NEW PUBLICATION: Exploring Young People's Experience with SRH and HIV Services
About one third of all new HIV infections globally occur among adolescents and young people between the ages 15 and 24. Adolescents’ access and uptake of sexual and reproductive health and HIV services are reported to be lower than among older groups. CHOICE for Youth and Sexuality conducted research into young people’s experiences with integrated youth-friendly sexual and reproductive health and HIV services. The research was conducted among youth-led organisations working in sexual and reproductive health and rights (SRHR) programmes in 11 countries in Europe, Sub-Saharan Africa, South and South-East Asia. 480 young people between the ages 12 to 30 shared their experiences on how to improve HIV services for young people and over 15 experts shared their knowledge on best practices.
Sharing Experiences: Young People’s Experiences with Sexual Reproductive Health and HIV Services
The findings were unanimous: Young people, in their diverse and intersecting identities, often face significant barriers when trying to access sexual and reproductive health (SRH) and HIV services. Barriers include, but are not limited to, age-based stigma, harmful societal norms, lack of youth-friendly health services (YFHS) and restrictive laws and policies. In many countries punitive and discriminatory laws— including age of consent laws, spousal consent laws, laws criminalising the (sexual) behaviour of young key population and laws prohibiting legal gender recognition—hinder young people’s access to SRH and HIV services. In countries where laws and policies are ambiguous, health workers may be unwilling to provide SRH and HIV services to young people. Consequently, discouraging young people from accessing services out of for fear of being stigmatised or discriminated against.
In Indonesia access to SRH and HIV services is hampered by harmful societal and gender norms which are reflected in national laws and policies. For instance, young women need spousal consent in order to access SRH and HIV services. Furthermore, both the 2009 Health Law and the 2015 Family, Population and Development Law present reproductive rights in accordance with societal values according to which only married people posses reproductive rights. Following this interpretation, community health-care provides often refuse to provide SRH and HIV services for unmarried people.Young people from indigenous communities, including Papuans, who are living with HIV face dual discrimination from health-care providers due to their status and ethnicity. The remoteness of their highland communities further hinders access to services putting them more at risk.
In Nigeria the main barriers to accessing SRHR and HIV services for young people are stigma and discrimination. Young key populations are the most impacted, especially where they are gender non-confirming or seeking treatment for other STIs. In Lagos and Abuja STI/HIV health services have been established to respond to the needs of key populations. However, following the 2014 Same-Sex Marriage Prohibition Act Nigerian police forces continue to clampdown on LGBT spaces, which at times double as avenues for HIV testing services. Similarly, stigma, discriminatory laws and contradicting laws and policies pose significant barriers to young men having sex with men in Kenya, Uganda and Malawi. Other barriers to accessing SRHR and HIV services for young people in Nigeria include the lack of YFHS, the long distance to services as well as the high level of poverty among young people. Nonetheless, HIV services are becoming more expensive in the country due to donor withdrawal.
Youth-friendly services in Nepal are scarce and oftentimes not able to provide quality and confidential services. To ensure their anonymity and avoid stigma young people often prefer to visit distant health facilities to access HIV services. Availability, accessibility and lack of integration of services also pose significant barriers: “In the context of Nepal every health service institution works in isolation. There is no inter-sectorial collaboration between these institutions even in context of programmes. Existing YFHS should also be made more youth-friendly by, for instance, assessing what youth-friendly services mean to young Nepalese people. Generally, young people want privacy, anonymity, confidentiality and quality. Upholding these criteria will increase health-seeking behaviour among young people in the country.” Similar, issues relating to the lack of confidential YFHS were also observed in Mozambique, Zambia and Uganda.
Despite significant progress in controlling the HIV epidemic over recent years, Malawi continues to have one of the highest HIV prevalences in the world. Young people are particularly faced by the grim implications of the epidemic. In 2016 12,500 new HIV infections occurred among young people aged 15-24. 70 per cent of those occurred among young women of the same age group. Social and cultural norms such as early and forced marriage, religious beliefs and, initiation ceremonies and rituals oftentimes encourage adolescent girls to engage in unprotected sex, putting them at risk for HIV and STIs. Due to stigma girls and young women are often afraid to access SRH and HIV services out of fear of being labelled as promiscuous. Differences in gender perception makes girls more vulnerable for HIV and other STIs. Especially in the rural areas, where girls have less negotiating power in relationships and as a result may not use protection or seek-out SRH services without the consent of their partner. Other groups of young people facing significant barriers in the country include young people with disabilities who are oftentimes stereotyped as being overtly sexual by health workers.
Young people with different abilities face serious challenges not only in Malawi but also in India, Zambia and Uganda.
Best-Practices: Involving Young People in the HIV Response & Strengthening Youth-Friendly SRHR and HIV Services
The specific challenges faced by young people when accessing SRH and HIV services must be recognised and addressed based on important determinants including sex, gender identity, sexual orientation and socioeconomic status. Significant efforts are needed to invest in health systems that promote access to youth-friendly and affordable SRH and HIV services for young people: “It is important, to involve young people themselves in programming to make health facilities youth-friendly. Young people know what their needs are. Young people know what challenges they face and how to get over these challenges” - Womba Wanki, Excutive Director Generation Alive
In India The YP Foundation (TYPF), works with the government to strengthen the youth-friendly capacity of the Adolescent Friendly Health Clinics (AFHCs). The YP Foundation has been working with young mystery guests to conduct audits on the adolescent and youth-friendliness of AFHCs. Based on the audits, TYPF found that there are significant gaps in health-care providers knowledge on SRHR and HIV and that young people oftentimes do not know of the existence of the AFHCs. As such there’s a need for service providers to be sensitised and held accountable for the provision of youth-friendly services. Simultaneously, community based interventions are needed to strengthen the programme dissemination component among young people. The YP Foundation, has mapped out the formal and informal eco-systems within which young people receive information on SRHR. This mapping can be used to identify the best interventions in providing young people with correct information on SRHR.
In Uganda, Reach a Hand Uganda (RAHU) and the Uganda the Uganda Network of Young People Living with HIV (UNYPA) work along side health providers to ensure young people have access to equitable SRH and HIV services. Among their success: setting-up youth-spaces in health centres to encourage young people to access services, training peer buddies to support young people living with HIV to access SRH and HIV services as well as organising yearly mass mobilisation campaigns for HIV awareness, testing and counselling. Similar activities have been undertaken in Ethiopia and Mozambique, under the Get Up Speak Out (GUSO) programme, to strengthen the youth-friendly capacity of SRH and HIV services as well eliminate the stigma around HIV/AIDS. To achieve the later, UNYPA also organises the Y+ Beauty Pageant, a project established to end the stigmatisation of people living with HIV as well as create awareness on positive living.
Access to youth-friendly SRH and HIV services in many Eastern European countries is impeded by conservative approaches and perspectives on SRHR. “Lack of CSE and generally comprehensive information on SRHR in schools is resulting in stereotypes, issues of domestic violence as well as gender inequality.” In Eastern Europe, and other regions, Y-Peer uses interactive social theatre as a tool of engagement for training peer educators and initiating conversations on SRHR, including HIV/AIDS.Young people follow a theatre based peer education training which concludes in a theatre performance. Through the theatre the performers and spectators engage in conversation. Using this approach Y-peer has engaged in several fruitful discussions with decision-makers.
- Youth-friendly services: strengthen the youth-friendly capacity of health workers and health facilities to ensure that young people have access to youth-friendly, affordable and confidential sexual reproductive health & HIV/AIDS services in an enabling environment.
- Increased access to comprehensive information: ensure young people have access to comprehensive sexuality education that is inclusive of sexual and reproductive health and rights & HIV/AIDS as well as comprehensive information on contraceptive methods, testing and treatment.
- Integrated services: provide integrated sexual and reproductive health and HIV/AIDS services to increase accessibility to services, decrease stigma and encourage health seeking behaviour among young people.Meaningful youth participation: involve young people in policymaking, programming and monitoring of interventions regarding sexual reproductive health rights & HIV/AIDs; as their meaningful participation is essential in ensuring that policies and programmes are effective in addressing their needs.