Cutting-edge youth services

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

Professor Linda-Gail Bekker, Director at the Desmond Tutu HIV Foundation. (Image: Thom Pierce)

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.

 

What is the state of the global HIV and TB response in December 2017?

credit: istock

“I am tired – to the point of despair – of all the congratulatory public raptures about the progress against HIV and AIDS. How could we not have made progress? It’s been thirty-six years, for heaven’s sake: we were bound to move forward. Instead indulging in an orgy of self-hypnotic success, we should be demanding to know how it’s possible that up to 19 million people still don’t have treatment; that women and adolescent girls continue to bear the brunt of the pandemic’s assault; that key populations are demonised by fossilised governments, so that prevention and treatment are never available; and that we’re in a staggering funding crisis, the sure outcome of which is even greater morbidity and mortality. Where is the political and multilateral leadership that can decisively and forever turn the tide? We should all be raging against the profusion of fatuous voices.” – Stephen Lewis, co-director, AIDS-Free World

 

“The world has made great strides in tackling HIV/AIDS, but we are in danger of coming to a standstill. Progress has slowed, for a variety of reasons; but a major roadblock is our failure to listen to young people. The largest-ever generation of adolescents in sub-Saharan Africa is at risk of HIV – in 2015, nearly 7 500 young women aged 15 to 24 years acquired the infection each week. Stigma, poor education, and services that are out of touch. We must understand what young people are going through, and react quickly and effectively, if we are to end HIV/AIDS.” – Professor Peter Piot, Director of the London School of Hygiene & Tropical Medicine and former Executive Director of UNAIDS

 

“In 2008, when the global economic crisis hit, funding for HIV and TB first plateaued and now is slowly declining. If the 2000s offered the promise of ‘the end of AIDS’ and new strides against TB, in the next few years we may be trying to figure out how to ‘do less harm’, and limit the damage that funding cuts will cause after promises made by donors have been broken and allocations curtailed. I can’t offer you false hopes about us getting to 90-90-90 anytime soon, but perhaps the brutal facts will spur us to action once again; they are surely better than spooning out comforting – and ultimately, untrue – platitudes for World AIDS Day.” – Gregg Gonsalves, long-time AIDS activist and Assistant Professor, Yale School of Public Health

 

 

“A bittersweet trajectory – We are in an epoch in which the HIV epidemic continues in an unremitting manner, eradicating the promise of a better tomorrow from our families and communities. In our country, more than seven million people are HIV-infected; and it is estimated that there are 1 000 new infections every day. Science continues to push the boundaries: progress new HIV treatment and care interventions, movements to control paediatric HIV by reducing maternal-foetal HIV transmission. These have translated into reductions in infant and under-five mortality rates, and increased life expectancy. In the HIV-prevention arena, progress in long-acting antiretrovirals for use in pre-exposure prophylaxis may translate into a powerful prevention intervention. As we advance three HIV vaccine concepts into efficacy studies, we start to think that we may have the kind of tools that have the potential to curb the HIV epidemic globally. However, the biggest hurdle to overcome in our fight against HIV is the stigma and discrimination that HIV-infected people face every day of their lives. The true test of beating this epidemic will be whether we as a people have the ability to overcome our prejudices against people living with HIV. While we have at our disposal a series of proven prevention tools to afford us safer sexual choices, it is evident that science and biomedical interventions alone will not help heal our communities and families. Structural factors such as poverty and unemployment, in addition to biological factors such as genital inflammation and viral load, and behavioural factors such as lack of condom use and age-disparate relationships, have combined to make our battle against HIV all the more challenging. If we are to grow the momentum of our battle strategy against HIV, then we must not define people by their living with HIV; but rather, by the lives they fulfil.” – Professor Glenda E. Gray, President of the South African Medical Research Council

 

“HIV and TB continue to be major global public-health issues, with an estimated 37 million people living with HIV and an estimated 10.4 million with TB. The vast majority of people living with HIV and TB are from the low and middle-income countries, and the majority of them are public healthcare users. We can’t afford to lose this battle; political rhetoric without action won’t win this battle. The only revolutionary step towards ending HIV and AIDS is to invest more resources in public health care, and have the political commitment and will required to overhaul public healthcare systems. Only a functional, well-maintained, well-resourced public healthcare system that will serve the people – irrespective of their class, sexual orientation, financial status and of other discriminatory laws – can take us to where we want to see ourselves with our global response to HIV and TB.” – Anele Yawa, General Secretary, Treatment Action Campaign

 

“In 2017, it is very encouraging to see expansion of life-saving antiretrovirals

to 21 million individuals worldwide; however, in order to get the full impact of this treatment expansion, we also need to ensure that all 21 million stay on their treatment and become virally suppressed. Sadly, we are not doing well in tuberculosis and without a doubt more emphasis is needed worldwide on improving primary prevention of both HIV and tuberculosis. This will require that we also address structural determinants of universal health: a much harder challenge to meet.” – Professor Linda-Gail Bekker is the President of the International AIDS Society and Deputy Director and Chief Operating Officer of the Desmond Tutu HIV Foundation at the University of Cape Town

 

“South Africa has the largest HIV treatment programme in the world with 4.2-million patients on treatment. This has been achieved through a combination of factors including high levels of activism by civil society formations, political leadership from Minister Aaron Motsoaledi, funding from national Treasury in the form of a conditional grant, training of nurses to initiate patients on first line treatment (NIMART) and support from development partners. However with an estimated 270 000 new HIV infections in 2016 as well as 7.1-million living with HIV and AIDS, it is clear that we have much more to do in both preventing new HIV infections as well as reaching the 90-90-90 targets by 2020. The recently launched Global HIV Prevention Coalition’s HIV Prevention Roadmap proposes a target of no more than 88 000 new HIV infections by 2020. In addition, reaching the 90-90-90 targets means that we should have 6.2-million patients on ART by 2020 as well. To meet these targets we will require that all stakeholders fully commit to them, find additional resources as well as work collaboratively.  It will also require changes to how we provide services to reach the treatment targets and how we support patients to ensure high levels of viral suppression. We also need to more rapidly decrease new HIV infections by being more creative and fully implementing combination prevention strategies. Our strategies must include dealing decisively with the TB epidemic as well – preventing new TB infections, finding those that have TB and successfully treating them. We have the political will, the motivation, and the means to reach epidemic control by 2020!” – Dr Yogan Pillay, Deputy Director General, South Africa, National Department of Health

 

“The state of the intertwined, global HIV and TB response is characterised by two signature themes. In the first instance, we have a global community unified in strategic intent to achieve epidemic(s) control, as encapsulated by the UNAIDS 90-90-90 strategy. This unified focus needs to be bolstered even further, as the impact of a successful 90-90-90 strategy will be healthy, HIV positive persons living long, productive lives, while transmitting the virus at far lower rates. The second signature theme relates to generalised insecurities globally, and the emerging dominance of more conservative, inward-looking views among donors. This directly affects the HIV/TB programmes that support the poorest and most marginalised of communities. Efforts should be amplified towards lobbying wealthy countries to increase donor support to developing countries, while developing countries should find greater internal resources to support the same. HIV/TB epidemic control requires long-term, global, sustainable support by – and for – all.” – Dr Tim Tucker is CEO of SEAD Consulting and specialist Clinical Virologist

 

“Thanks to anti-retrovirals, AIDS is no longer an inevitably fatal condition, but a chronic, manageable one; rates of infant transmission have been reduced to about 1.5%; and their impact on prevention – directly through viral suppression of infected persons, or through prophylactic use by infected persons – is starting to emerge. Though with nearly 20 million people still to be initiated on treatment globally, a million deaths, and 1.8 million new infections still continuing to occur, we can hardly claim to have turned the corner or the tide! We do have sufficient knowledge to achieve epidemic control, however in sub-Saharan Africa, the HIV and TB epidemics are closely intertwined; failure to integrate HIV and TB services is resulting in continued high mortality rates – as are stigma and discrimination, through creating a barrier to accessing services. Stigma remains a major barrier to access to services. We need to partner with infected and affected communities much earlier, and across all stages of developing, evaluating and implementing new interventions.
Getting to this point has required a lot of teamwork, political commitment, global solidarity and innovation – and the next phase is going to be a lot more challenging. But can we afford to reverse the gains made to date?” – Quarraisha Abdool Karim is the Associate Scientific Director of CAPRISA in South Africa

 

“The political momentum for the fight against TB is now garnering the same type of global attention that HIV achieved in 2000, when the UN General Assembly hosted a Special Session on AIDS, the Global Fund was created, and investments shifted from the millions to the billions. It’s not before time. Still lagging behind is any serious attention being paid to the plight of women and girls. In fact, things are going into reverse: in January 2017, US President Trump used his first days in the White House to expand the Global Gag Rule to all $8.8 billion allocated to US global health – including funds dedicated to HIV and TB. This is likely to have a devastating impact on the lives of girls and women, especially girls and women impacted by these two diseases. NGOs registered outside the US can no longer provide information or advice about safe abortion, even with their own or other people’s funds, if they want to retain funding flows from the US. All of the hard work done so far to address the human rights of girls and women, and to break through silos, has been endangered. Many HIV programmes have worked hard to address the needs and rights of the women and girls they serve, so that they can access the full spectrum of sexual and reproductive health services alongside their HIV and TB services. Given the heavy reliance of HIV and TB programmes on US funding, catastrophic impacts are predicted that will be counted in the lives and well-being of women, girls and their communities. Brave politicians – initially from the Netherlands and other European countries, and now from Canada, Afghanistan and a range of African countries – have mobilised. Around the world, thousands of individuals and organisations are standing together under the banner of SheDecides to fight for a ‘new normal’, in which every girl, every woman, everywhere decides for herself what to do with her body, her life and her future. And you can join them, by signing the manifesto at www.shedecides.com.” Robin Gorna co-leads SheDecides