HIV Prevention Among Young People in Sub-Saharan Africa: The Way Forward

This report, published by the London School of Hygiene and Tropical Medicine (LSHTM), reports on a technical workshop organised by LSHTM and the Mwanza Research Centre of the Tanzanian National Institute for Medical Research. Held in 2009 in Tanzania, the objective of the workshop was to provide guidance and support for evidence-informed interventions to prevent HIV among young people in Sub-Saharan Africa. Based on data examined during the workshop, the report suggests that interventions to prevent new infections among young people must be designed both to reduce their risk of acquiring HIV, and also reduce the risk of transmitting the virus to others, which may require different approaches and designing interventions for different groups.

The report suggests that interventions need to be of high quality and be sustained as there are new generations continuously entering adolescence. It also notes a need to better understand the links between HIV and key transitions in the lives of young people. In addition, the report states that there are important differences in epidemiology of HIV among young people in sub-Saharan Africa; there is a need to move beyond simplistic analyses and acknowledge that the epidemic is constantly changing. Also, HIV prevention efforts need to be built on a detailed understanding of disaggregated data around the "who", "where", and "what" of new HIV infections, and that this should be combined with an in-depth analysis of the context and local epidemics.

The report also includes findings from an updated systematic review of behavioural interventions in young people, called "Steady, Ready, Go!" The review was led by the World Health Organization (WHO) and LSHTM. Interventions were looked at by setting, mass media, and interventions for young people most at risk. A discussion of the review concluded that multiple factors can mediate behaviour change in young people; as such, careful evaluation of local risk factors and context is necessary to inform the optimal intervention design. In addition, in order to address the range of factors affecting the individual and his/her environment, the challenge remains to ensure the implementation of simultaneous interventions in several settings. Most interventions to date have primarily looked at changes in young people's self-reported sexual risk behaviours or use of health services. However, given the potential for inaccurate and biased reporting of sexual risk behaviours which are particularly severe among young people, much greater weight needs to be put on evaluations that include the measurement of the impact on biological outcomes such as HIV incidence itself. In terms of interventions, more effort should be made to link the programming with interventions that aim to change wider population norms and address structural issues that drive the HIV epidemic.

The report makes a number of recommendations for four key sectors engaged at different levels of HIV/AIDS programming. For policy makers, the report recommends strengthening partnerships and collaboration and involving new partners; implementing existing evidence-based policies; providing political leadership for responding to sensitive issues; developing new and updated policies; and tackling new issues, such as the structural determinants of HIV.

For programme implementers, the document recommends: knowing what the existing evidence-based policies are and implementing them; and implementing and sustaining specific types of interventions, including sexual health education programmes in schools, mass media interventions, service provider training programmes, and interventions designed for young people at risk. It also suggests following good practice with careful monitoring and evaluation for all interventions; creating space for innovation and new approaches; thinking structurally when developing programmes; and insisting on AIDS impact assessments for all major new development or economic initiatives.

For researchers, the report recommends developing a better understanding of the changing dynamics and socio-cultural contexts of local epidemics. It also suggests identifying potential social, psychosocial, cultural, and economic determinants of HIV risk, developing better-validated tools to measure these and investigate their importance to epidemic trends. According to the report, more operations research is required on quality, content, intensity, and a range of issues affecting the scale-up and effective delivery of programmes. In addition, researchers need to evaluate innovative approaches to support existing HIV prevention programmes for young people using the most appropriate mix of evaluation methods. Results should be presented in a clear, user-friendly format and language for programme implementers and policy makers.

The final section of the report makes recommendations for donors. It suggests that donors should support government priorities and young people; ensure intervention rigour; "join up" intervention-based and research-based funding; recognise that programmes and research can take a long time to be effective; fund test practices as well as best practices; and retain flexibility.