As girls begin to initiate sexual activity earlier and marry later in many countries, they are exposed longer than ever to the risk of unplanned pregnancy and sexually transmitted infections (STIs).¹ Given the public health consequences of this increasing vulnerability, many experts say reproductive health programs should make adolescents’ needs a priority.

Data on 10- to 19-year-olds in developing countries are not reliable enough to draw firm conclusions about trends in their sexual behavior before marriage.² But Demographic and Health Survey results show an increasing gap between age at first sexual intercourse and age at first marriage in 32 of 37 countries surveyed in every region of the developing world, suggesting that premarital sex is rising throughout sub-Saharan Africa and in most countries of other regions.³ In the United States, the gap between sexual initiation and marriage widened by almost 30 percent during the 1980s.⁴ Women in the United States now typically begin sexual activity about seven years before marriage and are sexually active for almost one quarter of their reproductive lives before giving birth.⁵

Beginning sex at earlier ages increases the risk of STIs for young women and men because the longer a person is sexually active before marriage, the more partners he or she is likely to have.⁶ Marrying later can open educational and vocational opportunities to young women,⁷ but later marriage combined with increasing premarital sex among adolescents puts them at greater risk of unplanned pregnancies, unsafe abortions, and STIs, including HIV.⁸

Sexually active adolescents’ risk of pregnancy and STIs is already high. They are less likely than adults to use condoms and other contraceptives and more likely to experience contraceptive failures.⁹ (They are also more likely to resort to unsafe abortion if they decide to terminate unplanned pregnancies.¹⁰) Adolescent girls are at greater risk for STIs than older women because of specific biological characteristics that make them more susceptible to such infections and because they are less likely to be able to refuse unwanted or coercive sex or to negotiate condom use.¹¹

Serving adolescents with differing needs

Most people worldwide have their first sexual experiences — which can have lifelong effects on their sexual and reproductive health — before reaching age 20.¹² Dr. Malcolm Potts, FHI president emeritus and Bixby Professor at the University of California, Berkeley, USA, and his colleagues write that the earliest stages of men’s and women’s reproductive lives are so important for public health that countries with scarce medical resources should devote most of those resources to protecting young people’s sexual and reproductive health. They propose that public reproductive health programs focus on providing education, counseling, and other services to adolescents and young adults at two distinct stages of their reproductive lives: when they are not yet sexually active, and when they are sexually active but do not yet wish to have children. Meanwhile, social marketing programs and private providers would be expected to meet the needs of most women at two other stages of their reproductive lives: when they plan to have a child or more children, and while they are fertile but do not want more children.¹³

Just as adults’ priorities for contraception and STI protection change over the course of their reproductive lives, young people’s reproductive health needs differ as they move through adolescence. Ten-year-olds need information about the changes they will face with the onset of puberty, while older adolescents may need protection against unplanned pregnancy and STIs.

Adolescents are not a homogeneous group. Thus, experts suggest tailoring education, counseling, and other reproductive health services to address the needs of young people with different kinds of experiences. Two young women in a market in Guatemala City, Guatemala.

Recognizing that adolescents are not a homogeneous group, Jane Hughes of the NewYork- based Population Council and Dr. Anne McCauley of the Washington-based International Center for Research on Women have suggested tailoring programs to meet the needs of young people with three different kinds of experiences: those who are not yet sexually active, those who are sexually active and have experienced no unhealthy consequences of their sexual activity, and those whose sexual experiences have resulted in unhealthy consequences, such as abortion complications or STIs. Noting that most providers primarily serve young people in the latter group, Hughes and Dr. McCauley point to the need to put more emphasis on reproductive health education, counseling, and services for adolescents in the first two groups.¹⁴ This approach is supported by research that shows that family life education and other programs to prevent teenage pregnancy and STIs are most effective when they reach young people before they are sexually active.¹⁵

— Kathleen Henry Shears

1. Mensch B, Bruce J, Greene M. The Uncharted Passage: Girls’ Adolescence in the Developing World. New York: Population Council, 1998.
2. Mensch.
3. Blanc AK, Way AA. Sexual behavior and contraceptive knowledge and use among adolescents in developing countries. Stud Fam Plann 1998;29(2):106-16.
4. Forrest JD, Cates W. Stages of women’s reproductive life: impact on contraceptive choice. In Hazeltine FP, LaGuardia K, eds. Opportunities in Contraception: Research and Development. Washington: American Association for the Advancement of Science, 1993.
5. Forrest JD. Timing of reproductive life stages. Obstet Gynecol 1993;82(1):105-11.
6. Alan Guttmacher Institute. Into a New World: Young Women’s Sexual and Reproductive Lives. New York: Alan Guttmacher Institute, 1998.
7. Singh S. Adolescent childbearing in developing countries: a global review. Stud Fam Plann 1998;29(2):117-36.
8. Population Reference Bureau. The World’s Youth 2000. Washington: Population Reference Bureau, 2000.
9. Blanc.
10. Ipas. Children, Youth and Unsafe Abortion. Chapel Hill, NC: Ipas, 2001. Available: http://www.ipas.org/english/publications/children_youth_unsafe_abortions.pdf 
11. Alan Guttmacher Institute.
12. Mensch.
13. Potts M, Rooks J, Holt BY. How to improve family planning and save lives using a stage-of-life approach. Int Fam Plann Perspect 1998;24(4):195-97.
14. Hughes J, McCauley AP. Improving the fit: adolescents’ needs and future programs for sexual and reproductive health in developing countries. Stud Fam Plann 1998;29(2):233-45.
15. Frost JJ, Forrest JD. Understanding the impact of effective teenage pregnancy prevention programs. Fam Plann Perspect 1995;27(5):188-95; Grunseit A, Kippax S, Aggleton P, et al. Sexuality education and young people’s sexual behavior: a review of studies. J Adol Res 1997;12(4):421-53; Kirby D. School-based programs to reduce sexual risk-taking behaviors. J School Health 1992;62(7):280-87; Stanton B, Li X, Kahihuata J. Increased protected sex and abstinence among Namibian youth following a HIV risk-reduction intervention: a randomized, longitudinal study. AIDS 1998;12(18):2473-80.

Many young people in countries where HIV prevalence is high want to know their HIV status, recent studies indicate, and experts see voluntary counseling and testing (VCT) services for youth as a useful way to address their HIV prevention and care needs. However, such services are limited and more research is needed to determine their impact.

With as many as one of every two new HIV infections occurring in some countries among young people,¹ it is important to focus on youth, says Deborah Boswell, an FHI expert on HIV/AIDS care and support services who helped develop VCT services in Zambia. "Some countries are trying to implement and expand VCT services for youth. To ensure quality, counselors and other staff must be trained to work with young people and to be discreet, confidential, and nonjudgmental. Also, care and support services must be available, including direct referral to supportive clinicians and options after testing for those who test either positive or negative."

Working on behalf of the United Nations Children’s Fund, Boswell and colleagues at FHI recently compiled a reference guide on VCT and the needs of young people, children, pregnant women, and their partners.² Among key issues involving young people are the level of their demand for VCT services, the impact of VCT on their behavior, and programmatic challenges that include legal and ethical concerns, adequate counseling, and ongoing support.

Demand for services

In Demographic and Health Surveys in Kenya and Zimbabwe, more than 60 percent of some 6,000 males and females ages 15 to 19 years who had not undergone VCT reported that they would like to be tested.³

In another survey of males and females ages 14 to 21 years, about 90 percent of 210 Ugandans and 75 percent of 122 Kenyans who said they had not received VCT services reported that they wanted to be tested.⁴ However, in these and other studies, some young people feared testing. Some worried that their test results would be positive. Others were concerned that their test results would not remain confidential, that they might lose their partners, and that the services would be costly or be provided in inconvenient locations.

In a Ugandan study of 369 young people ages 14 to 21 years who had sought VCT, young women who decided to get tested tended to do so if they were about to be married, enjoyed their partners’ support, and knew their partners were willing to pay for the service. Nearly two of every three girls said their partners encouraged them to be tested. In contrast, boys were more likely to decide on their own to be tested and to pay for testing themselves. A third of boys said their decision to seek VCT testing was influenced by partners; a third, by friends; and another third, by no one.⁵

Impact of VCT

It appears that VCT can help young people adopt safer sexual practices and even reduce their rates of sexually transmitted infections (STIs), but more research is needed. In a randomized trial involving some 4,000 adults in Kenya, Tanzania, and Trinidad, reduction of unprotected intercourse with non-primary partners was significantly greater among individuals who received VCT than among individuals who received only basic HIV prevention information.⁶ The impact of VCT on behavior by age was not reported. But in an analysis of a subgroup of study participants, a third were 22 years or younger and nearly half were 25 years or younger.⁷

In the survey conducted in Uganda and Kenya, most of the 240 who had been tested said they intended to adopt safer sexual behaviors such as sexual abstinence, monogamy, use of condoms, and reduction in number of sexual partners.⁸ This study did not measure the impact of VCT on HIV infection rates, but a study in the United States involving more than 4,000 males and females ages 15 to 25 years found that incidence of STIs decreased for those testing negative for HIV. (It did not change for those testing positive.)⁹

Reaching out to youth

Over the last 10 years, a growing number of VCT programs for adults have been established and have dealt with such challenges as recruitment, confidentiality, stigma associated with testing positive, testing procedures, and the importance of pre- and post-test counseling. Some of these programs have also begun to focus on youth.

One example is the AIDS Information Center (AIC) in Uganda, which originally offered VCT services with adults in mind. It now has a clinic area specifically designated for young people and has developed a curriculum for youth counseling. The change came after the center analyzed its client data and found that many young people were seeking VCT services. "We began asking questions about how to be more responsive to the challenges that youth face," says Jane Harriet Namwebya, VCT technical officer at FHI, who directed the AIC project in Uganda before moving to FHI’s Kenya office. "Do we need to train youth counselors? What are the challenges youth have in accessing the services? How can we support them after they have been tested?"

 

HIV testing can be quick, with a finger prick providing blood that is analyzed in 15 minutes.

Similarly, in Kenya, the International Centre for Reproductive Health (ICRH), in collaboration with the Kenyan Ministry of Health and FHI, originally set up nine VCT centers in Mombasa, offering a quick, confidential HIV test. (A finger prick is used to obtain blood, and a rapid assay test yields results in 15 minutes.) Realizing that they needed to do more to reach youth, project managers established three other counseling centers where trained community peer educators provide youth with HIV information. Trained counselors then work with the young people for referral to VCT testing centers, if appropriate, says Dr. Mark Hawken, ICRH project coordinator.

Existing youth-oriented projects are also beginning to offer VCT services. In Uganda, for example, the Naguru Teenage Information and Health Center, which runs a large outreach effort through radio, expanded its existing youth reproductive health services by adding the laboratory equipment and training needed to offer VCT as well.

Programmatic challenges

In these expanded efforts to provide VCT services to young people, key programmatic challenges are confidentiality, parental consent, adequate counseling, and ongoing support. Unless VCT is strictly confidential, young people (especially women) run the risk — as do adults — of being stigmatized, suffering violence, and being disowned by family members or partners.

One of the key challenges for programs is deciding whether to involve a youth’s parents in the VCT process, gaining approval for testing and reporting of results. Ideally, each country would determine informed consent procedures for using VCT. In Kenya, national VCT guidelines issued in 2001 advise that "mature minors" do not need parental consent. "Mature minors" include those individuals younger than 18 years who are "married, pregnant, parents, engaged in behavior that puts them at risk, or are child sex workers."¹⁰

In countries where such formal guidelines do not exist, agency policies and individual counselors use various approaches to determine whether parental permission is needed. "Before HIV testing is done, it is important for counselors to establish the degree of maturity of the youth in terms of ability to handle the HIV test results," says Namwebya. "A lot is left to the counselor’s judgment." Effective pre-test counseling would explore such issues as youths’ support systems, whom they have told they might get tested, and with whom they would share the results. Youth deemed to have the maturity to accept test results are given the opportunity to learn their HIV status and obtain support and counseling without having to tell their parents and risking negative consequences.

Counseling young people, in general, requires special skills. And counseling youth about HIV testing is even more challenging. It is important to be nonjudgmental, establish rapport, and instill hope in young people, particularly those testing positive. "Counselors have to be trained to handle young people’s needs, which differ from those of adults," says Namwebya. "Young people who are HIV positive still have their dreams and many years ahead. What will happen to their dreams? How long can they sustain behavior change? We should be able to help them cope."

— William Finger

William Finger works on information dissemination for YouthNet, a five-year program coordinated by FHI and funded by the U.S. Agency for International Development to improve reproductive health and prevent HIV/AIDS among young people. YouthLens is an activity of YouthNet.

References

1. AIDS Epidemic Update. December 2001. United Nations Programme on HIV/AIDS. Most current version available: http://www.unaids.org/ 
2. Boswell D, Baggaley R. Voluntary Counseling and Testing: A Reference Guide — Responding to the Needs of Young People, Children, Pregnant Women and their Partners. Arlington, VA: Family Health International, 2002.
3. Kenya Demographic and Health Survey 1998. Calverton, MD: National Council for Population and Development and Macro International, Inc., 1999; Zimbabwe Demographic and Health Survey 1999. Calverton, MD: Central Statistical Office and Macro International, Inc., 2000.
4. Horizons Program. HIV Voluntary Counseling and Testing among Youth: Results from an Exploratory Study in Nairobi, Kenya, and Kampala and Masaka, Uganda. Washington: Population Council, 2001.
5. Juma M, McCauley A, Kirumira E, et al. Gender variations in uptake of VCT services among youth in Uganda. The XIV International Conference on HIV/AIDS, Barcelona, Spain, July 7-12, 2002.
6. The Voluntary HIV-1 Counseling and Testing Efficacy Study Group. Efficacy of voluntary HIV-1 counselling and testing in individuals and couples in Kenya, Tanzania, and Trinidad: a randomized trial. Lancet 2000;356(9224):103-12.
7. Sangiwa MG, van der Straten A, Grinstead OA, et al. Clients’ perspectives of the role of voluntary counseling and testing in HIV/AIDS prevention and care in Dar Es Salaam, Tanzania: the Voluntary Counseling and Testing Efficacy Study. AIDS Behavior 2000;4(1):35-48.
8. Horizons Program.
9. Chamot E, Coughlin SS, Farley TA, et al. Gonorrhoea incidence and HIV testing and counseling among adolescents and young adults seen at a clinic for sexually transmitted diseases. AIDS 1999;13(8):971-79.
10. Kenya Ministry of Health, National AIDS and STD Control Programme. National Guidelines for Voluntary Counseling and Testing. (Nairobi: NASCOP, 2001)5.