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I. PROGRAM RESOURCES
1. Before She's Ready: 15 Places Girls Marry by 15
2. Building Knowledge about HIV and AIDS: An Interactive Course for Educators
3. 'The Child Within': Called to Care Toolkit No. 6
4. Cross-Generational Sex: Risks and Opportunities
5. Essential Prevention and Care Interventions for Adults and Adolescents Living with HIV in Resource-Limited Settings
6. Evaluation of the Jamaica Adolescent Reproductive Health Activity 2000-2007
7. A Framework for Integrating Reproductive Health and Family Planning into Youth Development Programs
8. Gender Equality and "Sugar Daddies"
9. Kids ART Education Series - The Children's Treatment Literacy Toolkit
10. Make it Matter – 10 Key Advocacy Messages to Prevent HIV in Girls and Young Women
11. Operations Research Study to Improve Postabortion Care (PAC) Services among Adolescents in the Dominican Republic
12. The Politics of Prevention: A Global Crisis in AIDS and Education
13. Reducing Adolescent Girls' Vulnerability to HIV Infection: Examining Microfinance and Sustainable Livelihood Approaches. A Literature and Program Review
14. Supporting Youth at Risk: A Policy Toolkit for Middle-Income Countries
15. Triple Jeopardy: Female Adolescence, Sexual Violence, and HIV/AIDS
16. Youth and Sustainable Livelihoods: Linking Vocational Training Programs to Market Opportunities in Northern Uganda
II. RESEARCH SUMMARIES
1. Circumcision among adolescent boys in rural northwestern Tanzania
2. A combined microfinance and training intervention can reduce HIV risk behaviour in young female participants
3. Depressive symptoms in youth heads of household in Rwanda: correlates and implications for intervention
4. Factors associated with risky sexual behaviour among out-of-school youth in Kenya
5. HIV status and age at first marriage among women in Cameroon
6. Impact of Stepping Stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial
7. Knowledge, attitudes, and behaviors related to HIV and AIDS among college students in Taiwan
8. A population-based survey of the prevalence of HIV, syphilis, hepatitis B, and hepatitis C infections, and associated risk factors among young women in Vitoria, Brazil
9. Prevalence and risk of blood-borne and sexually transmitted viral infections in incarcerated youth in Salvador, Brazil: opportunity and obligation for intervention
10. Prevention of HIV in young people in Africa
11. Recent evaluations of the peer-led approach in adolescent sexual health education: a systematic review
12. What is 'sex' exactly? Using cognitive interviewing to improve the validity of sexual behaviour reporting among young people in rural Zimbabwe
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I. PROGRAM RESOURCES
1. Before She's Ready: 15 Places Girls Marry by 15 (2008, PDF, 35 pages, 4.6 MB)
Around the world, an estimated 3,500 girls under the age of 15 get married every day. The consequences of early marriage include an increased risk of HIV and maternal death, an abrupt end to a girl's education, and a greater chance of violence and abuse.
Organization: World Vision
Contact: info@worldvision.org
2. Building Knowledge about HIV and AIDS: An Interactive Course for Educators (2008)
This on-line course is primarily designed for those who educate young people in formal and informal settings. Learners will gain an in-depth understanding of the scientific, social, behavioral, and health-related aspects of HIV and AIDS. By the end of the course, learners should understand the links between the factors that drive the pandemic and those that affect people living with HIV and AIDS.
Organization: UNESCO
Contact: bkk.aids@unesco.org
3. 'The Child Within': Called to Care Toolkit No. 6 (2008)
(The publication can be ordered at this link, for a small fee, or downloaded for free.)
This 68-page workbook was developed in collaboration with an orphan care project in South Africa. The book promotes resilience in children who have suffered grief and personal loss, including the AIDS-related death of a parent. It does so by teaching parents, guardians, and professionals who work with children to communicate more openly and effectively with them. The book incorporates a Christian approach but can be used by a wide variety of community groups and organizations. Although based on professional research on child and adolescent development, the book is written in clear, simple language; has numerous illustrations; and is easily accessible to nonprofessional child caregivers.
Organization: Strategies for Hope Trust
Contact: info@talcuk.org or sfh@stratshope.org
4. Cross-Generational Sex: Risks and Opportunities (2008, PDF, 6 pages, 394 KB)
This publication draws on a recently completed desk review of research and programs. The brief succinctly defines cross-generational sex, summarizes where it occurs most, outlines the motivations behind the behavior, and recommends actions for policy-makers and program managers.
Organizations: Population Reference Bureau, IGWG, IYWG
Contact: prborders@prb.org
5. Essential Prevention and Care Interventions for Adults and Adolescents Living with HIV in Resource-Limited Settings (2008, PDF, 120 pages, 1.6 MB)
This document describes interventions that should be made available to people living with HIV in resource-limited settings in order to prevent illness and HIV transmission. Some of these interventions include psychosocial counseling and support; counseling on disclosure and partner notification; cotrimoxazole prophylaxis; tuberculosis diagnosis and prevention; prevention of fungal infections, sexually transmitted infections, and malaria; family planning; vaccinations; nutritional services; and others.
Organization: World Health Organization
Contact: bookorders@who.int
6. Evaluation of the Jamaica Adolescent Reproductive Health Activity 2000-2007 (2007, PDF, 66 pages, 224 KB)
This report presents an evaluation of two youth programs, Youth.now and JA-Style. It examines the design, strategies, implementation, and results of both programs and offers recommendations for using HIV funds to support youth and adolescent reproductive health.
Organization: Global Health Technical Assistance Project
Contact: info@ghtechproject.com
7. A Framework for Integrating Reproductive Health and Family Planning into Youth Development Programs (2008, PDF, 35 pages, 1.4 MB)
Evidence demonstrates that positive youth reproductive health outcomes are closely linked with educational and economic opportunities. This document identifies guiding principles for integration of reproductive health and development programs, defines key programmatic elements, and provides an organizational self-assessment tool.
Organization: International Youth Foundation
Contact: youth@iyfnet.org
8. Gender Equality and "Sugar Daddies" (2007, 6 pages, 112 KB)
This paper considers the risks to young women of cross-generational sex, given that young women (15-24 years old) in sub-Saharan Africa are three times more likely to be infected with HIV than young men of the same age.
Organization: Center for Reproductive Health, HIV/AIDS and Gender Equity, MIDEGO
Contact: ruth@midego.com
9. Kids ART Education Series - The Children's Treatment Literacy Toolkit (2008, 13 separate files between 250 KB and 4.5 MB)
Children living with HIV are often overlooked when efforts are made to promote community literacy on antiretroviral therapy (ART). This "edutainment" package, which targets children between 6 and 12 years of age, provides information and a series of creative and fun activities about ART. The package contains the following tools:
- ART knowledge board game
- Pack of 20 ART quiz cards
- Interactive poster
- Advocacy stickers
- Calendar on adherence
- A watch to help with adherence
- And a brochure on tuberculosis and HIV
It also includes a series of eight booklets that discuss ART treatment, HIV/AIDS, family issues, support networks, and the daily life of people living with HIV and AIDS.
Organization: SAfAIDS
Contact: info@safaids.org.zw
10. Make it Matter – 10 Key Advocacy Messages to Prevent HIV in Girls and Young Women (2007, PDF, 43 pages, 2.1 MB)
This document focuses on three goals that are recognized as important components of a successful response to the HIV epidemic:
- Improving access to sexual and reproductive health for girls and young women
- Expanding socio-economic opportunities for girls and young women
- Ending child marriage
Included are ten advocacy messages that support these goals. The messages are illustrated by facts, case studies, activities, and signs of success.
Organizations: IPPF, UNFPA, Young Positives, Global Coalition on Women and AIDS
Contact: info@ippf.org
11. Operations Research Study to Improve Postabortion Care (PAC) Services among Adolescents in the Dominican Republic (2007, PDF, 37 pages, 350 KB)
This paper summarizes an operations research study to improve PAC counseling and contraceptive uptake among adolescent PAC patients seeking services in the Dominican Republic. Before the study and intervention, few patients left with contraception; after the intervention, 40 percent of patients who wished to delay pregnancy left with a contraceptive method.
Organization: Family Health International (FHI)
Contact: publications@fhi.org
12. The Politics of Prevention: A Global Crisis in AIDS and Education (available for purchase, 2008, 176 pages)
This book presents stories from around the world that explore the underlying "politics of prevention" that deny millions of people life-saving education on HIV prevention. The larger issues and trends in the global fight against AIDS are also studied, including the rise of the controversial abstinence-only movement.
Organization: Pluto Press
Contact: pluto@plutobooks.com
13. Reducing Adolescent Girls' Vulnerability to HIV Infection: Examining Microfinance and Sustainable Livelihood Approaches. A Literature and Program Review (2008, PDF, 67 pages, 468 KB)
Part one of this document focuses on youth-centered programs to prevent HIV infection — including microfinance and sustainable livelihood programs — among vulnerable female adolescents. Part two analyzes the relationship between microfinance and HIV prevention in the general population, with a focus on women and the oldest adolescents in the target group.
Organization: Health Policy Initiative
Contact: policyinfo@healthpolicyinitiative.com
14. Supporting Youth at Risk: A Policy Toolkit for Middle-Income Countries (2008, 135 pages, 2.2 MB)
This toolkit describes six policies that have an established track record in preventingdisadvantaged children and young people from engaging in risky behaviors. It also discusses approaches for helping those already engaged in these behaviors to return to a safe, productive path to adulthood. The final section of the document presents strategies and tools for turning policy recommendations into a well-designed and well-implemented youth portfolio.
Organization: World Bank
Contact: feedback@worldbank.org
15. Triple Jeopardy: Female Adolescence, Sexual Violence, and HIV/AIDS (2008, PDF, 6 pages, 310 KB)
Pervasive gender inequalities mean that girls face numerous violations to their sexual and reproductive health and rights, including sexual initiation before they are physically or emotionally ready. Girls who live in extreme poverty, among marginalized populations, without family support, or in situations of conflict and displacement are particularly vulnerable to coerced sexual encounters and abuse.
Organization: International Women's Health Coalition
Contact: communications@iwhc.org
16. Youth and Sustainable Livelihoods: Linking Vocational Training Programs to Market Opportunities in Northern Uganda (2008, 47 pages, 981 KB)
This report serves as a resource on vocational training (VT) and market analysis. Focusing on Northern Uganda, this report analyzes a variety of youth VT programs at each stage of a VT programming cycle, identifying best practices and lessons learned.
Organization: Women's Commission for Refugee Women and Children
Contact: info@womenscommission.org
II. RESEARCH SUMMARIES
1. Circumcision among adolescent boys in rural northwestern Tanzania. Weiss HA, Plummer ML, Changalucha J, et al. Trop Med Int Health 2008;13(8):1054-61.
The authors analyzed survey and in-depth interview (IDI) data from adolescents enrolled in a community-randomized sexual health intervention trial in rural Mwanza, Tanzania to investigate the validity of self-reported circumcision status. About 5,300 adolescent boys (median age 15.5 years) attending school were recruited in 1998 and followed for three years. At baseline, circumcision prevalence was 13.7% by self-report and 11.8% by examination by local clinicians, rising to 17.3% by clinical examination at final survey. Of 506 participants who reported being circumcised at baseline, only 78.9% reported this at interim. Similarly, only 84.2% of participants clinically assessed as circumcised at baseline were also assessed as circumcised at interim. Despite low prevalence, there was a high tolerance and respect for circumcision among male IDI respondents, with widespread belief that it was beneficial for penile hygiene and disease prevention. The majority of female IDI respondents said that they did not know what male circumcision was. Methods are needed to improve self-report and training of clinicians in this setting.
2. A combined microfinance and training intervention can reduce HIV risk behaviour in young female participants. Pronyk PM, Kim JC, Abramsky T, et al. AIDS 2008;22(13):1659-65.
This paper describes a secondary analysis of quantitative and qualitative data from a cluster randomized trial, called the "Intervention with Microfinance for AIDS and Gender Equity" study. Eight villages in rural South Africa were pair-matched and randomly allocated to receive the intervention. At baseline and after two years, HIV risk behavior was assessed among female participants aged 14-35 years. Their responses were compared with women of the same age and poverty group from control villages. Intervention effects were calculated using adjusted risk ratios employing village-level summaries. Qualitative data collected during the study explored participants' responses, including HIV risk behavior, to the intervention. After two years of follow-up, when compared with women in the control group, young participants had higher levels of HIV-related communication, were more likely to have accessed voluntary counseling and testing, and were less likely to have had unprotected sex at last intercourse with a nonspousal partner. Women gained increased confidence and skills from participating in the intervention, which helped them introduce condoms in sexual relationships. In addition to having an impact on economic well being, women's empowerment, and intimate partner violence, interventions addressing the economic and social vulnerability of women may contribute to reductions in HIV risk behavior.
3. Depressive symptoms in youth heads of household in Rwanda: correlates and implications for intervention. Boris NW, Brown LA, Thurman TR, et al. Arch Pediatr Adolesc Med 2008;162(9):836-43.
The authors employed a cross-sectional survey in four adjoining districts in Gigonkoro, an impoverished rural province in the southwestern Rwanda. Trained interviewers met with the eldest member of each household (n = 539) in which a youth 24 years old or younger was caring for one child or more. The study measured rates and severity of depressive symptoms, grief, adult support, and social marginalization. Seventy-seven percent of the participants were subsistence farmers and only 7% had attended school for six years or more. Almost half reported eating only one meal a day in the last week, and 80% rated their health as fair or poor. Reports of depressive symptoms that exceeded the clinical cutoff were associated with having only three basic household assets (e.g., a mattress and a spare set of clothes) or fewer, eating less than one meal per day, reporting fair health or poor health, enduring high levels of grief, having at least one parent die in the genocide as opposed to all other causes of parental death, and not having a close friend. Interventions designed to go beyond improving food security and increasing household assets may be needed to reduce social isolation of youth heads of household. The effect of head-of-household depressive symptoms on other children living in youth-headed households is unknown.
4. Factors associated with risky sexual behaviour among out-of-school youth in Kenya. Khasakhala AA, Mturi AJ. J Biosoc Sci 2008;40(5):641-53.
Data for analysis of risky sexual behaviors were derived from the behavior surveillance survey carried out in Kenya in late 2002. Interviews of 3,961 male and female unmarried, unemployed, sexually experienced, out-of-school youth between 15 and 24 years of age were used. Methods of analysis included descriptive statistics and multinomial logistic regression. Results for males indicate that factors associated with low and high risk were whether they had fathered a child, district of residence, and frequency of alcohol use, while current age and age at first sexual debut stood out for those with low risk alone. For females, the district of residence and age of partner at sexual debut were the factors that predisposed them to low-risk sexual behavior, while for high risk the district of residence, current age, and ever being pregnant were significant. The results indicate that for these youth, contextual and probably social factors appear to be the main determinants of risky sexual behavior for both males and females. The findings also support those of other studies that link risky sexual behavior among youth, especially males, to alcohol consumption. Programs for intervention therefore need to focus on these aspects. There is also a need for studies that can look at district-specific factors for more focused interventions.
5. HIV status and age at first marriage among women in Cameroon. Adair T. J Biosoc Sci 2008;40(5):743-60.
This study assesses whether a relationship exists, for women who have completed their adolescence (age 20-29 years), between HIV status and age at first marriage and the length of time between first sex and first marriage. Multivariate analysis using the nationally representative 2004 Cameroon Demographic and Health Survey shows that late-marrying women and those with a longer period of pre-marital sex have the highest risk of HIV. Although women in urban areas overall marry later than their rural counterparts, the positive relationship between age at marriage and HIV risk is stronger in rural areas. The higher wealth status and greater number of lifetime sexual partners of late-marrying women contribute to their higher HIV risk. Given that the age at first marriage and the gap between first marriage and first sex have increased in recent years, focusing preventive efforts on late-marrying women will be important in reducing HIV prevalence among females.
6. Impact of Stepping Stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial. Jewkes R, Nduna M, Levin, J, et al. BMJ 2008;337:a506.
The authors used a design cluster randomized controlled trial to assess the impact of Stepping Stones, a 50-hour HIV prevention program, on incidence of HIV and herpes simplex type 2 (HSV-2) and sexual behavior. Participants were men (1,360) and women (1,416) between the ages of 15 and 26, who were mostly attending schools in 70 villages in the Eastern Cape province of South Africa. Stepping Stones aimed to improve sexual health by using participatory learning approaches to build knowledge, risk awareness, and communication skills. Villages were randomized to receive either this or a three-hour intervention on HIV and safer sex. Interviewers administered questionnaires at baseline and 12 and 24 months and blood was tested for HIV and HSV-2. There was no evidence that Stepping Stones lowered the incidence of HIV. The program was associated with a reduction of about 33% in the incidence of HSV-2. Stepping Stones significantly improved a number of reported risk behaviors in men, with a lower proportion of men reporting perpetration of intimate partner violence across two years of follow-up and less transactional sex and problem drinking at 12 months. In women, desired behavior changes were not reported and those in the Stepping Stones program reported more transactional sex at 12 months.
7. Knowledge, attitudes, and behaviors related to HIV and AIDS among college students in Taiwan. Tung W-C, Ding K, Farmer S. J Assoc Nurses AIDS Care 2008;19(5):397-408.
Data for this study were collected through a self-administered questionnaire from 132 Taiwanese college students enrolled in two private universities. Study results showed that fewer than half of the participants were aware that HIV could be spread through infected semen, and nearly a quarter of participants believed that HIV could be contracted through mosquito bites, toilet seats, or swimming pools. Only 29.5% reported ever having had sex. This research provides additional insights that may be used to develop effective HIV prevention strategies in Taiwan.
8. A population-based survey of the prevalence of HIV, syphilis, hepatitis B, and hepatitis C infections, and associated risk factors among young women in Vitoria, Brazil. Miranda AE, Figueiredo NC, Schmidt R, et al. AIDS Behav 2008;12(4 Suppl):S25-31.
From March to December 2006, a cross-sectional sample of women aged 18-29 years was recruited into a single-stage, population-based study. Serological markers of HIV, hepatitis B and C (HBV and HCV, respectively), and syphilis infections and associated risk exposures were assessed. Of 1,200 eligible women, 1,029 (85.8%) enrolled. Median age was 23 years; 32.2% had eight or fewer years of education. The survey weighted prevalence estimates were: HIV, 0.6; anti-HBc, 4.2%; HBsAg, 0.9%; anti-HCV, 0.6%; and syphilis, 1.2%. Overall, 6.1% had at least one positive serological marker for any of the tested infections. A majority (87.9%) was sexually active, of whom 12.1% reported a previously diagnosed sexually transmitted infection (STI) and 1.4% a history of commercial sex work. Variables independently associated with any positive serological test included older age (25 or older vs. younger than 25), low monthly income (less than or equal to four times minimum wage vs. more than 4 times minimum wage), previously diagnosed STI, one sexual partner or more, and any illicit drug use.
9. Prevalence and risk of blood-borne and sexually transmitted viral infections in incarcerated youth in Salvador, Brazil: opportunity and obligation for intervention. Fialho M, Messias M, Page-Shafer K, et al. AIDS Behav 2008;12(4 Suppl):S17-24.
Three hundred incarcerated youth aged 11-18 years received a physical examination and provided a blood sample to test for HIV-1, hepatitis B and C viruses exposure, human T-cells lymphotrophic virus, and syphilis. Overall prevalence was anti-HIV, 0.34%; anti-HBc, 11.1%; HBsAg, 2.4%; anti-HCV, 6.4%; HTLV, 1.09%; and syphilis, 3.4%. The majority (86.3%) reported a history of sexual activity; 27% had never used condoms. Girls also reported previous pregnancy (35%), abortion (26%), and sexual abuse (74%). Many youth reported a family history of alcohol abuse (56%), illicit drug use (24.7%), or legal problems (38%). Serological results show that youth in Salvador are at high risk for blood-borne and sexually transmitted infections. Policies to reduce the risk and impact of these infections should be a requisite part of health care for incarcerated youth.
10. Prevention of HIV in young people in Africa. Hayes R. BMJ 2008;337:a743.
This editorial comments on an evaluation by Jewkes et al. (BMJ 2008;337:a506) of "Stepping Stones," a 50-hour program that used participatory learning approaches in an effort to improve the sexual health of young men and women. After two years of follow-up, the incidence of HIV (the primary outcome) was not significantly affected, but infection with herpes simplex type 2 virus (HSV-2) was significantly reduced. Jewkes et al. suggest that the cause of this apparent discrepancy could be that women are more likely to acquire HIV from older male partners and HSV-2 from younger partners, and older males did not participate in the intervention. This suggests that future interventions should be targeted to the wider community and should include out-of-school youth. In addition, the editorial suggests that the results should be interpreted with caution because of the study's limitations — low incidence of HIV, high variation among participating villages, low generalizability.
11. Recent evaluations of the peer-led approach in adolescent sexual health education: a systematic review. Kim CR, Free C. Int Fam Plan Persp 2008;34(2):89-96.
Electronic and hand searches were conducted to identify quasi-randomized and randomized controlled trials of peer-led adolescent sexual health education published from 1998 to 2005. Studies were eligible if they had an appropriate comparison group, provided preintervention and postintervention data, and reported all outcomes. Study results were summarized and, where appropriate, pooled. In addition, 10 aspects of studies' methodological quality were assessed. Thirteen articles met the inclusion criteria. Pooled, adjusted results from seven trials that examined the effects of peer-led interventions on condom use at last sex found no overall benefit. None of the three trials that assessed consistent condom use found a benefit. One study reported a reduced risk of chlamydia, but another found no impact on incidence of sexually transmitted infections. One study found that young women (but not young men) who received peer-led education were more likely than nonrecipients to have never had sex. Most interventions produced improvements in knowledge, attitudes, and intentions. Only three studies fulfilled all 10 of the assessed quality criteria; two others met nine criteria. The authors conclude that despite promising results in some trials, overall findings do not provide convincing evidence that peer-led education improves sexual outcomes among adolescents. Future trials should build on the successful trials conducted to date and should strive to fulfill existing quality criteria.
12. What is 'sex' exactly? Using cognitive interviewing to improve the validity of sexual behaviour reporting among young people in rural Zimbabwe. Mavhu W, Langhaug L, Manyonga B, et al. Cult Health Sex 2008;10(6):563-72.
Self-reporting of sensitive data is often unreliable, particularly when questions are asked about culturally or socially censured behaviors. This study aimed to improve the validity of this information. A questionnaire was developed in English and translated into Shona. Three rounds of cognitive interviewing were conducted with 65 young people. Data were coded and analyzed using principles of grounded theory. Young women emphasized that they would not admit to having participated in sexual activities if questions were phrased in such a way that they could be seen as having initiated sex. They suggested that the wording of sexual questions should use the passive tense. Also, the Shona term for 'vaginal sex' is used to refer to both consensual and nonconsensual sex, so careful wording of questions, again, is important. Finally, in Shona, there is no formal term for anal sex, and phrasing this activity in a way that was both acceptable and understood proved particularly challenging. Cognitive interviewing is useful in exploring the underlying thought processes and the cultural context behind question responses. Examining the cultural and societal norms within a study population is key to obtaining valid responses.
