Three Case Studies

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Introduction

People under the age of 25 represent nearly half of the world's population,[1] giving them a powerful role in the world's health and future. Despite youth's diversity in culture, background, language, and socioeconomic status, their lives reflect similar, intersecting issues and events. For youth ages 15 through 24, life sometimes seems to be overshadowed by sexual health issues, including unintended pregnancy and HIV as well as other sexually transmitted infections (STIs).

• Youth under age 25 have never known a world without HIV and AIDS. Worldwide, about 6,000 youth ages 15 to 24 are infected with HIV each day.[2]
• Young people experience over 100 million new cases of STIs each year.[2] Several STIs are associated with easier transmission of HIV between sexual partners.[2]
• Young women experience high rates of unintended pregnancy. Each year, about 15 million young women, ages 15 to 19, give birth.[3] In some countries in Africa, Latin America and the Caribbean, over 50 percent of teenage pregnancies are unintended.[4]

Youth's decisions about their sexual and reproductive health affect not only their lives, but also the health of the global community. Thus, there is an urgent need for programs and policies to address the complex sexual and reproductive health needs of earth's one billion youth ages 15 to 24.[5] This paper discusses integration and offers case studies, lessons learned, and tips for integrated approaches to preventing HIV, STIs, and unintended pregnancy among youth.

Background

At the 1994 International Conference on Population and Development (ICPD), the international public health community for the first time acknowledged the sexual health challenges that young people face. At ICPD, nations agreed to make adolescent sexual and reproductive health a priority. Additionally, ICPD championed a holistic, integrated approach to reproductive health[6]—one based on the rights of the individual to information and services rather than on nations' population goals. The Programme of Action called for unfettered universal access to a variety of family planning methods as well as to services to prevent and treat STIs, including HIV.[7] The emergence of the Millennium Development Goals (MDGs) in 2000 made it critical to continue to support integrated, comprehensive programs that holistically address adolescents' reproductive and sexual health. While the MDGs include no explicit adolescent reproductive health goals, adolescents' reproductive and sexual health certainly affects a country's ability to meet the MDG goals regarding poverty, HIV and AIDS, and maternal and child mortality rates.[8]

Recently, conservative elements in many countries, including donor countries like the United States, have begun undermining adolescents' access to family planning information and services. Although countries remain committed to ICPD's integrated and universal philosophy, in practice their approaches to adolescent sexual health have sometimes been narrowly focused, under-funded, and limited in scope. Yet, rates of HIV, other STIs, and unintended pregnancy among youth speak to their need for comprehensive, integrated sexual health information and services.

An Integrated Approach to Promoting Sexual Health among Youth

The basis of an integrated approach is determination to improve sexual health. Any time an opportunity arises, the young person, parent, educator, or health care provider seizes the chance to present new and relevant information. An integrated approach to promoting young people's sexual health include:

• Adding STI and HIV information to pregnancy prevention information and services;
• Adding pregnancy prevention to HIV and STI prevention information and services;
• Incorporating sexual health information into youth development and employment programs;
• Encouraging health care providers to make their services youth-friendly; and
• Offering varied health and social services in one place or sending youth to the services they need.9

In a practical sense, integrating HIV/STI and pregnancy prevention can involve a wide range of activities, including developing integrated messages and programs, networking with other service providers, approaching sexual health issues holistically, and shifting the organization's overall approach regarding its delivery of programs and services.[9]

Elements of Integration

Integration can be either explicit or implicit to a program. For example, a programmer may explicitly and purposefully design an integrated intervention that simultaneously addresses the prevention of HIV, other STIs, and pregnancy. Such a program would have specific objectives, expected outcomes, and indicators related to each sexual health issue. The case studies (below) highlight programs that are explicitly integrated. On the other hand, implicit integration includes such times as when a family planning clinic encourages pregnancy prevention through the use of modern methods of contraception, then stresses that these methods alone will not protect against HIV and other STIs. Teens and other clients learn that their use in conjunction with a condom (either male or female) will protect against pregnancy, HIV, and some STIs. Whether a program explicitly or implicitly addresses combined outcomes, making these connections clear can help youth remain healthy and can help parents, educators, health care providers, and others to view young people's health and behaviors holistically.

One of the many ways to integrate prevention of HIV, other STIs, and pregnancy is to promote methods of protection against both unintended pregnancy and STIs, including HIV. Called dual protection, it means using two methods—a condom plus another highly effective pregnancy prevention method, such as birth control pills, the IUD, or implants. Other integrated strategies can include encouraging youth to:

1. Maintain safer sexual behaviors, including 100 percent abstinence from sexual intercourse (vaginal, anal, and/or oral);
2. Maintain mutual monogamy between uninfected partners and use an appropriate and effective method of prevention (condoms or modern contraception, as appropriate);
3. Use condoms alone for protection against pregnancy and some STIs and for highly effective protection against HIV and to avoid unprotected vaginal, anal, or oral sex;
4. Use condoms and another form of birth control and use emergency contraception (EC) as a back-up when needed.

Be sure to offer all these options, not just A, to youth.

Benefits and Challenges of Integrated Programming

Benefits to youth—

• Youth generally view pregnancy and HIV/STI as two sides of the same coin; integrating information and services aligns with youths' perspectives.
• Youth can receive respectful treatment as whole people (who may also have various sexual health issues), rather than as sexually active youth (facing unwanted sexual health outcomes).
• Youth at higher risk of unintended pregnancy and STIs, including HIV, can receive culturally appropriate, affordable services.
• Youth can learn about a range of protective sexual health behaviors, including abstinence and the use of contraception and condoms.
• Young people can participate in HIV/STI programming and services without fear of the stigma sometimes associated with STI or HIV prevention services.
• Youth can receive "one-stop shopping" for sexual health information and services as well as for other health care and social services or be referred for these services.[9]

Benefits to organizations—

• Organizations can reap the benefits of building economy of scale—reaching more youth more effectively and addressing more sexual health issues than do single issue programs.
• Organizations can tap into new funding streams—ones that may have been unknown or unavailable to them before.
• Staff can increase expertise and has more opportunities for professional development, more colleagues with whom to work, and new opportunities for interagency collaboration.
• Organizations have the opportunity to learn strategies that other fields have found effective in improving youth's sexual health-related skills, attitudes, and behaviors.
• Organizations can limit duplication of efforts and re-direct scarce resources.
• Organizations have the opportunity to heighten youth-serving colleagues' awareness of the sexuality-related vulnerability and needs of youth.[9]

Challenges—

• Institutions and policies may restrict information on pregnancy, HIV and AIDS, and other STIs.
• Separate funding streams can complicate grant seeking and/or grant reporting, and some funding sources may refuse to fund comprehensive approaches to preventing pregnancy, HIV, and/or STIs.
• Organizations may lack financial resources to adequately address all three issues (pregnancy, HIV, and STIs). At the same time, organizations may encounter unexpected rivalries for funding, contracts, space, or media attention.
• Staff may feel discomfort about and/or lack the skills to deal with behaviors and topics outside a primary field or fear that integration really means downsizing. Also, providers may feel that integrated services require additional work on their part.
• Integration may require a shift or expansion in the organization's target population.
• Organizations that hadn't before coped with social stigma may have to address stigma regarding sexual health issues, such as the effectiveness of condoms in preventing pregnancy and the transmission of HIV and STIs.[9]

Selected Case Studies

Integrated programs show promise in improving the sexual health attitudes and behaviors related to unintended pregnancy and HIV/STI among youth. Here, case studies illustrate a few of these integrated programs and the strategies they use to try to achieve healthier outcomes among youth.

TOP Réseau (Best Network)

Research demonstrated rising rates of HIV and STIs among Madagascar's youth along with little awareness when they are infected. Thus, youth in Madagascar needed better access to sexual and reproductive health information and services. In 2001, Population Services International opened 13 youth-friendly clinics under the title of TOP Réseau (Best Network). In these clinics, medical professionals offered youth affordable, high-quality services. Since 2001, TOP Réseau has expanded into many clinics throughout Madagascar. The purpose of TOP Réseau has been to prevent STIs and unintended pregnancies among sexually active youth by promoting correct and consistent condom use and by increasing young people's use of medical professionals for treatment of STI symptoms. A complementary media campaign has promoted the clinics, endorsed condom use for dual protection, encouraged treatment of STIs, and taught skills for condom negotiation and sexual abstinence.[10]

Integrated services in youth-friendly clinics give young people access to affordable, confidential, good quality health care services that holistically address their sexual health needs. By simultaneously providing youth-friendly, modern, family planning services and STI diagnosis, treatment, and counseling, TOP Réseau eliminates youth's need to visit more than one health care provider. At the same time, TOP Réseau addresses many of the barriers to receiving care that Madagascar's youth face, and it also benefits clinic staff who receive comprehensive STI training.[10]

Juntos Decidimos (Together We Decide)

Nicaragua has one of the highest rates of teen pregnancy in Latin America. To address this public health concern, the Nicaraguan Interagency Commission for Reproductive Health, in collaboration with the Johns Hopkins Bloomberg School of Public Health Center for Communications Programs, launched a national reproductive health campaign to promote youth's use of dual protection. The campaign, Juntos Decidimos (Together We Decide), was the second of three related campaigns focused on preventing unintended pregnancy and STIs, including HIV, among youth. The multi-phased approach included mass media campaigns; committees of youth that mobilized grassroots activities and educational strategies; and a social marketing program for BodyGuard condoms.[11]

Juntos Decidimos also worked to change social norms by making condom use a more socially accepted behavior. PROFAMILIA marketed BodyGuard as a symbol of protection and with a dual protection message. The BodyGuard campaign and the prevention campaign were launched at the same time. The messages were disseminated through a comprehensive media campaign. The condoms were distributed through traditional and non-traditional outlets, including bars and discos. In addition, the messages of the campaign were true to an integrated approach. Juntos Decidimos' messages advocated for safer sex behaviors, ranging from abstinence to the use of dual protection. The campaign also sought to increase youth's self-efficacy and skills regarding communicating with partners and negotiating the use of protection.[11]

Entre Nous Jeunes (Among Youth) Peer Education Program**

After a promising pilot study, the Institute for Behavioral Research and Studies (IRESCO), in collaboration with the Population Council's Frontiers in Reproductive Health program, implemented an integrated intervention in Cameroon for in- and out-of-school urban youth. The campaign sought to assess the value of peer education in increasing the proportion of adolescents who rely on modern contraception, including condoms, to prevent pregnancy, HIV, and other STIs. Forty-nine trained peer educators led discussion groups in existing, community-based, youth service clubs and youth associations.

Peer educators also worked one-on-one with their peers and distributed sexual health educational materials, such as comic strips, posters, and calendars.[12] Peer educators in the program benefited by receiving training in effective reproductive and sexual health communication and teaching techniques. Research has shown that the responsibility and stature associated with being a peer educator can result in improved self-efficacy and reduced risk-taking among peer educators.[13] Moreover, this program holistically connected various aspects of the lives of youth exposed to program. Messages, materials, and activities related to a broad range of issues, including dating, friendships, sexuality, pregnancy prevention, abortion, and HIV and other STIs. This holistic regard for the entire young person illustrates the principles of integration to their fullest extent.[12]

Lessons Learned for Effective HIV, STI, and Pregnancy Prevention Integration

Professionals associated with these and other programs identified some lessons that can help others to build even more successful programs.

• Understand that youth do not see condoms as protection against only one unwanted outcome. Rather, they see condoms as offering protection against a variety of negative outcomes. They see this as "value added" to condoms.[13]
• Messages must be culturally specific and tailored to the specific program's goals. For example, in countries with low (or perceived low) HIV prevalence, promoting condoms' effectiveness for family planning may be more powerful than promoting condoms to prevent HIV/STI.[13]
• It is not necessary to promote a dual message on each and every program component. A campaign may include separate and distinct prevention messages on its various components that, taken together, will successfully promote dual protection.[13]
• Youth must participate in developing the programs targeted to youth. Youth are experts on youth; they play a critical role in defining effective messages.[13]
• Youth must be involved in program's operations. Peer education is one promising strategy that involves youth in meaningful ways and that can contribute to behavior change.[14,15]
• Peer education is most successful when used in small groups and on a repeated basis.[16]

Conclusion

Integrating sexual health messages and services is critical to assisting youth to make healthy choices and to achieve healthy adulthood. Integration is achieved by:

• Focusing on and involving youth in all aspects of programs' design, implementation, and evaluation;
• Developing integrated messages and resources that take advantage of youth's natural view of condoms as multi-purpose and prevention as cool, modern, and/or mature;
• Ensuring that programs are culturally specific and age-appropriate for the youth to whom they are targeted; and
• Ensuring that programs address adolescents and their sexual health holistically.

Resources on Integration

• Alford S, Cheetham N, Hauser D. Science & Success in Developing Countries: Holistic Programs that Work to Prevent Teen Pregnancy, HIV &Sexually Transmitted Infections. Washington, DC: Advocates for Youth, 2005.
• Boonstra H. The role of reproductive health providers in preventing HIV. Guttmacher Report on Public Policy, 2004;7(4).
• Earls M, Feijoo A, Moss T et al. Science-Based Practices in Teen Pregnancy and HIV/STI Prevention: Selected Annotated Bibliography. [From Research to Practice] Washington, DC: Advocates for Youth, 2004.
• EngenderHealth. Preventing HIV/AIDS through Family Planning. New York, NY: Author, 2004.
• Rogers J, Augustine J, Alford S. Integrating Efforts to Prevent HIV, Other Sexually Transmitted Infections, and Pregnancy among Teens. [Issues at a Glance] Washington, DC: Advocates for Youth, 2005.

Curricula

• Centre for Development and Population Activities (CEDPA). Integrating STDs and AIDS Services into Family Planning Programs: Training Community Workers. Washington, DC: Author, 2003.
• EngenderHealth. Integration of HIV/STI Prevention, Sexuality, and Dual Protection in Family Planning Counseling: A Training Manual. New York, NY: Author, 2002.
• Marshall M, Adeji-Sakyi K. Female Condom and Dual Protection: Training for Community-Based Distributors and Peer Educators. Washington, DC: CEDPA, 2003.
• U.S. Agency for International Development. Family Planning/HIV Integration: Technical Guidance for USAID-Supported Field Programs. Washington, DC: Author, 2003.

* This paper focuses specifically on programs to prevent HIV infection and not on programs that treat HIV infection, prevent or slow the onset of AIDS, or treat people living with AIDS.

** For information on evaluation of Entre Nous Jeunes and other effective programs, please visit Science & Success in Developing Countries: Holistic Programs that Work to Prevent Teen Pregnancy, HIV & Sexually Transmitted Infections

References

1. UNAIDS. 2004 Report on the Global AIDS Epidemic. [4th Global Report] Geneva, Switzerland: Author, 2004.
2. UNAIDS. Young People and HIV/AIDS: Opportunity in Crisis. Geneva, Switzerland: Author, 2002.
3. Boyd A et al. The World's Youth 2000. Washington, DC: Population Reference Bureau, 2000.
4. Mahler K, Rosoff JL. Into a New World: Young Women's Sexual and Reproductive Lives. New York: Alan Guttmacher Institute, 1998.
5. United Nations. World Population Monitoring, 2000: Population, Gender and Development. New York: Author, 2001.
6. United Nations Population Fund. Report of the Round Table on Adolescent Sexual and Reproductive Health: Key Future Actions: New York, 14-17 April 1998. New York: Author, 1998.
7. United Nations Population Fund. The State of World Population, 1997. New York: Author, 1997.
8. World Bank. World Development Indicators 2002. Washington, DC: Author, 2002.
9. Rogers J et al. Integrating Efforts to Prevent HIV, Other Sexually Transmitted Infections and Pregnancy among Teens. [Issues at a Glance] Washington, DC: Advocates for Youth, 2005.
10. Population Services International. Franchised Youth Clinics Motivate Behavior Change in Madagascar. [Research Brief, no. 4] Washington, DC: Author, 2004.
11. John Hopkins Center for Communication Programs. Nicaraguan Youth Begin to Play It Safe. [Communication Impact!, no. 12] Baltimore, MD: Author, 2001.
12. Speizer IS et al. An evaluation of the Entre Nous Jeunes peer educator program for adolescents in Cameroon. Studies in Family Planning 2001; 32:339-351.
13. Personal communication with Yomi Gedeon, Institute of Research and Behavioral Studies, Yaoude, Cameroon, fall 2004.
14. Mason H. Peer Education: Promoting Healthy Behaviors. [The Facts] Washington DC: Advocates for Youth, 2003.
15. Alford S et al. Science & Success in Developing Countries: Holistic Programs that Work to Prevent Teen Pregnancy, HIV & Sexually Transmitted Infections. Washington, DC: Advocates for Youth, 2005.
16. Family Health International. Dual Protection for Youth: Results from Nicaragua, Zambia, and Uganda. Research Triangle Park, NC: Author, 2004.

Written by Allison Tombros
June 2005 © Advocates for Youth