Although HIV is declining in sub-Saharan Africa, HIV incidence and mortality in adolescents remains intractable: in 2014, 64% of new infections were among adolescents aged 10-19 years of age.
One of the biggest challenges South Africa faces is how to prevent adolescent HIV, how to enrol the large numbers of adolescents living with HIV into care, and to how keep them adherent to their medications. Day One of the conference covered a wide range of research and programmes dedicated to these tasks.
At their Hillbrow clinic in Johannesburg, the Wits Reproductive Health Institute has experimented with expanding their clinical HIV services to include contraception. They wanted to understand whether this would work as an inducement and entry point to care, ultimately improving HIV testing, prevention and treatment uptake for young women at risk of HIV infection. They found that by widening the services offered at the clinic they achieved a substantial increase in clinic visits -a 57% increase to over 1,000 headcount visits a month since April 2016. There was also a reported 63% increase in HIV testing - and contraceptive service uptake increased by 632%. These results suggest that offering contraceptive services is an important entry point to care for adolescent girls and young women, and should be leveraged to ensure reach to vulnerable populations and maximise HIV testing and other SRH services.
Limited research demonstrates very low rates of ART adherence among adolescents, with only about 20% of adolescents regularly taking their ARV medicine. The EHPSA-funded Mzantsi Wakho study has found that 36% of their 1,000-strong cohort of HIV-positive adolescents reported "past week" non-adherence to ARVs, and 52% reported "past yea"r non-adherence. Their research shows that strong adherence is a result of a triumvirate of care: youth-friendly health worker support, caregiver support (parent/ guardian), and self-support from the individual adolescents themselves.
Whilst ART adherence is often understood clinically, Mzantsi Wakho undertook to understand non-adherence qualitatively by running a Masterchef-style participatory workshop (“Yummy or Crummy”), which explored the multisensory dimensions of medicine-taking. Results from this workshop highlighted the sociological aspects of ART adherence – whether adolescents had access to water/food particularly when taking sizeable pills; pill packets that were discrete and easy to transport and conceal, and “knowability”, as participants had a strong preference for medicines which they could easily identify.
Another morning session included two presentations on youth adherence clubs, which reported adherence successes of up to 94% of club members staying on treatment for the period of the study. In both examples the adherence clubs, while located at clinic facilities, are resourced and supported by external funding. The long-term sustainability of adherence clubs, even against the backdrop of national guidelines on adherence, may present a challenge once external funding is ended. Making adherence clubs universally accessible could be an even larger challenge.
Other research, also from Mzantsi Wakho, raised a more complex issue in relation to the envisaged effectiveness of adherence clubs. It indicates a high level of mobility amongst young people who would benefit from regular attendance of adherence clubs. It appears that these young people relocate for the very reasons that put them at risk in the first place: lack of economic opportunities, abuse, gender based violence, etc. And girls are more likely to relocate than boys. This mobility and the reasons for the mobility present a serious challenge.
Research from the Soul City Institute provides a ray of hope in the whole adolescent HIV conundrum. A retrospective study following up ex-members of their Soul Buddyz programme set out to discover if members of the programme had experienced any long-term benefits. At its height, Soul Buddyz had over 200,000 members across the country who received HIV prevention support in a youth club setting. Ten years later the study used innovative strategies to hunt down female ex-Buddies, and compare their profiles with a community control group. The headline news is that the ex-Buddies were three times more likely to be HIV-negative than the control group. The study attributes this to the fact that they were more likely to use condoms at first sex and less likely to have many sexual partners – both elements of the Soul Buddyz ethos.
The conference offered a mix of sessions – with skills-building workshops alongside formal presentations. One workshop showed participants how the HIV prevention and 90-90-90 treatment goals could be achieved through “fun and games”.
Participants learnt how to implement the games in their HIV programmes via the Bridges Model, offered by the Bridges of Hope Training. Different games were played to demonstrate issues like stigmatisation and self-stigma, HIV transmission, ART adherence, peer-to-peer support and HIV prevention.
Participants walked on “stick bridges” to avoid the sharks, hippos and crocodiles (health threats and challenges) and reach the destination (desired future); and the “shaking hands” exercise demonstrated the HIV virus’ ability to transmit rapidly through a sexual network.