Providing comprehensive health services for young key populations: needs, barriers and gaps

Delany-Moretlwe, S; Cowan, F.M.; Busza, J; Bolton-Moore, C; Kelley, K; Fairlie, L Journal of the International AIDS Society , 2015; www.ncbi.nlm.nih.gov/pmc/articles/PMC4344539

Young key populations (YKP) have specific needs in terms of health services. In this article, Sinead Delany Moretlwe of STRIVE partner Wits RHI and her co-authors examine what these needs are and identify the barriers to and gaps in filling them. A comprehensive package of care is urgently needed, they conclude, for those aged 10-24 years.

Young key populations

More than any other life stage, adolescent health is strongly determined by social context. Both structural determinants of health (such as national wealth, income inequality, access to education and health services, employment opportunities and gender inequality) and more proximate determinants of health (such as connectedness of adolescents to family and school) affect health-related behaviour and outcomes during adolescence.

Key populations (KP) contribute disproportionately to HIV transmission dynamics within countries, with recent estimates suggesting that 50% of new HIV infections occur among these populations. In YKP, the effects of stigma, discrimination and violence are exacerbated by policy and legal barriers related to the age of consent for sex and for access to selected medical interventions, further limiting access to a range of health services. As a consequence, YKP are frequently a hidden population. Reliable and representative epidemiological data on their health are scarce.

Guided by a conceptual framework of adolescent health, this review undertook a targeted, web-based search to identify age-specific data on the health needs and barriers to care for YKP.

Significant investments in research and implementation will be required to ensure adequate provision and coverage of services for YKP. In addition, greater commitments to harm reduction and rights-based approaches are needed to address structural barriers to access to care.

Challenges

YKP experience an even higher burden of disease than older KP, as well as a higher burden of disease than their age peers in the general population. The study identified a range of challenges.

Unprotected sex

For many, the ability to negotiate safer sex with partners is limited by imbalances in relationship power, compounded by adolescent aspirations for love and intimacy.

Reproductive health

Pregnancy is frequently unwanted, termination of pregnancy is common and contraceptive use, including of emergency contraception, is low, suggesting significant unmet needs.

Mental health

Sex workers below the age of 20 experience the highest rates of depression, suicide and substance use compared to those older than 20 in China.

Substance use

YKP are more likely to initiate substance use at an earlier age, to engage in polysubstance use and to experience more rapid increases in substance use over time.

Barriers to care

YKP are less likely to be engaged in care, experience poor access to condoms and HIV testing and have lower rates of adherence, viral suppression and retention in care.

Individual-level barriers to care

YKP with internalised stigma experience more social isolation and are less able to ask trusted adults for support in decision-making.

Health-system-level barriers to care

YKP experience stigma, discrimination or victimisation at the hands of health care providers. Younger people who inject drugs (PWID) expressed a preference for syringe-dispensing machines over staffed needle exchange programmes because of their desire to hide their identity or because they did not like the way they were treated at staffed services.

Structural-level barriers

Criminalisation reduces YKP’s control over their behaviour, impedes their access to health services and obstructs health service provision and legal protection. In many settings, YKP are criminalised for their behaviour/s and risk incarceration.

Conclusions

The findings confirm that - in addition to interventions for the prevention, treatment and care of HIV - YKP require other, non-HIV-related health services that respond to their significant health and development needs as adolescents. Evaluating optimal approaches for the delivery of a comprehensive package of care of YKP should be a priority.

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