What works when it comes to youth-friendly HIV services?

What makes treatment services work for young people with HIV is a much-debated topic. A recent assessment of youth-friendly services in Nigeria has come up with seven key conditions for success. 

What is the research about? 

The study involved 50 young people with HIV (ages 15 to 24) attending 10 healthcare facilities in Benue State.  

The facilities provided youth-friendly HIV services based on the Operation Triple Zero (OTZ) model. This aims for zero missed appointments, zero missed medications and zero viral load for young people. The OTZ package includes fast-track and multi-month ART dispensing, adolescent refill clubs and pharmacy refills. It also links young people to a network of peer supporters, community-based organisations and civil society groups, economic support and legal resources. 

Researchers interviewed two young people and one healthcare provider from each facility and assessed patient data. Assessments were also done on facility services. To consolidate the findings, 30 young people were selected as ‘case studies’ and re-interviewed.  

Why is this research important? 

Young people are at high risk of HIV and represent a growing share of people with HIV worldwide. But unfriendly clinics can stop young people with HIV from getting the treatment they need. In 2021, the World Health Organization endorsed the use of youth-friendly health services. But there are knowledge gaps on what the most effective youth-friendly strategies are. 

What did they find out? 

Between the start of the study in 2018 and the end of the study in 2022, viral suppression coverage among young people increased in 8 of the 10 facilities. At the study’s start, 90% or more young people with HIV were virally suppressed in two facilities. By the study’s end, seven facilities had achieved this rate. One facility remained unchanged, and another had a decline in coverage.  

Among the 30 young people selected as case studies, 18 were virally suppressed during the first test in the study and 24 at the second test.  

Differentiated services  

When there was high HIV stigma and low privacy and confidentiality, young people’s retention in care and viral suppression improved if there were differentiated services. These are services that fit into a person’s life, rather than a person having to fit their life around the services they need. 

Participants described how introducing flexible and differentiated services provided young people with non-stigmatising ways to access services. This improved relationships between young people and healthcare providers. And this improved retention in care and viral suppression rates. 

As one healthcare provider said: “Adolescents only come pick drugs twice a year because we have case managers or community-groups who can deliver their drugs at home... Now confidentiality breaches and stigma are very, very down the ladder in this facility; they [young people] now see us as family…” 

Incentives  

For young people with limited access to resources, financial and material incentives linked to care or access to vocational work motivated them to stay on HIV treatment. Incentives were provide for things such as attending appointments or coming for a viral load test. 

Peer support  

Participants described how role models within peer networks encouraged other young people to stay on treatment. Peer-support groups’ focus on self-managed care encouraged young people to define their treatment goals, develop strategies and be accountable for their care.  

But the findings suggest that, while peer support plays a role in achieving viral suppression, it may not be essential. This is because other factors more strongly contribute to improvements in viral suppression.  

Self-managed care 

Healthcare providers highlighted the effectiveness of supporting young people to develop personalised adherence strategies. These strategies were tailored to specific challenges in young people’s lives. Health workers helped young people develop skills to self-monitor their health and treatment. Then they provided support until young people got into the habit of doing these things.  

The seven factors of effective youth-friendly HIV services  

Overall, the study identified seven things that make HIV care effective for young people: 

1. Privacy and confidentiality  

2. Differentiated care services 

3. Respectful care  

4. Incentives  

5. Personal motivation  

6. Peer support 

7. Young people’s agency to manage their own treatment 

What the most effective combination of these factors will depend on the context.  

For example, in places where HIV stigma and a lack of privacy and confidentiality are high, supporting young people’s agency and motivation becomes especially important. And material incentives might not be as effective in places where there are high levels of stigma or non-respectful care. 

What does this mean for HIV services? 

Youth-friendly services can improve young people’s engagement with HIV services. But their effectiveness depends on the context in which they are delivered. Understanding this context is the key to getting the right combination of support and interventions in place.  

Guidance is available that can help you assess the context you are working in to design the right combination of support, such as this framework.