“The barriers that impede our access to high-quality health services also affect us uniquely. We know the solutions to these barriers, but we need spaces to engage in mitigating them.”
Fahe Kerubo, Y+ Global
This chapter summarizes and updates information from four WHO HIV technical briefs for young key population groups published in 20151 (261–264). WHO did not publish a technical brief on HIV and young people in juvenile detention and prison, but many considerations for young people who sell sex, young men who have sex with men, young trans and gender diverse people, and young people who inject drugs will also apply to this population. This chapter aims to catalyse and inform discussions about how best to provide health services, programmes and support for young key populations. While the focus is on health for young key populations, the considerations will be relevant to other programmes: welfare, justice, protection, education and social protection (261–264).
Background
Attention is growing globally on the importance of addressing the specific health needs of young people (those aged from 10 to 24 years). Adolescence and young adulthood are periods with significant physiological changes, and a time where young people establish identities and sexual preferences and explore new life experiences (265). Structural factors and the vulnerabilities of youth (power imbalances in relationships; evolving identity and capacity; restricted access to sexual and reproductive health; effective prevention interventions; and, sometimes, alienation from the school system, family and friends) reduce young people’s access to prevention, harm reduction, and reproductive health services, and put them at higher risk of infection from HIV, STIs and viral hepatitis (261–264, 266–268).
Epidemiological data on the global status of HIV, STIs and viral hepatitis among young people remain limited, with significant gaps for young key populations (265, 269, 270). Available data show that young key populations are disproportionally vulnerable to, and affected by, HIV (270) and STIs compared to their peers and older key populations (183, 271–276). For HCV infection, data show that rates are high and rising among young people who inject drugs and young men who have sex with men (277–280). Transmission of HBV mainly occurs in early childhood, from mother to child, and many countries have high HBV immunization programme coverage. Despite this, young people born before the initiation of the infant immunization programme, or not vaccinated, will remain susceptible to HBV infection (19, 281). Young people remain at higher risk for STIs, and may be biologically more susceptible to STIs, particular younger women (183, 282).
The global response to HIV, STIs and viral hepatitis has not reached adequate numbers of young key populations (269). Young key populations’ lower access to prevention, diagnosis and treatment is due to a range of factors (282–290):
misconceptions about risks;
lack of knowledge and accurate age-appropriate information;
lack of comprehensive sexuality education (CSE);
low awareness of available, friendly health services; and
barriers to access and uptake of services (including legal and policy barriers around consent requirements).
In addition, social determinants, such as wealth, race and gender inequality, and access to education greatly impact health behaviour and outcomes for this population (269, 291).
Services and providers are often poorly equipped to provide services for young key populations, and staff frequently lack training, skills and knowledge to deliver acceptable and appropriate services for young key populations (292–294). Furthermore, inadequate investments and availability, or use of age- and sex-disaggregated data in primary research, monitoring and evaluation is a barrier to programming for young key populations (295–298).
States have a legal obligation to respect, protect and fulfil children’s right to life, health and development. Societies share an ethical duty to ensure this right for all young people. Addressing underlying structural barriers for young key populations is critical.
One of the added structural barriers specifically young key populations face that is distinct from their adult counterparts’ barriers is the requirement for parental, caregiver or guardian consent (261–264) to access services, including harm reduction services. For young people who do not wish to disclose an issue to their caregivers, this can be directly inhibitive to accessing care, resulting in missed opportunities for prevention and treatment. Countries are encouraged to examine their age of consent policies, and to consider revising them to reduce age-related barriers to access and uptake of services and interventions that are critical to the health and wellbeing of this population.
Changes to the legal and policy environments
The United Nations Convention on the Rights of the Child (CRC) obliges the state to protect the rights of all young people under 18 years of age. The treaty includes protection from sexual exploitation and sexual abuse; it emphasizes four guiding principles: non-discrimination; the best interests of the child; the right to life, survival and development; and respect for the young person’s views (299). Commitment to the CRC includes lowering the risk of infectious diseases and strengthening protective systems to reduce vulnerabilities for young people. The rights of children are contravened when those young people under 18 years of age are excluded from effective HIV, STI and viral hepatitis prevention and life-saving prevention, testing, treatment, care and support services (261–264).
Elements of successful programming for young key populations
WHO recommended interventions and service delivery strategies for all key population groups also apply to young key populations (See Chapters 4–7).
Summary of key characteristics of effective young key population services.
Informed by WHO and UN partner publications, the elements of successful programming for young key populations update the 2015 WHO policy briefs (261–264). Services must be designed and delivered to consider the differing needs and rights of young people according to their age, gender identity, sexual orientation, specific behaviours, the complexities of their social and legal environment and the epidemic setting, while simultaneously respecting the CRC.
Meaningful involvement of young people
The WHO global consensus statement on meaningful adolescent and youth engagement states that meaningful adolescent and youth engagement requires a mutually-respectful partnership between adolescents, youth and adults. Power is thereby shared; respective contributions are valued; and young people’s ideas, perspectives, skills and strengths are integrated into the design and delivery of programmes, strategies, policies, funding mechanisms and organizations that affect their lives and their communities, countries and world (300). Meaningfully and ethically involving young key populations in the planning, design, implementation, monitoring and evaluation of services requires acknowledging and building upon the strengths, competencies and evolving capacities of young key populations, especially their ability to express their views and articulate what services they need (301).
Work with trusted partners and existing infrastructure to design and deliver services
It is important to partner with community-led youth and key population organizations, build upon their experience and credibility, and use appropriate, effective and efficient approaches to design and provide services for young people.
Provide quality, comprehensive and adolescent-friendly services
It is crucial to ensure that health (including immunization), welfare, justice, protection, education and social protection services are integrated, linked and multidisciplinary in nature, with a strong system for referral along the continuum of care. Provision of a comprehensive range of services with online delivery options (see the service delivery chapter) can help to address the overlapping vulnerabilities and intersecting behaviours of different young key populations. The WHO adolescent-friendly health services principles guide adolescent-friendly health services (302). WHO and UNAIDS have also published global standards that define the quality in delivering of health services for adolescents (303).
Improve access to and retention in services
It is essential to ensure that young key populations have access to the necessary health services and information regardless of their marital status and caregiver consent. Medical treatment without caregiver consent is possible and should be considered when in the individual’s best interests. Making services accessible includes ensuring that service locations are easy, affordable, confidential and safe for young key populations to access, and are provided at times that are convenient to young people. Providers have discretion to provide services to young people and should not be prosecuted for doing so. Adolescents, irrespective of age, should be permitted access to counselling and advice without the consent of a parent or guardian (303). Young people should be made aware of their rights to confidentiality, and any limits of confidentiality made clear by those with mandatory reporting responsibilities (304).
Provide developmentally appropriate information and education
Services for young key populations must provide developmentally appropriate, accurate and inclusive information and education. Prevention of HIV, STI and viral hepatitis prevention, in addition to comprehensive sexuality education for young key populations and their partners (including for adolescents and young people out of school) should focus on skills-based risk reduction. Information can be shared using various media platforms, such as online, mobile phone technology and participatory approaches (261–264, 305–307).
Build capacity in the health sector and beyond
Sufficient capacity amongst professionals, particularly in the health, social welfare, justice and education sectors, to work with young key populations and apply rights-based approaches and evidence-informed practice is critical. Capacity-building involves expanding knowledge on the health needs and rights of different young key populations, and relevant overlapping vulnerabilities (namely, injecting drugs, sexual exploitation or selling of sex) (308, 309). Training is needed on providing respectful, non-judgemental services that consider sexual and gender diversity, gender and power relations, gender-affirming care, and further development of communication and negotiation skills – as they relate to key populations (310).
Implement peer-driven models
Adolescent and youth peer-driven models and support are key implementation strategies towards the global standard of adolescent participation (311, 312). Young people highly value peer support programmes. Peer navigators are crucial in bridging online information and offline action, such as accessing testing and treatment services (313). Appropriate training, support and mentoring are essential to help young key populations advocate within their communities to support them in accessing services (204, 261, 263, 264). The WHO technical brief Adolescent-friendly health services for adolescents living with HIV (302) provides implementation considerations for adapting and scaling-up peer-based, adolescent-friendly models.
Strengthen protection and welfare for families
Helping parents and families to fulfil their responsibilities to protect, care for and support young key populations effectively is critical. For adolescents aged between 10 and 17 years old, it is important to try to reintegrate them with their families when appropriate, if in their individual best interests, or to provide other appropriate living arrangements and care options in line with the 2010 UN Guidelines for Alternative Care (314).
Update national policies
To ensure harmonized implementation across programmes, evidence-informed services for young key populations must be clearly stated in national policies; that is, the National Strategic Plans (NSPs). (See Chapter 9.)
This toolkit is a collection of online resources to help plan and scale-up
HIV prevention programmes with adolescents and young key populations (ayKP) – people aged 10–24 years.
Monitoring and evaluation
Programming for young people needs to consider the population size, demographics and epidemiology; data disaggregation should be done by sex or gender and age group (298). Collect and collate baseline measurements, monitoring and evaluation systems into programmes to strengthen quality and effectiveness and develop a culture of learning and evidence-based practice to better inform future policies and programmes. (See Chapter 9.)
Addressing the additional needs and rights of young key populations
Ensuring that the needs of young key populations are met will improve health outcomes and overall wellness for these populations. The following particular needs should be considered when designing and implementing programmes and services (261–264).
Protection is needed from all forms of physical, emotional and sexual violence and exploitation, whether by law enforcement officials or other perpetrators (
315–
320).
Access to information on the harm that early marriage and early pregnancy can cause is needed.
Young people who become pregnant need access to health services sensitive to their rights and needs. This includes providing access to sexual and reproductive health services, including family planning, contraception and information and access to youth friendly safe abortion services, adequate and comprehensive obstetric care, and counselling (
321–
323).
Psychosocial support services are called for; namely, therapy, counselling, peer support groups and networks to address the impact of self-stigma, discrimination, social exclusion, coming out, gender-affirming care, and to address mental health issues (
312,
324).
Support is critical to remain in or to access education or vocational training, and opportunities to return to school need to be offered, and access to preventative strategies for bullying, stigma and discrimination (
307,
315,
317,
325,
326).
Independent living and group housing shelter are necessities as immediate or long-term accommodation arrangements (
327,
328).
Food security, including nutritional assessments, is all-important (
329,
330).
Livelihood development, economic strengthening, and support to access social services and state benefits are needed (
331).
Access to free or affordable legal information and services is critical, including information about their rights, reporting mechanisms and access to legal redress.
Counselling for families when requested to facilitate access to services is essential, especially where parental/guardian consent is required.
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Young trans and gender diverse people, young men who have sex with men, young people who sell sex and young people who inject drugs.
