HIV treatment and care services for adolescents: a situational analysis of 218 facilities in 23 sub-Saharan African countries.

INTRODUCTION: In 2013, an estimated 2.1 million adolescents (age 10-19 years) were living with HIV globally. The extent to which health facilities provide appropriate treatment and care was unknown. To support understanding of service availability in 2014, Paediatric-Adolescent Treatment Africa (PATA), a non-governmental organisation (NGO) supporting a network of health facilities across sub-Saharan Africa, undertook a facility-level situational analysis of adolescent HIV treatment and care services in 23 countries. METHODS: Two hundred and eighteen facilities, responsible for an estimated 80,072 HIV-infected adolescents in care, were surveyed. Sixty per cent of the sample were from PATA's network, with the remaining gathered via local NGO partners and snowball sampling. Data were analysed using descriptive statistics and coding to describe central tendencies and identify themes. RESULTS: Respondents represented three subregions: West and Central Africa (n = 59; 27%), East Africa (n = 77, 35%) and southern Africa (n = 82, 38%). Half (50%) of the facilities were in urban areas, 17% peri-urban and 33% rural settings. Insufficient data disaggregation and outcomes monitoring were critical issues. A quarter of facilities did not have a working definition of adolescence. Facilities reported non-adherence as their key challenge in adolescent service provision, but had insufficient protocols for determining and managing poor adherence and loss to follow-up. Adherence counselling focused on implications of non-adherence rather than its drivers. Facilities recommended peer support as an effective adherence and retention intervention, yet not all offered these services. Almost two-thirds reported attending to adolescents with adults and/or children, and half had no transitioning protocols. Of those with transitioning protocols, 21% moved pregnant adolescents into adult services earlier than their peers. There was limited sexual and reproductive health integration, with 63% of facilities offering these services within their HIV programmes and 46% catering to the special needs of HIV-infected pregnant adolescents. CONCLUSIONS: Results indicate that providers are challenged by adolescent adherence and reflect an insufficiently targeted approach for adolescents. Guidance on standard definitions for adherence, retention and counselling approaches is needed. Peer support may create an enabling environment and sensitize personnel. Service delivery gaps should be addressed, with standardized transition and quality counselling. Integrated, comprehensive sexual reproductive health services are needed, with support for pregnant adolescents.

Measuring change in vulnerable adolescents: findings from a peer education evaluation in South Africa.

INTRODUCTION: In the context of poverty and HIV and AIDS, peer education is thought to be capable of providing vulnerable youth with psychosocial support as well as information and decision-making skills otherwise limited by scarce social and material resources. As a preventative education intervention method, peer education is a strategy aimed at norms and peer group influences that affect health behaviours and attitudes. However, too few evaluations of peer-led programmes are available, and they frequently fail to reflect real differences between those who have been recipients of peer education and those who have not. This article reports on an evaluation of a pilot peer-led intervention, entitled Vhutshilo, implemented on principles agreed upon through a collaborative effort in South Africa by the Harvard School of Public Health and the Centre for the Support of Peer Education (the Rutanang collaboration). Vhutshilo targeted vulnerable adolescents aged 14-16 years living in some of South Africa's under-resourced communities. METHODOLOGY: The research design was a mixed-method (qualitative and quantitative), longitudinal, quasi-experimental evaluation. Tools used included a quantitative survey questionnaire (n = 183) and semi-structured interviews (n = 32) with beneficiaries of peer education. Surveys were administered twice for beneficiaries of peer education (n = 73), immediately after completion of the programme (post-test) and 4 months later (delayed post-test), and once for control group members (n = 110). The three main methodological limitations in this study were the use of a once-off control group assessment as the baseline for comparison, without a pre-test, due to timing and resource constraints; a small sample size (n = 183), which reduced the statistical power of the evaluation; and the unavailability of existing tested survey questions to measure the impact of peer education and its role in behaviour change. FINDINGS: This article reports on the difficulties of designing a comprehensive evaluation within time and financial constraints, critically evaluates survey design with multi-item indicators, and discusses six statistically significant changes observed in Vhutshilo participants out of a 92-point survey. Youth struggling with poor quality education and living in economically fraught contexts with little social support, nonetheless, showed evidence of having greater knowledge of support networks and an expanded emotional repertoire by the end of the Vhutshilo programme, and 4 months later. At both individual and group level, many with low socio-economic status showed great improvement with regard to programme indicator scores. CONCLUSION: For the poorest adolescents, especially those living in the rural parts of South Africa, peer education has the potential to change future orientation, attitudes and knowledge regarding HIV and AIDS, including an intolerance for multiple concurrent partnerships. When well organised and properly supported, peer education programmes (and the Vhutshilo curriculum, in particular) provide vulnerable youth with opportunities to develop psychosocial skills and informational resources that contribute to the changing of norms, attitudes and behaviours. However, the article also flags the need for effective peer education evaluations that take into account limited financial resources and that possess tested indicators of programme effectiveness.