services, the ministry of health and national health departments need to lead the use of monitoring and evaluation data to improve service delivery, including identifying gaps, assessing the outcomes of integrated services, and making data-driven decisions to enhance program effectiveness.
3. A person-centered, rights-based approach is essential for ensuring equity as we move towards comprehensive, integrated services.
Evidence from AGYW engagement suggests that the current approaches to integrated service delivery do not adequately put AGYW perspectives of quality at the center. Integration must benefit the end users—the clients—and prioritize their needs, rights, and preferences and ensure that services are accessible, acceptable, and of high quality. Communities should be included not only as beneficiaries but also as key stakeholders and decision-makers working in partnership with others. This may include incorporating AGYW in problem identification, designing solutions, community-led monitoring, and other critical aspects of program design that may occur as part of national or local technical working groups. This can also include equipping health workers with the skills needed to deliver integrated, right-based SRH/HIV care and how to seek the perspectives and feedback of their clients. Governments and health workers need to create more opportunities for engaging AGYW at all stages of design, finding value in these partnerships, and strengthening their skills in partnering with AGYW and communities in meaningful ways.
Guidance to share
To strengthen the connective tissue between what is happening at policy and service delivery levels, we developed guidance to support governments in achieving SRH/HIV integration and coordination for—and with—AGYW. Through our experience supporting this process in five countries, we found similar solutions, including the need to optimize the national health management information system to incorporate integration indicators and data use.
The authors are Jhpiego staff on the Adolescent and Young People HIV/Sexual and Reproductive Health Integration Project, funded by the Global Fund.[ET1]
[1] Jonas K, et al. Perceptions of contraception services among recipients of a combination HIV-prevention intervention for adolescent girls and young women in South Africa: a qualitative study. Reprod Health. 2020 Aug 14;17(1):122.
[2] Holmes LE, et al. Qualitative characterizations of relationships among South African adolescent girls and young women and male partners: implications for engagement across HIV self-testing and pre-exposure prophylaxis prevention cascades. JAIDS. 2020; 23(S3):e25521.
[3] Warenius LU, et al. Nurse midwives’ attitudes towards adolescent sexual and reproductive health needs in Kenya and Zambia. Reprod Health Matters. 2006 May;14(27):119-28.
[4] UNAIDS. The path that ends AIDS: UNAIDS Global AIDS Update 2023.
[5] WHO. Adolescent pregnancy.
[6] Guttmacher Institute. Adding it up: Costs and Benefits of Meeting the Contraceptive Needs of Adolescents.
[7] Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial Consortium. HIV incidence among women using intramuscular depot medroxyprogesterone acetate, a copper intrauterine device, or a levonorgestrel implant for contraception: a randomized, multicenter, open-label trial. Lancet. 2019;394:303-13.