by Thuthukile Mbatha, Spotlight
The Desmond Tutu HIV Foundation (DTHF) is implementing a number of innovative youth-focused health services around Cape Town. Others could learn from their approach and successes.
The DTHF Youth Centre was established in 2011; situated in Masiphumelele
township, it is at the forefront of trying to find answers to the tough questions regarding young people and access to healthcare services. The foundation is specifically interested in innovative HIV research, and even more so where it intersects with young people’s issues. Simply, they want to find innovative health-delivery mechanisms that keep young people healthy, HIV-free, and without the burden of teenage pregnancy and similar challenges.
The adolescent girls and young women division focuses on sexual and reproductive health rights, mental health, HIV, life skills, and sero-neutral service delivery. ‘Sero-neutral services’ means that everyone is treated the same, irrespective of their HIV status.
The DTHF’s director, Professor Linda-Gail Bekker, has been at the helm for over 10 years, and has led a team trying to figure out how young adolescents can be ethically involved in HIV prevention research. This is because the laws against HIV research on adolescents are very tough, prompted by the assumption that because adolescents are below the age of consent, they are therefore vulnerable. However, the DTHF has made great strides in fighting for adolescents to be included in HIV research trials.
The DTHF has been involved in adolescent PrEP studies, including PlusPills, the 3P project, and the ADAPT study. The Foundation has also conducted HIV vaccine studies (SASHA) and HIV self-testing studies. “Our current range of research (treatment, prevention, socio-behavioural, structural) is vast, but we are always looking to explore and expand the evidence base around what works for adolescents. Permission to conduct research is sought through our ethics committee, and is – rightly – a strict process. We take great measures to adhere to ethical guidelines around adolescent research, and work with our ethics committee and youth advisory board to make sure we go about this in the best way. To best serve adolescents and meet their needs, we need to know what works; so this research is important to do,” says Bekker.
Responding to a question regarding the emphasis on young women, Bekker says: “Young people, particularly young women and girls, are disproportionately affected by the HIV epidemic, and are at high risk for infection. Young people are also undergoing a unique phase of life, characterised by biological and physiological changes, increased risk-taking behaviour, etc.; and so it is important to have services and strategies that are specifically tailored to them.
“The foundation employs a harm-reduction approach, as opposed to a ‘prevent sex from happening’ strategy,” Bekker explains from her office on UCT’s medical campus. In 2005, the foundation conducted a survey at Masiphumelele township in Cape Town’s southern suburbs, and found that many young women they spoke to were already infected with HIV. One of the outcomes of their survey was information that a contributing factor to the high HIV incidence rates was that young women had no-one to talk to about sex.
The DTHF is now running a number of youth programmes at youth centres, such as the Philippi Village and Hannan Crusaid Youth Clinics (in Philippi and Gugulethu respectively); the Masiphumelele Youth Centre; and the Tutu Teen Truck (mobile service). These include the Health Zone (where young people learn about sexual and reproductive health rights, for example), an Edu Zone (where learners are assisted with school homework), a Fun Zone (where young people participate in sports), the Women of Worth study (see article on page 29), and 18-month internships – offered to youth who have graduated from the Zimele programme, and no longer fit the targeted age category of 10-24 years; these interns run the Zones.
The DTHF delivers youth-friendly sexual and reproductive health services through various platforms, including the Tutu Teen Truck (a mobile clinic delivering health services to young people) and youth-friendly clinics (mobile health facilities providing services that are targeted at and designed for young people). About 4 000 young women use the youth centres, and 300 of those are on Pre-Exposure Prophylaxis (PrEP). This form of PrEP is an antiretroviral drug called TRUVADA, taken daily by HIV-negative people to prevent HIV acquisition.
Innovative reward system
The programme uses some innovative systems to keep track of the young people. Every young person who is part of the youth programme has a unique identifier, logging in using a fingerprint on the biometric machine at the entrance, at which point their medical file is uploaded on the healthcare provider’s computer.
To encourage young people to stay healthy and HIV-free, the foundation has a reward system for all its young members through which they earn points for doing all the vital tests. Undergoing an HIV test gets you double points. This initiative is also aimed at normalising HIV among young people. The ‘currency’ used for the points system is the ‘Tutu’ – three Tutus are equivalent to R1. These can be exchanged for food vouchers. An HIV test is rewarded with 100 Tutus. According to Bekker, “You’ll find a 19-year-old boy asking his friends if they have done an HIV test yet, because he is short of Tutus.” The youth use Tutus to buy a number of items from a local mall or an onsite café.
If someone has a negative test result, they are reminded about the importance of staying HIV-negative, and encouraged to use available HIV-prevention tools. A person who tests positive will receive the same number of Tutu rewards. “We do not penalise mistakes, because that doesn’t work well,” says Bekker. This means that young people get rewards regardless of their HIV status; however, they receive different packages of care. For instance, a person who tests positive would be offered counselling, encouraged to go onto treatment, and advised to encourage their partners to be tested as well.
The Tutu reward system is also aimed at preparing the youth for the grown-up world, and teaching the importance of saving. This is part of positive youth development. The foundation offers 18-month internships to youth who have graduated from the programme, from age 24. The internships involve running the three Zones for younger people, and teaching life skills. There are two interns for each Zone. Most young people relate better to their peers. “What I’m really passionate about doing for this country is to develop a cadre of community healthcare workers who are adolescents,” says Bekker.
The Tutu Teen Truck
According to Bekker, the Youth Centre has been criticised for its perceived inability to be scaled up, as it would not be possible for the government to replicate the same programmes for the entire country. But there are some important elements of the programme that the government could apply, and which are cost effective. The Tutu Teen Truck is one of them. It takes the elements of the sexual and reproductive health services and puts them in a funky-looking truck, which is an “adult-free and adolescent-aware environment”. It is brightly painted, and designed to be attractive to young people. The staff are properly sensitised and trained to be adolescent-friendly.
A range of services is offered to 12- to 24-year-olds. Bekker is trying to get the government to approve the provision of antiretroviral therapy (ART) through the Truck, so that young people – whatever their test results – can get appropriate care and support as part of a combination prevention strategy, without delay.
The Truck travels around Mitchells Plain, Klipfontein and Mfuleni townships, and stops in areas with high HIV prevalence. It draws the attention of young people by playing loud music. It operates every Monday to Friday from 12pm to 6pm, as well as some Saturdays. It offers a range of contraceptives and sexually-transmitted illness (STI) screening interventions, through the use of a GeneXpert machine installed in the truck – a machine mainly used to detect TB, via sputum samples, but which can also be used to test for various other diseases.
A person’s sample is inserted into the GeneXpert, which then conducts an antigen test. “A large number of young people are walking around with untreated gonorrhoea and chlamydia that we are missing, so this offers same-time STI detection and treatment,” says Bekker. The truck also offers tuberculosis (TB) screening to young people suspected of having the infection. Those who require abortion services are referred to health facilities in their neighbourhood that offer such services. “A lot of the young people who use these services just need to talk to someone who will not judge them in any way,” Bekker adds.
To explore the cost-effectiveness of providing effective youth-friendly services to young people, the same elements of the youth centre and the Tutu Teen Truck are being piloted in some public health facilities. The Global Fund to Fight AIDS, Tuberculosis and Malaria has funded a three-year programme aimed at 22 000 young women and adolescent girls between the ages of 10 and 24 years, in the Klipfontein and Mitchells Plain areas. Alongside the DTHF youth centres, the foundation has identified 24 public health facilities in the Mitchells Plain and Klipfontein health sub-district where they could render the same youth-friendly services to young women and girls. In all of these facilities, they are guided by the National Adolescent and Youth Policy 2017.
Part of the Global Fund grant is used to pay peer navigators at government clinics. A peer navigator is a young person who welcomes young people at the clinic as they arrive at the door, and directs them to the relevant staff. Each clinic also has an adolescent-youth-friendly service champion who has been identified at the clinic. This could be anyone at the clinic: a nurse, a security guard or an administrator, for example. The role of the champion is to ensure that youth-friendly services are rendered to young people without prejudice.
The Foundation is currently developing what is called an ‘adolescent pack’, which outlines how nurses should treat adolescents in clinics. This was prompted by the fact that traditionally, nurses only operate using ‘adult’ and ‘child’ packs; they do not know how to address adolescent health issues, which are largely sexual- and reproductive-health-related. Every clinic staff member – including the security guards, nurses and cleaners – is trained in how to render youth-friendly services.
On top of these programmes, the Foundation has approached all the high schools in the sub-districts to find out from the headmasters what kind of services they would allow to be provided in their schools. Some choose contraception only; others want the comprehensive sexual- and reproductive-health package. Again through the Global Fund grant, the foundation has hired four nurses who visit all the schools that require these services. Some schools only allow counselling to be offered to learners, and nothing else.
Keeping girls in school
The DTHF has another initiative, called the Keeping Girls in School programme, which targets 15- to 19-year-old girls, with the aim of keeping them in school. Young women and girls are taught about their reproductive organs, and the importance of HIV and pregnancy prevention. This initiative is run by peer educators in schools; through the initiative, the foundation supplies sanitary pads and tampons to female learners.
The DTHF is also conducting a study called Women of Worth, targeting 19- to 24-year-old girls out of school. The study aims to enrol 10 000 young women in order to equip them with self-empowerment skills, in 12 sessions. These sessions cover a variety of issues, such as gender-based violence, sexual and reproductive health, and how to prepare for the job market; a type of life-skills training.
Of the 10 000 young women, 5 000 will receive a cash incentive as part of the study. This research aims to establish whether a cash incentive could help improve health outcomes. The sessions offered include topics such as self-empowerment, sex talks dealing with HIV, STIs and family planning, gender-based violence, personal finance management, and so on.
The study will assess how well these programmes work. Half of the participants will be randomly selected to receive a cash incentive and the empowerment course, whereas the other half will only receive the empowerment course. The study will establish whether these young women’s health outcomes are significantly improved by them attending empowerment sessions and receiving a cash incentive. The cash incentive is an example of behavioural economics, based on the assumption that a lot of young women get into difficult relationships because they want cash. The cash transfer is dependent on their involvement in the study. After completing the 12 sessions, the young women will graduate, and some will be enrolled in the learnership programme in the DTHF – provided they finish and excel during the two-year period of the programme. The majority of the young women in the study already have a child, and come from very poor backgrounds.
“Unless we try to address the socio-economic challenges that young women face on a daily basis, through equipping them with income-generation skills, we can offer as many contraceptives and HIV-prevention tools as we want; but we will not see any progress,” says Bekker. The young women who have completed the programme are encouraged to recruit their peers to enrol as well.
There is a parallel programme targeting young men, in which participants discuss men’s issues and how to treat women. The sessions are a ‘woman no-go zone’. Both the Women of Worth programme and the men’s health component include a session on LGBTI needs and issues. Every young person has a tailor-made programme meant to address issues specifically related to them.
“If all these programmes do not work in three years, I will know that we had a fair try,” says Bekker.