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Meeting Young People's Reproductive Health Needs with Integrated Family Planning and HIV Service
Increasingly, family planning and other reproductive health programs are focusing on meeting the needs of young people1 in developing countries. This effort reflects growing recognition of the serious reproductive health risks that millions of young people face:
- Complications of pregnancy, childbirth, and abortion are the major causes of death and illness among young women aged 15 to 19 (27, 35).
- In 2006, young people aged 15 to 24 accounted for 40% of new HIV infections among adults (45). Infection rates are higher among young women than young men in areas where AIDS transmission is primarily heterosexual (44).
- The incidence of STIs other than HIV is highest in young people aged 20 to 24, followed by those aged 15 to 19 (10).
- Many young people have an unmet need for family planning (47). Studies show that, among unmarried young women aged 15 to 19 worldwide, from 32% to 94% of births were unwanted or mistimed; the same is true for up to 61% of last births to married women in that age group (40).
- Many young people infected with HIV want to have children, but they need help to minimize risks to their own health and to prevent the transmission of HIV to their babies (6, 33).
Lack of information, undeveloped life skills, and limited access to family planning, HIV/AIDS, and other types of reproductive health care contribute to high rates of pregnancy and infection among young people.Youth often know little about the risks of sex and how they can protect themselves (21, 44).They also lack the decision-making, negotiation, communication, and other life skills needed to practice safer sex behaviors, such as abstinence, delaying sex, and using condoms consistently and correctly (32, 46). Finally, they lack ready access to essential services, including the provision of condoms and other contraceptives, STI diagnosis and treatment, HIV counseling and testing, and services to prevent mother-to-child transmission (PMTCT) of HIV (4, 21).
Unlike teenage boys—who mostly engage in sex outside marriage—teenage girls in developing countries largely engage in sex within marriage (41). Early marriage, instead of protecting girls, may actually heighten their reproductive health risks (8, 16).Teenage girls tend to marry older men, who may have already been exposed to HIV.These young women are under pressure to have children quickly, they cannot readily negotiate condom use with their husbands, and so they have no choice but to engage in frequent unprotected sex.
Addressing young people’s reproductive health needs requires and has received a broad response, including advocacy for policy changes, family life education in schools and other community settings, mass media campaigns, and social marketing of contraceptives (14).This report focuses on just one key area: the delivery of family planning, STIs, HIV/AIDS, and maternal and child health services to young clients.
The value of integrated services. Integrating family planning, STIs, HIV/AIDS, and maternal and child health programming can increase young people’s access to both information and services (30, 51). First, an integrated approach may persuade more young clients to seek services, both because integrated services are more convenient and because they can camouflage services that carry a stigma, such as HIV testing. Second, an integrated approach offers clients more comprehensive care because providers can address the full range of young clients’ reproductive health needs, no matter what problem prompts their visit. For example, providers may screen young family planning clients for STIs and refer them for treatment.They may counsel youth requesting an HIV test on how to avoid pregnancy. Or they may advise HIV-infected youth who want children on how to reduce the associated health risks, for example, by using the Standard Days Method to minimize the risk of HIV transmission when they try to get pregnant (by limiting unprotected intercourse) and by seeking PMTCT services after they become pregnant.
An integrated approach also benefits reproductive health organizations (17, 30, 39). It has the potential to increase the cost-effectiveness of service delivery by making greater use of existing infrastructure and personnel and by delivering more services per visit. It may also strengthen managers’ and providers’ skills by giving them the opportunity to learn from other reproductive health disciplines and by helping them more fully understand young people’s needs.
An integrated approach may not be appropriate in all situations. For example, integrating HIV counseling and testing into family planning services may be a waste of resources in countries where HIV is concentrated in certain high-risk groups, such as injecting drug users or prostitutes. Linking family planning and HIV/AIDS programs with a robust referral system may be a more efficient way to meet the full range of young clients’ reproductive health needs in such a setting.
Service Delivery Models for Integrated Services
Programs have taken many different approaches to offer integrated family planning, STI, and HIV services to young people. Here are some examples.
Adult clinics: In Colombia PROFAMILIA (Asociación Pro-Bienestar de la Familia Colombiana) began basing youth-friendly services inside adult clinics after dedicated youth facilities proved costly and difficult to sustain (7). PROFAMILIA now offers youth-friendly services in 35 cities and towns across Colombia. Where young clients are numerous, managers set aside space and assign personnel exclusively for young people. Elsewhere, young people share clinic spaces and providers with adult clients. Regardless of the service model, all staff members are trained on young people’s special reproductive health and family planning needs.
Youth corners: In Zimbabwe the Family Planning Service Expansion and Technical Support Project (SEATS) collaborated with the Gweru City Council to establish youth corners at adult clinics. These spaces were located away from the busiest parts of the clinic to give young people a private place to talk with peer educators and to read informational materials. Peer educators could refer young people who wanted clinical services to nurses who were specially trained in youth-friendly services (24).
Social franchising: In Madagascar a franchised network of over 120 private, youth-oriented clinics offer young people family planning and STI services, and in some cases HIV/AIDS counseling and testing. TOP Réseau franchise members share a brand name and business strategy. Flexible hours, discreet locations, inviting surroundings, and subsidized fees help make the clinics youth-friendly, while special training, job aids, onsite supervision, and regular monitoring ensure good quality of care (23, 28).
Workplace clinics: In Bangladesh adolescent girls make up most of the workforce at many garment and fish-processing factories. Teams of providers from the Marie Stopes Clinic Society offer family planning, antenatal care, and the treatment of STIs and gynecological problems along with health education at over 140 of these factories; employers subsidize the cost of services (34).
Outreach services for disadvantaged, displaced, and marginalized young people: The Uganda Youth Development Link (UYDEL) offers services such as family planning, STI treatment, and HIV counseling and testing to street children and adolescent prostitutes at conveniently located drop-in centers and mobile outposts. Teams of health providers make weekly visits to the outposts, which are placed at clubs, restaurants, and other places where youth congregate (25, 43).
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Youth-friendly retail outlets: Cities across Mexico are replicating the youth-friendly pharmacies pioneered in Guanajuato, Mexico by the Centro Latinoamericano para Salud y Mujer (CELSAM). The project trained pharmacy staff on adolescent reproductive health, stocked the pharmacies with posters and informational materials, and promoted the youth-friendly outlets in schools, cafes, bars, discotheques, a telephone hotline, and a Web site (49).
Multipurpose youth centers: Youth centers offer recreational and vocational activities, such as games, movies, and computer training, along with information, counseling, and services on pregnancy prevention and the prevention and diagnosis of STIs, including HIV. Program evaluations in Latin America and sub-Saharan Africa, however, have cast doubt on their sustainability and cost-effectiveness. Most young people use youth centers for recreation rather than services, those using services tend to be older, and recreational activities raise costs (14, 15).
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The Marie Stopes Clinic Society (MSCS) in Bangladesh established its first small clinic in 1988 to provide family planning services to urban women. It now offers a broad array of services to a variety of clients in diverse locations, including local factories.
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