The state of the national response to prevent HIV among young people:

The state of the national response to prevent HIV among young

people: A review of national reporting

in 20 high-prevalence countries I Birdthistle, S Dringus, L Knight, E Yankah, P Idele, C Suzuki, L Nguyen, S Kasedde

Evidence-Based Recommendations(Steady, Ready, Go! Review)Outline

• Purpose of the review

• Methods

• Epidemiology of HIV in countries studied

• Review Findings

• Conclusions

For 20 countries with generalized HIV epidemics, national reports were reviewed to assess the national response for YP in terms of:

1. Planning What priority is given to prevention among YP aged 10-24 in national AIDS plans?

2. Implementation Are HIV prevention programs reaching young people? If so, through what activities and settings?

3. FinancingWhat are the absolute and relative amounts spent on youth-specific prevention activities, and are they adequate?

Purpose of the review

MethodsPREPARATION OF COUNTRY SUMMARIES

Selection of 20 countries with generalised HIV epidemics

Core documents identified and retrieved

Construction of template summary and key tables

Core documents reviewed and key information extracted for text and tables

Country (phone) and IATT consultations to validate and revise summaries

CROSS-COUNTRY COMPARISONS AND SYNTHESIS

Findings on national planning

Findings on program implementation &

financing

Finings on data reporting

East Africa (7) Kenya, Malawi, Mozambique, Tanzania, Uganda,

Zambia, ZimbabweSouthern Africa (5) Botswana, Lesotho, Namibia, South Africa, SwazilandWest Africa (3) Cote d’Ivoire, Ghana, NigeriaCentral Africa (3) Cameroon, Central African Republic, GabonCaribbean (2) The Bahamas, Guyana

20 countries included in review

Documents Reviewed

Type of core document Number of countries found and reviewed

National AIDS Strategy / Plan (most recent or current)

19

Mid-term review of National AIDS Plan 7UNGASS Progress Report 2010 20National Composite Policy Index 20National OVC Plan 11National AIDS Spending Assessment (or other national financial report)

16

And other important national reports where available (e.g., National Strategies for Behavior Change; National HIV Prevention Strategy, etc)

EPIDEMIOLOGICAL CONTEXT:‘Know Your Epidemic’

Epidemiological Context: Summary

*Source: Intl Group on Analysis of Trends, Sex Transm Inf 2010 [national data for 3 points in time]^Source: UNAIDS Global AIDS Report 2010 [data for 2 points in time: 2001 and 2009]

Progress toward the UNGASS goal for YP

BotswanaCote d’IvoireKenyaMalawiNamibiaZimbabweZambiaCARSouth AfricaTanzaniaLesothoNigeriaSwazilandBahamasUgandaMozambiqueCameroon



Progress toward the UNGASS goal for Young PeopleHIV decline among 15-24 yr olds since 2001?

Botswana Yes >25% *Cote d’Ivoire Yes >25% *Kenya Yes >25% *Malawi Yes >25% (urban) * Namibia Yes >25% *Zimbabwe Yes >25% *Zambia Yes, females only * CAR Yes, females only ^South Africa Yes, males only *Tanzania Yes, males only *Lesotho Yes, rural only *Nigeria Yes, rural only *Swaziland Yes, urban only *Bahamas Yes, urban *Uganda No *Mozambique No, possible increase *Cameroon No ^



Progress toward the UNGASS goal for YP HIV decline among 15-24 yr olds since 2001?

Evidence of change in sexual behaviour?

Botswana Yes >25% * Not clearCote d’Ivoire Yes >25% * Yes, M&F *Kenya Yes >25% * Yes, M&F *Malawi Yes >25% (urban) * Yes, M&F *Namibia Yes >25% * Yes, M only * Zimbabwe Yes >25% * Yes, M&FZambia Yes, females only * Yes, M&F *CAR Yes, females only ^ Yes, M only * South Africa Yes, males only * No *Tanzania Yes, males only * Yes, M&F *Lesotho Yes, rural only * Not clearNigeria Yes, rural only * Yes, F only *Swaziland Yes, urban only * Not clearBahamas Yes, urban *Uganda No * Yes, M&F *Mozambique No, possible increase * No *Cameroon No ^ Yes, M&F *

Epidemiological Context : HIV prevalence by gender and age

3.3

6.2

16.4

35.6

43.3

4.8 1.4 2.7

9.1

19.1

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

10-14 15-17 18-19 20-22 23-24 10-14 15-17 18-19 20-22 23-24

Female Male

HIV

Prev

elan

ce %

Age groups by sex

Source: Swaziland Demographic and Health Survey 2006-07

Swaziland

Numbers of orphans in 2001 and 2009

Epidemiological Context:Numbers of orphans 2001-2009

NIGERIA

UGANDA

TANZANIA

KENYA

ZIMBABWE

SOUTH AFRICA

ZAMBIA

MALAWI

COTE D’IVOIRE

MOZAMBIQUE

CAMEROON

CAR

GABON

SWAZILAND

GHANA

BOTSWANA

LESOTHO

NAMIBIA

0tan28a566028 0tan15a702915 0tan3a83983 0tan22a976722 0tan10a11136100tan27a12504270tan14a1387314

2009 2001

Source: UNAIDS Global Epidemic Report 2010

The state of national response

1. Planning2. Implementation3. Financing

…and the quality of national reporting

Findings from the review

Part 1: National Planning

The review of all current and most recent National AIDS Plans showed that:

• All 20 countries include youth-specific strategies in their current national AIDS plan.

• A wide range of youth-specific strategies are included across countries

• School-based HIV prevention is the youth-specific strategy most often included …

Part 1: National Planning

School based prevention

Out of school interventions

BCC/IEC, mass media

Condom promotion

Delaying sexual debut

Partner reduction

Abstinence promotion

Training of teachers

Scaling up youth-friendly health svcs

Training peer educators

VCT expansion/promotion

STI services for YP

Youth clubs/associations/groups

Parent involvement

Community sensitisation*

Training health care workers

Male circumcision for youth

Income generating activities

Drug/alcohol interventions

HIV vulnerability mapping

0tan28a566028 0tan1a56601 0tan3a56603 0tan5a56605 0tan7a56607 0tan9a56609 0tan11a566011

Youth-specific HIV prevention strategies listed in current national AIDS plans (and number of countries that list each strategy in their plan)





Scale of Programmes for YP “The majority of people in need have access

to...?”

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Prevention- youth in school

Condom social marketing/promotion

IEC on risk reduction

IEC on stigma & discrimination

Universal precautions

Prevention & treatment of STI

Blood safety

PMTCT

VCT

Prevention in the workplace

Prevention- youth out of school

Post-exposure prophylaxis (PEP)

Prevention for sex workers and clients

Prevention for MSM

Harm-reduction programmes for IDU

NAS

A Pr

even

tion

Cate

gory

Percentage of Countries (% out of 20)

Agree Do not Agree Not Applicable Not Reported

GO!Take these interventions to scale NOW!

Interventions in Schools Curriculum-based interventions led by adults

Media Media delivered through Radio AND TV

READYImplement widely but continue to evaluate

Interventions to improve young people’s access to, and acceptability of, health services

Training service providers AND actions in the clinic to make them more youth friendly AND with activities in the community

Training service providers AND actions in the clinic to make them more youth friendly AND with activities in the community AND involvement of other sectors

Interventions in geographically defined communities

Interventions targeting youth where a new mechanism or infrastructure to deliver the intervention is created Interventions targeting the whole community which are delivered through traditional networks

Evidence-Based Recommendations(Steady, Ready, Go! Review)

Evidence-based programming:‘Steady, Ready, Go!’ review of research

Adapted from SRG2 review in JoAH 2011

Botswan

aKen

ya

South Afric

a

Zimbab

we

Lesotho

Ghana

Namibia

Baham

as

Guyana

Swazi

land

Tanzan

iaGab

on

Centra

l Afric

an Rep

ublic

Uganda

Camero

on

Cote d'Iv

oire

Malawi

Mozambique

Nigeria

Zambia

0tan28a566028

0tan9a56609

0tan19a566019

0tan29a566029

0tan9a56609

0tan19a566019

0tan29a566029

0tan9a56609

0tan19a566019

0tan29a566029

0tan10a566010

0tan27a566027

0tan18a5660180tan18a5660180tan16a566016

0tan30a566030

0tan19a566019

0tan6a566060tan4a56604

0tan25a566025

0tan14a566014

0tan5a566050tan1a56601

Proportion of schools that provided life skills based HIV education in the last academic year (as reported in UNGASS 2010)*

Perc

enta

ge o

f Sch

ools

(%)

NR NRNR NR

*Most recent reported overall estimate for 2007 - 2010 (from different sources)

In-School Investment in Young People Focuses on Lifeskills

Education

INDICATORS OF CONTENT AND QUALITY of SCHOOL-BASED HIV EDUCATION

YES

Does the country have a policy or strategy promoting HIV -related reproductive and sexual health education for young people?

20/20

Is HIV education part of the curriculum in: Primary education 20/20 Secondary education 20/20 Teacher training

20/20

Does the strategy/curriculum provide the same reproductive and sexual health education for young men and young women?

20/20

Does the country have an HIV education strategy for out-of-school young people?

17/20 (No = Botswana, CAR,

Nigeria) Participatory learning methods?

Not consistently reported

Were materials developed?


Do materials need updating?


Parent component?


Includes skills in correct and consistent condom use?


Links/referrals to adolescent-friendly health services? Not consistently reported

Assessing Quality





Funding for HIV Prevention

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Botswana

Cameroon

Central African Republic

Cote d'Ivoire

Gabon

Ghana

Kenya

Lesotho

Malawi

Mozambique

Namibia

Nigeria

S. Africa (2007/08)

Uganda

Zimbabwe (2009)

Prevention Care and Treatment Orphans and Vu lnerab le Children P rogram Management & Ad min Human resou rces Social P rotection & Svcs Enab ling Environment Research

Breakdown of National AIDS Spending by ‘Broad Area’ in 2008

Funding for Youth-Specific HIV prevention

Botswana 2008Cameroon 2007

2008CAR 2007

2008Cote d'Ivoire 2007

2008Gabon 2007

20082009

Ghana 2008Kenya 2007

20082009

Lesotho 20072008

Malawi 20082009

Mozambique 20072008

Nigeria 20072008

Swaziland 2007Zimbabwe 2009

-5% 0% 5% 10% 15% 20% 25% 30%

0% for out-of-school

0% for out-of-school0% for out-of-school

0% for out-of-school0% for out-of-school



0% for out-of-school0%

Spending for in-school youth Spending for out-of-school youth

Proportion of all national HIV prevention funds spent on youth-specific prevention

Example Cote d’Ivoire (2008)OVC: 3%

Children and youth out of school: 0%Junior high / high school students: 0.47%

General population of young people (15-24): 1.05%

Spending by Beneficiary

So, who are the main beneficiaries…? 1. General population not disaggregated: 50% 2. People living with HIV/AIDS, not disaggregated: 27%

Conclusions

Young people are a priority within national plans and strategies.

Relatively little is reported on youth specific coverage and investments in priority areas like HTC and condom promotion.

The intervention most widely planned, implemented and reported on for youth is school-based prevention.

Limited targeted spending on youth and predominant source of funding for youth programmes from external rather than government resources.

Critical to strengthen: routine age-specific reporting validation of quality alignment of investments with evidence domestic funding to ensure sustainability and effective scale of

delivery.