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.


Young women: Seven myths about menstruation and reproductive health

Lerato Makate, Spotlight

Sexual and reproductive health education being taught in South African

Activists demand free sanitary pads for school girls at the 2016 AIDS conference in
Durban during Minister of Health Aaron Motsoaledi’s speech

schools has left some female learners and young women feeling less confident about the right time to engage in sexual activity, about what to do when their menstrual cycle comes, and even about understanding how contraceptives should be used.

This is according to nursing sister Anna Moloi, the acting head of Department of the Campus Health Clinic Services at the University of the Witwatersrand.

Moloi says the clinic has had several encounters and consultations with female students – mostly in their first year of tertiary education – who were experiencing their menstrual cycle for the first time, and did not understand what was happening or what they needed to do.

She says that as a result, the clinic has seen the need to conduct thorough consultations, including one-on-one sessions, explaining to these young women the process their bodies are undergoing.

“A lot of them, especially the young ones [students], will come with menstrual pains. What we normally do is to advise them on what menstruation is; because in high school, they do not get a lot of [reproductive health] education,” Moloi says.

Menstruation, or having periods, is normal vaginal bleeding that occurs as part of a woman’s monthly cycle. Every month, the female body prepares for pregnancy. If no pregnancy occurs, the uterus, or womb, sheds its lining. The menstrual blood is partly blood and partly tissue from inside the uterus. It passes out of the body through the vagina.

Periods usually start between the ages of 11 and 14, and continue until menopause at about age 51. They usually last from three to five days. Besides bleeding from the vagina, there may be:

  • Abdominal or pelvic cramping pain
  • Lower back pain
  • Bloating and sore breasts
  • Food cravings
  • Mood swings and irritability
  • Headache and fatigue

Explaining the persistent myths concerning women’s menstrual cycles, Moloi says there are still many young women who need accurate information on and a thorough explanation of sexual activity and how it can affect the menstrual cycle. Despite the sexual and reproductive health education taught in South Africa’s schools, many young women continue to believe these myths about menstruation.

Here are seven menstruation and sexual reproductive health myths:

  1. You will not get pregnant if you ‘douche’ after sex. Many people wonder if douching with either regular douching fluid or bubbly cooldrink (such as Coca-Cola) can get all the sperm out after sex, effectively preventing pregnancy. The truth is that it won’t. Biologically, women’s vaginal muscles contract during orgasm as the body’s way of bringing the semen toward her eggs; so even if you douche immediately after sex, some of the sperm will already be too deep to be flushed out. Plus, douching with soda or other liquids not meant for that purpose can cause irritation and infection, which is also not a good thing.
  2. If you do not have a condom, you can use a balloon. No plastic baggie/rubber band or balloon/twist-tie combination will provide the protection of a traditional, approved condom. And it may not even stay on. The ones you’ll find on shop shelves are electronically tested to meet strict standards of strength, reliability, and resistance to tearing. Frankly, it costs about the same amount of money to buy the real thing, which offers far more reliable protection. Also, many clinics will give you free condoms.
  3. You will not fall pregnant if you have sex while standing up, or if the woman is on top during sexual activity. If you have vaginal intercourse, it doesn’t matter if you’re up, down, sideways or even under water; the woman can still get pregnant. The one ‘position’ that won’t cause pregnancy is oral sex, because no semen enters the woman’s vagina – though oral sex does have its own set of health risks, including STD transmission.
  4. You will not fall pregnant if you have sex during ‘safe times’, i.e. various periods during the menstrual cycle and ovulation cycle. While the average female’s monthly cycle may be 29 days, others may have a cycle that varies from 20 to 40 days, or even longer. A woman’s likelihood of falling pregnant rises and falls throughout her ovulation cycle; the likelihood that a woman will fall pregnant one to two days after she starts bleeding is nearly zero. But the likelihood increases with each successive day, even though she’s still bleeding. At roughly day 13 after starting her period, her chance of pregnancy is an estimated 9 per cent. While these numbers may be low, it means a woman can never be 100 per cent assured that she won’t fall pregnant during her period.
  5.  You will not fall pregnant the first time you have sex. It is thought by many people that sex for the first time will not get a woman pregnant. This is far from the truth; having sex without the use of contraception can get a woman pregnant, irrespective of whether she is having sex for the first time or has had it plenty of times before. Pregnancy depends on fertility, which can be a very irregular thing. It might take months or even years of desperate trying for some women to conceive, while others might conceive whenever they have sex, even if it is their first time and they have no desire to be pregnant. Pregnancy is a possibility every time a woman and a man engage in intercourse. The only requirement is that a sperm must reach an egg.
  6. Because you have started using the pill, you will not fall pregnant. This is a myth; it is incorrect information. The pill is 99 per cent effective in preventing pregnancy. Even so, every year between two and eight per cent of women who use it become pregnant.
  7. If you urinate after sex, you will not fall pregnant. This is a myth, and a misconception about or misunderstanding of female anatomy, by both men and women. For people with vaginas, the tube you urinate through (the urethra) is not the same tube a penis ejaculates into during sex (the vagina). Many people don’t realize these are two separate holes, because the urethra is often very tiny, and right next to the vaginal opening. Urinating after sex won’t rinse sperm out of the vagina, because you don’t urinate out of your vagina.

Lesedi Mashinini, a first-year film and television student, shared her experience.

“In primary school, they taught us about menstruation, sex, and all that. But in high school, I don’t remember them teaching us. I don’t remember a lot of details from when I learned about having my periods,” Mashinini says.

“I know how to take care of myself during my period because of help from my sister and my mom, about what I had to do the first time I had it. So now, I’m more confident about what I need to do.”

Marona Seekane, a postgraduate student, says that menstruation as a topic was only covered properly and thoroughly in Life Sciences from about Grade 10 in high school; and it was only then that she started feeling as though she knew what was happening in her body.

“I don’t think that sex education was done properly, because almost all the knowledge that I have, I read up on by myself. The basics were covered in Life Orientation, where we were told that sex without protection would lead to STIs, pregnancy and HIV,” Seekane says.

“Things like HPV I only learned about when I got to varsity. I only started feeling confident about sexual health after I had done some research of my own.”