Guidelines on

Best Practices for

Adolescent- and Youth-
Friendly HIV Services
An Examination of 13 Projects in
PEPFAR-Supported Countries

March 2017

SR-16-134
 Guidelines on
Best Practices for
Adolescent- and Youth-
Friendly HIV Services
An Examination of 13 Projects in
PEPFAR-Supported Countries

Anastasia J. Gage, Mai Do, and Donald Grant

MEASURE Evaluation This publication was produced with the support of the United
States Agency for International Development (USAID) under
University of North Carolina at Chapel Hill the terms of MEASURE Evaluation cooperative agreement AID-
400 Meadowmont Village Circle, 3rd Floor OAA-L-14-00004. MEASURE Evaluation is implemented by the
Carolina Population Center, University of North Carolina at
Chapel Hill, NC 27517 USA
Chapel Hill in partnership with ICF International; John Snow,
Phone: +1 919-445-9350 Inc.; Management Sciences for Health; Palladium; and Tulane
[email protected] University. Views expressed are not necessarily those of USAID
or the United States government. SR-16-134
www.measureevaluation.org
ISBN: 978-1-9433-6444-2
ACKNOWLEDGMENTS

We thank all those who submitted proposals or helped to finalize the entries that MEASURE Evaluation
compiled. We are grateful to technical advisors Annaliese Limb and Kristen Wares, at the U.S. Agency for
International Development, for their contributions to and participation in the Best Practices Proposal
Review Group.

Cover photo: A group of young women at SUPPORT Girls Center, in Mumbai, India. SUPPORT provides
vocational training and educates street children on STDs, AIDS, and sexual abuse.

© 2002 Vijay Sureshkumar, courtesy of Photoshare

Guidelines on Best Practices for Youth-Friendly HIV Services 3

ABBREVIATIONS

AYLHIV adolescents and youth living with HIV

CATS community adolescent treatment supporters

HSV2 herpes simplex virus 2

PEPFAR U.S. President’s Emergency Plan for AIDS Relief

SYMPA Supporting Youth and Motivating Positive Action

USAID U.S. Agency for International Development
VMMC voluntary medical male circumcision

4 Guidelines on Best Practices for Youth-Friendly HIV Services

INTRODUCTION
Adolescents (ages 10–19) and youth (ages 15–24) bear a disproportionate share of the HIV burden,
especially in sub-Saharan Africa. However, little is known about what projects are doing to make their
interventions adolescent- and youth-friendly and what interventions are effective for changing HIV-related
outcomes for these age groups. Program managers and policymakers have little rigorous evidence on how
best to invest resources to achieve 90-90-90 targets among adolescents and young people. Recognizing this
evidence gap, MEASURE Evaluation—funded by the U.S. Agency for International Development
(USAID)—reviewed the evidence on adolescent- and youth-friendly HIV services as a contribution to the
goal of an AIDS-free generation that the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) is
pursuing. This review had three objectives: (1) document knowledge of what is working and what is not
working in terms of delivering adolescent- and youth-friendly HIV services, and why strategies and program
activities work or do not work; (2) identify useful lessons learned about key elements of successful
adolescent- and youth-friendly HIV services; and (3) promote the use and adaptation of best practices for
adolescent- and youth-friendly HIV services in order to improve the quality of HIV services delivered to
young people and to attract adolescents and youth to retain them in those services.

“Best Practices for Adolescent- and Youth-Friendly HIV Services: A Compendium of Selected Projects in
PEPFAR-Supported Countries” reflects the results of a call for best-practices proposals and an examination
of peer-reviewed and gray literature in 22 PEPFAR-supported countries. These guidelines are a companion
to that document.

The 13 projects covered in the compendium are those we received permission to summarize. A review
group graded the projects using well-established criteria. These criteria were adolescent and youth
involvement, relevance, effectiveness/impact, reach, feasibility, sustainability, replicability or transferability,
ethical soundness, and efficiency. Seven best practices, four promising practices, and two emerging practices
were identified, of which five provided strong evidence needed to recommend priorities for action. Best
practices are (1) Adolescent-friendly Voluntary Medical Male Circumcision Project, in South Africa; (2)
Futbol para la Vida (Deportes para la Vida), in Dominican Republic; (3) Mema kwa Vijana, in the United
Republic of Tanzania, (4) One2one Integrated Digital Platform, in Kenya; (5) Supporting Youth and
Motivating Positive Action (SYMPA), in the Democratic Republic of the Congo; (6) Program H, in
Ethiopia and Namibia; and (7) Zvandiri Project, in Zimbabwe. Promising practices are (1) Integrated
Project against HIV/AIDS, in Chibombo District, Zambia; (2) Project Accept, in South Africa, United
Republic of Tanzania, and Zimbabwe; (3) Sunbursts Project, in Kenya; and (4) Toolkit and Training Manual
for Transition of Care and Other Services for Adolescents with HIV. Emerging practices are (1) Feel the
Future, in Malawi; and (2) Youth Voluntary Counseling and Testing, in Botswana. (For details on all of
these, see Table 1).

The interventions these projects provided were classified into four groups according to common
characteristics and choices that program managers and policymakers might have to make when deciding
what to do:

• Clinic-based interventions with or without a community component

• Clinic-based and school-based interventions with or without a community component
• Community-based interventions
• Mobile- and web-based interventions

Guidelines on Best Practices for Youth-Friendly HIV Services 5

MAKING PROJECTS ADOLESCENT- AND YOUTH-FRIENDLY
At the program design and implementation levels, projects took several initiatives to make their
interventions adolescent- and youth-friendly.

• Meaningful engagement of adolescents and youth in program design and implementation

• Increasing accessibility to services, by extending services to after-school hours, establishing
adolescent centers run by trained adolescents and youth within health facilities, and providing
mobile HIV testing services in venues easily accessible by youth
• Affordable fees or free services (e.g., free HIV testing, free condoms, and free medical care for
adolescents and youth living with HIV [AYLHIV])
• Linkages between schools, youth clubs, youth corners, and other youth-friendly institutions
• Providing alternative ways to access information, counseling, or services (e.g., use of digital
technologies through mobile- or web-based platforms and cartoon videos)
• Training staff to provide adolescent- and youth-friendly services
• Maintaining privacy and confidentiality (e.g., conducting mock circumcision for male adolescents
and youth who test positive for HIV, to maintain confidentiality and reduce stigma)
• Peer counseling on risk reduction, safer sex, voluntary counseling and testing for HIV, and
adherence to antiretroviral drugs

6 Guidelines on Best Practices for Youth-Friendly HIV Services

IMPACT ON ADOLESCENT AND YOUTH HIV-RELATED
OUTCOMES
Five projects were categorized as having rigorous evaluation designs (experimental studies with random
assignment to an intervention or control condition or quasi-experimental designs involving comparison
groups without random assignment): Futbol para la Vida, Mema kwa Vijana, Program H, Zvandiri project,
and Project Accept. Based on the results of the impact evaluations, projects were categorized in five
nonmutually exclusive groups:

• Effective for HIV-related and attitudinal outcomes (e.g., Mema kwa Vijana and Program H)

• Effective for HIV-related behavioral outcomes

o Sexual behavior (MEMA kwa Vijana)

o Condom use (MEMA kwa Vijana)
o Intimate partner violence (Program H)
o HIV testing (Project Accept)
o Disclosure and adherence to antiretroviral therapy (Zvandiri project)

• Not effective for HIV-related behavioral outcomes

o Sexual behavior (Project Accept)

• Effective for HIV-related biological outcomes

o Clinical symptoms and signs of sexually transmitted infection (STI) (MEMA kwa Vijana)

• Not effective for HIV-related biological outcomes

o HIV incidence and HSV2 prevalence (MEMA kwa Vijana)

Eight projects used nonrigorous or qualitative evaluation designs. In some cases, these projects found
positive effects on HIV-related knowledge, attitudes, and behavioral outcomes. Nonrigorous designs are
often cost-effective for establishing the need for and reach of an intervention and for building the evidence
base. However, progress in identifying effective strategies to meet the HIV-related needs of adolescents and
youth depends on the use of more rigorous methods for determining what works, for how long, and for
whom.

Guidelines on Best Practices for Youth-Friendly HIV Services 7

LESSONS LEARNED FROM THESE PROJECTS

• Clinic-based interventions with or without a community component

o When implementing curricula among HIV-positive youth, it is to be noted that the

educational level of participants can vary. Outside of school-based settings, specific
activities requiring written responses would need to be adapted for adolescents and youth
who are unable to write (SYMPA project).
o To manage the unique needs of adolescents and youth who are living with HIV,
individualized transition-to-adult care programs must be built (Toolkit and Training
Manual)
o In a context where few health facilities offer HIV services that are tailored to adolescents
and youth, counselors are able to reach more adolescents and youth during mobile testing
as opposed to fixed-site service delivery (Project Accept and Youth VCT [Voluntary
Counseling and Testing] Project)

• Clinic-based and school-based interventions with or without a community component

o Community involvement and consultations are critical for creating an enabling

environment for recruitment of in-school adolescents for VMMC services (Adolescent-
Friendly VMMC Project).
o A single training during scale-up of a school-based curriculum appears to be insufficient to
impart skills required to teach the psychosocial aspects of the curriculum. Systematic
preservice training of teachers would be more cost-efficient (MEMA kwa Vijana).

• Community-based interventions

o Involvement of local people and community-based governmental and nongovernmental

organizations is critical to success in improving HIV-related knowledge and attitudes
among adolescents and youth (Futbol para la Vida/Deportes para la Vida).
o If HIV-testing services are provided in convenient and accessible locations such as
markets, churches, community and shopping centers, and transportation hubs, adolescents
and youth will make use of the services and new populations not serviced by facility-based
services can be reached (Project Accept).
o There is no magic bullet for community mobilization. Strategies used in varying
combinations are stakeholder buy-in; community coalition building; direct community
engagement; community participation in project-related activities; raising community
awareness; involving community leaders; and creating partnerships with local organizations
(Project Accept).

• Mobile and web-based interventions

o Mobile platforms are a crucial delivery point for adolescents and youth, because these age
groups favor them and also because they are anonymous. Anonymity makes it easier for
adolescents and youth to ask questions and seek advice about health issues (One2One
Integrated Digital Platform [OIDP]).

8 Guidelines on Best Practices for Youth-Friendly HIV Services

POTENTIAL FOR SUSTAINABILITY
Sustainability was interpreted in terms of sustaining project activities, transferring best practices to other
programs and settings, identifying new funding streams, and maintaining improved health outcomes for
adolescents and youth over time. Projects identified several factors that contribute to the sustainability of
their adolescent- and youth-friendly practices:

• Integration of project activities in existing health systems and government and community structures
• Community buy-in and advocacy for the project
• Collaborative relationships and partnerships
• Coordinating funding from multiple sources to sustain the project
• Evaluation results demonstrating that the project is making a difference
However, unless partnerships are built with communities, governments, and local organizations right at the
program design stage, and unless communities are taught how to secure continued funding and other
support, even programs that rigorous evaluations have shown to work may not continue beyond the life of
the initial intervention.

Guidelines on Best Practices for Youth-Friendly HIV Services 9

ADDITIONAL CONSIDERATIONS

• Programs should document their activities in detail to clarify what is being done and the expected
outcomes.
• Most programs need high-quality monitoring and impact evaluation of interventions among
adolescents and youth. Where possible, future evaluations should use randomized or quasi-
experimental designs to strengthen the evidence.
• More research is needed on the practices that are best for engaging adolescents and youth in
planning, implementing, and evaluating HIV prevention, care, treatment, and retention services.
• Studies are needed to identify features or characteristics that increase the effectiveness of
adolescent- and youth-friendly HIV programs.
• Programs need to make substantial investment in providing estimates of program efficiency and
estimates of cost-effectiveness. These data were lacking (or not in the public domain) for most
projects included in these guidelines.
• During scale-up of adolescent- and youth-friendly interventions that have been proven to be
effective, attention must be paid to maintaining an intervention’s quality (e.g., providing a
supportive implementation infrastructure, ongoing capacity strengthening activities for program
implementers, and increased attention to supportive supervision and monitoring).
• Assessment of the long-term impact of programs is needed.
• Adequate funding must be allocated for rigorous impact evaluation, for assessments of program
efficiency, and to strengthen the methodological expertise of implementing partners and research
staff in PEPFAR-supported countries.

10 Guidelines on Best Practices for Youth-Friendly HIV Services

Table 1. Description of interventions included in the Compendium

Study Location and

Type Target Population Description
Program

BEST PRACTICES
South Africa: Clinic- and In-school male • Community consultation and engagement
Adolescent-Friendly school-based adolescents, ages 16– • In-school voluntary medical male circumcision (VMMC) awareness sessions and
Voluntary Medical Male 20 years, in rural areas service-access facilitation
Circumcision (VMMC)
• Health facility-based HIV counseling and testing and VMMC service access
• Peer recruitment
Dominican Republic: Community- Mobile and migrant, • Bilingual Spanish/Haitian Kreyol soccer camps and courses
Futbol para la Vida based street, in-school, and • Training-of-trainers workshops for community-based peer educators (local
(Deportes para la Vida) out-of-school batey soccer players), local nongovernmental organization staff, public
adolescents and schools, and health programs
youth; orphans and
vulnerable children in • Support for youth camps, soccer tournaments, and other outreach
rural and urban areas opportunities

United Republic of Clinic-, school-, Adolescents, ages 12– • Teacher-led, peer-assisted sexual health education curriculum in schools
Tanzania: MEMA kwa and community- 19 years, in rural areas • Youth-friendly health services
Vijana based
• Community-based condom promotion and distribution by youth
• Community activities (e.g., youth health weeks)
Kenya: One2One Mobile and web- Adolescents and • Mobile-based services for sexual and reproductive health, HIV, and gender-
Integrated Digital based youth, ages 10–24 based violence
Platform (OIDP) years, in six counties • Provision of health information and counseling through web-based platforms
with a high burden of
HIV • Engagement of AYLHIV and key populations in message development
• Toll-free hotline
The Democratic Clinic-based Youth living with HIV • Development and implementation of a curriculum on positive prevention
Republic of the Congo: (YLWH), ages 15–24 • Monthly peer education sessions
Supporting Youth and years, seeking care at
Motivating Positive a clinic in Kinshasa • Peer support groups
Action (SYMPA)

Guidelines on Best Practices for Youth-Friendly HIV Services 11

 Ethiopia and Namibia: Community- Yong men, ages 15– • Validated curriculum and educational video to promote attitude and behavior
Program H based 24 years change among men
• Lifestyle social marketing campaign to promote changes in community or
social norms related to what it means to be a man
• Group discussions to promote critical dialogue and reflection about gender
norms among young men
Zimbabwe: Zvandiri Clinic- and Adolescents and • Monthly community-based support groups run by trained facilitators (including
Project community- youth, ages 15–24 AYLHIV)
based years • Community outreach conducted by a multidisciplinary team (an HIV clinician,
nurse, counselors, a social worker, a psychologist, and a network of community
adolescent treatment supporters (CATS)
• Peer counseling by trained ALHIV, ages 17–23 years, in clinics and through
home visits
• Establishment of clinic-based adolescent/youth Zvandiri Centres run by CATS
• Community-based HIV counseling and testing for children and young people
• Caregiver training by CATS to improve their understanding of the needs and
experiences of the adolescents in their care
• Multimedia advocacy campaigns and participation in development of policy
and guidelines by Zvandiri adolescents and youth
• Provision by Zvandiri youth of training and mentorship for health workers, social
workers, and community organizations to strengthen the integration of
psychosocial support and clinical care

PROMISING PRACTICES
Zambia: Integrated Community- Adolescents and • Peer-educator training in life-skills education, behavior change
Program Against based youth, ages 15–24 communication, and psychosocial support for orphans and vulnerable children
HIV/AIDS in Chibombo years, in six rural • Peer-led social mobilization and awareness raising on preventing HIV and other
District communities sexually transmitted infections, and gender issues related to child abuse, rape,
and early marriage
• Income-generating activities for caregivers
Zimbabwe, Tanzania, Community- Ages 16–32 years in • Community mobilization (volunteer recruitment of HIV-positive and -negative
and South Africa: based urban and rural areas people and integration of them around educational, social, and political goals
Project Accept in community events)
• Community-based voluntary counseling and testing (free HIV testing, post-test
counseling, free male and female condoms to those who test)

12 Guidelines on Best Practices for Youth-Friendly HIV Services

 • Community-based posttest support services (information-sharing group
sessions; psychosocial support groups; crisis counseling; coping effectiveness
training; and stigma-reduction workshops)
Kenya – Sunbursts Community- Children, ages 6–9 • Peer-led community-support group program (open discussion, educational
Project based years, and lessons, artistic and therapeutic activities, games, and role-playing)
adolescents, ages • Family social events
10–14 & 15–19 years,
in urban areas • Community outreach for stigma reduction
• Summer camp program for children living with life- threatening illnesses

Toolkit and Training Clinic-based Healthcare providers • Development of a toolkit and training manual
Manual for Transition of and AYLHIV • Pilot of the toolkit
Care and Other Services
for Adolescents Living • Comprehensive training conducted for healthcare and community-care
with HIV providers in four sites
• Monthly supportive supervision visits
• Adaptation of toolkit to local contexts

EMERGING PRACTICES
Malawi: Feel the Future Community- AYLHIV • Direct counseling of AYLHIV
based • Dedication of physical space at DREAM health centers for AYLHIV
• Creation of age-based support groups for AYLHIV (ages 11–16, 17–20, and 20–
24 years)
• Community-based activities to combat stigma and discrimination
Botswana: Youth Clinic-based Adolescents and • HIV testing and counseling
Voluntary Counseling youth in the general • Support for ongoing counseling and social support
and Testing population
• Referrals for family planning or CD4+ testing
• Continuous education and behavior-change communication campaign to
increase awareness
• Post Test Clubs for youth and promotion of positive living

Guidelines on Best Practices for Youth-Friendly HIV Services 13

MEASURE Evaluation
University of North Carolina at Chapel Hill
400 Meadowmont Village Circle, 3rd Floor
Chapel Hill, North Carolina 27517
Phone: +1-919-445-9359 • [email protected]
www.measureevaluation.org

This publication was produced with the support of the United States Agency for
International Development (USAID) under the terms of MEASURE Evaluation
cooperative agreement AID-OAA-L-14-00004. MEASURE Evaluation is
implemented by the Carolina Population Center, University of North Carolina at
Chapel Hill in partnership with ICF International; John Snow, Inc.; Management
Sciences for Health; Palladium; and Tulane University. Views expressed are not
necessarily those of USAID or the United States government. SR-16-134