Linking HIV and SRH programmes to adolescent health
“We need to meet the needs and fulfil the rights of adolescents”
Von Venkatraman Chandra-Mouli / Weltgesundheitsorganisation WHO
There are 1.2 billion adolescents (10-19 years) in the world today. This is the largest number of adolescents in the history of mankind. Sexual and Reproductive Health programmes and HIV programmes do not effectively address adolescents.
An estimated 6.1 million adolescent girls aged 15-19 years have unintended pregnancies every year. (DFID/USAID 2010) An estimated 569,000 women aged 10-24 years are infected with HIV every year (i.e. 64% of 890,000 young people are infected every year). (UNAIDS/WHO Report 2010) According to WHO's multicountry study on women's health and domestic violence against women (WHO's multicountry study) millions of adolescent girls are coerced into having sex every year, with the risk of both sexually transmitted infections and unwanted pregnancy. An estimated 49 million young people living with HIV need information and services for a range of issues including pregnancy prevention and pregnancy care (including Prevention of Mother to Child Transmission PMTCT). (UNAIDS/WHO Report 2010)
Given this, more effective and better linked HIV and Sexual and Reproductive Health (SRH) programmes would make good sense for the world's adolescents. They would make good sense for those who manage and deliver programmes to adolescents too, whether this is school based sexuality education, community action to change social norms or health service provision to adolescents.
How effective and how linked are HIV and SRH programmes, from the adolescent health view point? Here is a rough scoring based on three recent surveys: WHO's maternal, neonatal, child and adolescent health survey 2010, UNICEF's most at risk adolescents - pilot policy and programme effort index, for the Middle East and North African region, 2010, and UNFPA's Assessment of the State of SRH programming for young people in 20 countries, 2010.
- Epidemiology and programmatic data (2/10)
- Policies and strategies (5/10)
- Sexuality education (6/10)
- Health service provision (2-3/10)
- Structural interventions (Individual asset building, changing social norms, overcoming economic constraints) (0-1/10)
The key messages emerge from this are that there are more linkages than there were years ago and that there are more linkages in some areas than in others. Overall the situation is not satisfactory. Having said that, where there is a strong commitment to bringing these two streams of work together, and incentives provided for this, collaborative initiatives has been put in place and been sustained. One outstanding example of this is the Geracao Biz programme in Mozambique which addresses the sexual and reproductive health of young people in that country, in a holistic manner. (WHO/Pathfinder 2009)
Let us then move to a key question: Why are SRH and HIV programmes so weakly linked? There are three key reasons for this: separate funding streams; separate programmes; and separate measures of effectiveness.
Responding to the needs of adolescents
What are we in WHO doing to strengthen collaboration between HIV and SRH programmes?
1. Gathering, analysing and using strategic information: There is often a lack of accurate and up-to-date age disaggregated data on SRH and on HIV/AIDS which hinders well informed policy and strategy development. We are addressing this problem by supporting countries to analyse existing data from an adolescent perspective in order to advocate for concerted and coordinated attention to SRH and HIV/AIDS in this age group.
2. Developing supportive policies and strategies based on strategic information and sound evidence: One of the key problems we observe is that while national SRH and HIV strategy documents generally contain broad statements about the need to work in collaboration with each other, they provide little practical guidance to implementers on how this is to be done. We are addressing this problem by using opportunities created by national SRH and HIV programme reviews and sub-national strategy development exercises to identify opportunities for collaboration on a limited number of clearly defined issues of shared interest to both programmes.
3. Scaling up the provision of health services and commodities: Adolescents face many barriers in accessing the health services that they need to prevent HIV and unwanted pregnancy, and obtain care and support for pregnancy and HIV/AIDS. Although national SRH and HIV programmes in most countries recognize the need to provide such services, concerted action is often hindered by the lack of clear understanding on how to reach out to adolescents with the health information and services they need. There is often also discomfort about providing adolescents with such services, and where NGOs pick up the challenge their initiatives tend to be small in scale, limited in duration and patchy in quality, although there are some notable exceptions. We have been working to support ministries of health by convening consultative processes that bring together national SRH and HIV programmes in order to define the package of health services, the standards of quality for health service provision, criteria to achieve them, indicators to verify their achievement, and actions to be taken by programme managers and health facility managers to scale up in a phased manner.
4. Engaging and strengthening other sectors: Other sectors, such as education, social welfare and youth, have important contributions to make that complement the health sector's response to SRH and HIV. Unfortunately there are both missed opportunities and needless duplication in the work of different sectors, and we are therefore supporting ministries of health to work with other sectors on specific activities that could contribute to the twin goals of preventing HIV/STIs and preventing too-early pregnancy in adolescents. (WHO. Strengthening the health sector's response to adolescent health. WHO. Adolescent Health 2009 / V.Chandra-Mouli et al. 2010)
One new opportunity that we are exploring is to link male circumcision programmes which are being rolled out in many East and Southern African countries with sexuality education and gender sensitivity training.
To conclude, SRH and HIV programmes in many places do not effectively address adolescents and they are only weakly linked. There are initiatives under way to address both these challenges. We need to build on these experiences to meet the needs and fulfil the rights of adolescents.
*Dr Venkatraman Chandra-Mouli is the Coordinator of the Adolescent Health and Development, Department of Child and Adolescent Health and Development, in the World Health Organization WHO in Geneva. Before joining WHO he worked in India, Zambia and Zimbabwe for 12 years, initially as a clinician and later as a public health worker. Contact: firstname.lastname@example.org
- DFID/USAID. Choices for women. plannned pregnancy, safe births and healthy newborns. DFID. London.2010
- UNAIDS/WHO Report of the global AIDS epidemic. WHO Geneva 2010
- WHO, WHO's multicountry study on women's health and domestic violence against women http://www.who.int/gender/violence/who_multicountry_study/en/
- UNAIDS/WHO. Report of the global AIDS epidemic.2010
- WHO and Pathfinder. From inception to large scale. The Geracao Biz programme in Mozambique. WHO 2009
- WHO. Strengthening the health sector's response to adolescent health. WHO. 2009
- V.Chandra-Mouli, B Dick, O Lawe-Davies. Responding to the needs of adolescents. Bulletin of WHO. 2010, 88, 3