Effective Approaches for Programming to Reduce Adolescent Vulnerability to HIV Infection, HIV Risk, and HIV-Related Morbidity and Mortality: A Systematic Review of Systematic Reviews

"HIV programming for adolescents should focus on interventions of proven effectiveness and address underlying factors driving incidence and lack of effective treatment and care in this age group."

In this United Nations Children's Fund (UNICEF)-funded evidence review, researchers "conducted a systematic review of systematic reviews to summarize the global data on effectiveness of 20 intervention types, to identify characteristics of effective interventions, and to explore evidence of how adolescents can access interventions with proven effectiveness. Interventions were in 2 broad categories: those designed primarily for adults and those designed specifically for adolescents."

Results included "... evidence that in-school interventions and some interventions in geographically defined communities can positively impact important HIV-related outcomes, such as self-reported sexual risk behaviors. Interventions designed primarily for adults that had high-quality, consistent biological evidence of efficacy included voluntary medical male circumcision (VMMC), antiretrovirals [ARVs] for the prevention of mother-to-child transmission, HIV testing and counseling, HIV treatment, condom use, and provision of sterile injecting equipment to people who inject drugs. There was also an evidence of potential efficacy for oral pre-exposure prophylaxis and behavior change interventions among certain populations. There was a dearth of systematic review data on how best to enable adolescents to access the intervention types identified as having proven effectiveness among adults."

Researchers asked whether interventions can be made effective, what characteristics make each intervention most effective, and what needs to be done differently to ensure that adolescents will also benefit from any prevention, treatment, care, and support interventions that were found to be effective among adults.

Among the findings on adult interventions when used for adolescents - related to communication strategies:

• Evidence on adolescents' access to HIV testing and counselling showed unique barriers to access in some contexts, suggesting tailored support, "such as targeted out-of-facility services (e.g., mobile clinics, street- and youth center-based services, home-based testing), opt-out provider-initiated testing and counseling, the use of rapid testing, and provision of testing within a setting providing adolescent-friendly health services." Data suggest that African children and adolescents start ARV treatment later, inferring that there are barriers to diagnosis and/or treatment.
• "Community-based condom distribution strategies (e.g., street outreach, peer distribution) may increase access to condoms among adolescents, and combination of specific condom promotion interventions with other interventions, such as education and training related to communication and decision-making skills, also showed potential for increasing condom use among adolescents."
• Some countries, including the United States, had legal obstacles to adolescents accessing methadone replacement therapy as an HIV preventative, suggesting a need for advocacy to remove the obstacles.
• "Mass media interventions showed potential to be effective for improving several outcomes among adolescents, including HIV prevalence, through the use of interventions combining television and radio with supporting material. New technologies are also being used for mass media interventions, including using cellular communication, social media, and mobile health products to reach participants. They represent innovative new platforms for delivering interventions."

For specifically designed adolescent interventions related to communication:

• In-school interventions were found to be an efficient means of reaching school-going adolescents. "Delivery of interventions by trained adult facilitators, having multiple session programs, curricula that include skills and knowledge-building activities, and programs that are specifically designed or adapted for the local context were key characteristics of the more successful interventions."
• Youth centre venues were not found to reach female adolescents as effectively as adolescent-friendly clinics which need training of service providers, outreach activities, and out-of-facility services tailored to the local context and focus population.

The study concludes that more research is needed on adolescent programmes with the key question being how to reach adolescents with these interventions. Adult interventions also effective with adolescents include: VMMC, ARVs for prevention of mother-to-child transmission (PMTCT), HIV testing and counselling, HIV treatment, condom use, and provision of sterile injecting equipment to people who inject drugs (PWID). "There was also evidence of potential efficacy for oral PrEP [pre-exposure prophylaxis] among heterosexual couples and MSM [men who have sex with men] and behavior change interventions among PWID and MSM."