Adolescents and HIV: have we taken our eye off the ball?

By Kate Iorpenda

A blog by our Senior Advisor on Children and HIV  published to coincide with the 20th International AIDS Conference in Australia. It was first published on the AVERT website.

According to a World Health Organisation report published earlier this year, HIV is now estimated to be the number two cause of death among adolescents aged 10-19 globally, and the number one in Africa, and this at a time when HIV-related deaths are decreasing in all other age groups.

Adolescent health, and in particular adolescent health and HIV, continues to be a missing piece of the global health jigsaw and one of the reasons is the complexity of the issues – and consequent decisions that need to be taken - facing service providers working with this age group. Imagine for a moment that you’re a young homeless person living on the streets of Kiev with no adult care in your life, but you’re told that you’re unable to take an HIV test to ascertain your status without parental consent. What then?

Or take the example of a minor who is an injecting drug user, has been criminalised for drug possession and sent to an adult prison, but is then unable to access harm reduction and HIV services because they are under age. In yet another common scenario, a young woman being sexually exploited may, due to age or the need for parental consent, be unable to access sexual and reproductive health services in order to protect herself from HIV, sexually transmitted diseases and unwanted pregnancy.

Such uncomfortable paradoxes abound in the field of adolescent health and can be a minefield for practitioners to even discuss let alone agree a way forward when it comes to programming. Often adolescents most at risk of HIV are up against a set of challenging and overlapping circumstances that sees them slip through the cracks in terms of healthcare and social protection and render them still more vulnerable.

This then is the “messy stuff” that challenges those of us working at the forefront of adolescent health on a daily basis. There is certainly no one size fits all approach and, in many of the countries where the Alliance operates, overstretched and ill-equipped health systems often mean that young people go unserved both in terms of access to services and to potentially life-saving information. That’s why ambitious programmes like Link Up - a five country project aiming to improve the sexual and reproductive health and rights (SRHR) of more than one million young people living with and affected by HIV - are critical.

As HIV practitioners, we need to take extra care that we’re not leaving a vacuum and that instead we’re engaging with the “messy stuff” and providing a safe space for young people to voice their needs. It would be very easy for us to develop programmes that we think young people want or need but forget to include them in the decision making process - involving adolescents in the design and delivery of services is key to getting it right.

SRH youth group in Sylhet, Bangladesh (c) AllianceThat’s why Harm Reduction International, the Alliance, Youth RISE and Save the Children UK have come together to create a Step by Step tool to help organisations to think about child rights and protection, evolving the capacities of young people and how to balance conflicting ethical and legal issues. The tool has been developed in conjunction with and will be piloted by harm reduction service providers and helps to highlight the overlapping vulnerabilities of young drug users and builds knowledge in organizations on how to respond.

Resolving some of the ethical dilemmas involved in working with most at risk young people won’t happen overnight; nor will service providers putting aside moral judgements when working with vulnerable adolescents in difficult situations that don’t fit neatly into a tick box. In the meantime, we need to find ways within existing legal frameworks to ensure that we listen and respond and we need to collectively challenge the systems that continue to deny young people access to evidence-based interventions because of their age.