Evidence that sexual abstinence may have played an important role in reducing HIV infection in Uganda1 has renewed interest in promoting this method of protection against unplanned pregnancy, HIV, and other sexually transmitted infections (STIs).
Abstinence offers adolescents, in particular, a number of advantages. Young people are vulnerable to unplanned pregnancy, but they often find it difficult to obtain contraceptives. Sexual abstinence requires no supplies or clinic visits. And complete abstinence is the most effective means of protecting against both pregnancy and STIs.
In practice, however, abstaining from sex tends to be less effective than many contraceptive methods because complete abstinence requires strong motivation, self-control, and commitment. Also, many questions about sexual abstinence remain unanswered. How can it be encouraged? How should it even be defined? Controversy surrounds programs that promote abstinence as the only means of protection against unplanned pregnancy and STIs, and the effectiveness of such programs is still unknown.
Meanwhile, evidence from many countries suggests that comprehensive sexual health programs that encourage abstinence while providing medically accurate information about contraception and condom use can reduce sexual activity among young people. Such programs can also increase condom and other contraceptive use among sexually active youth.2
"Counseling of adolescents should include information about both abstinence and the use of contraceptive methods," says Dr. Roberto Rivera, director of FHI's Office of International Research Ethics and principal author of a World Health Organization (WHO) special communication on adolescent contraception.3 "The World Health Organization states that age alone is not a medical reason to deny any available contraceptive method to an adolescent. Many adolescents — married and unmarried — are sexually active and have the right to information that will enable them to protect themselves from unplanned pregnancy and STIs. Providers should be aware of adolescents' special needs to help them make well-informed choices about contraception."
Encouraging abstinence and fidelity in Uganda
Uganda's dramatic decline in HIV prevalence during the past decade has coincided with marked increases in sexual abstinence and greater fidelity in relationships, according to an analysis of data from the 1995 and 2000 Demographic and Health Surveys (DHS) and from Ugandan Ministry of Health (MOH) behavioral surveys conducted in 1997, 2000, and 2001.4
In 1996, Uganda became the first African country to report a substantial decline in national HIV rates.5 During the 1990s, the proportion of women testing positive for HIV in antenatal clinics (a population considered fairly representative of the adult population) dropped from 21 percent to 6 percent.6
Meanwhile, in the DHS and MOH surveys, a higher proportion of respondents reported being faithful to their partners, having fewer sex partners, abstaining from sex, or delaying sexual debut than reported using or beginning to use condoms. About one out of every five Ugandan men and women said they had ever used a condom, while only 5 percent to 9 percent reported having "non-regular" partners — a measure of fidelity to a regular partner or partners. Twenty-five percent to 35 percent said they abstained from sex.7
This high rate of sexual abstinence is mainly a result of the increasing number of young Ugandans postponing their first sexual activity. Nationally, the proportion of 15- to 19-year-olds reporting that they had "never had sex" rose from 31 percent to 56 percent among young men and from 26 percent to 46 percent among young women from 1989 to 1995.8 A study in the major urban districts of Kampala and Jinja, Uganda, found a two-year delay in sexual debut among 15- to 24-year-olds between 1989 and 1995.9 The increasingly high rate of sexual abstinence was even more striking among younger adolescents surveyed in Soroti District, Uganda. The proportion of 13- and 14-year-old students there reporting that they had "never had sex" rose from 39 percent to 95 percent among boys and from 66 percent to 98 percent among girls from 1994 to 2001.10
Uganda's unprecedented success in controlling HIV has been attributed to strong government leadership and its "ABC" approach to HIV prevention. Since the late 1980s, governmental and nongovernmental HIV prevention programs have urged Ugandans to: abstain from sex, be faithful to one partner, or — if they cannot do "A" or "B" — use condoms.
To gain a better understanding of the impact of each of these prevention strategies in Uganda, Zambia, and other countries, the U.S. Agency for International Development (USAID) is funding a two-phase "ABC Study." Conducted by the Harvard School of Public Health, MEASURE Evaluation, Population Services International, and the U.S. Bureau of the Census, the study will begin with a thorough review of data to assess "ABC" behavior change and its effect on HIV prevalence in countries where infection rates have declined and in countries where they have not.
The study will also analyze the effect of "ABC" behavior change on fertility. In Uganda, where the average number of children per family is seven,11 reduced sexual risk behavior does not appear to have affected fertility.
The abstinence-only debate
Many experts endorse a comprehensive strategy, such as Uganda's "ABC" approach, as the most effective way to prevent HIV and other STIs or unplanned pregnancy among youth. Others support promoting abstinence only, saying that teaching young people about both abstinence and condom or other contraceptive use sends a mixed message and encourages them to become sexually active.
Increase in Delay of Sexual Debut
Click on the image to see a larger version.
Abstinence promotion has become the main approach of the federal government to preventing adolescent pregnancy and HIV infection in the United States, where the government provides $100 million a year for abstinence-only education. Schools, youth programs, and media campaigns that receive this funding are required to teach that sexual activity outside of marriage is likely to have "harmful psychological and physical effects." They are also prohibited from providing information about contraception, except method failure rates.12 In a recent review of U.S. programs to reduce teen pregnancy, Dr. Douglas Kirby of California-based ETR Associates identified three studies with experimental or quasi-experimental designs evaluating the impact of abstinence-only programs. None of these studies found any effect on sexual behavior, but Dr. Kirby warns that the programs evaluated do not reflect the diversity of such programs.13
A conclusive answer to whether the abstinence-only approach is effective will require larger, more rigorous studies than have been conducted to date.14 One such study, which is being conducted for the U.S. Department of Health and Human Services, is a five-year evaluation of 11 abstinence-only programs. Findings on the short-term effects of the programs are due in 2003.15
Meanwhile, two major reviews have looked at the behavioral impact of comprehensive sexual health and HIV education. One analyzed 67 experimental and quasi-experimental studies conducted in the United States. The other reviewed 47 published studies from more than eight countries, including 11 controlled intervention studies. Both reviews found that comprehensive sex education did not lead to increased sexual activity among adolescents. In fact, some studies found that it had raised the age of sexual initiation, reduced the frequency of sex, and convinced young people to have fewer sexual partners.16
What is abstinence?
The U.S. law that created abstinence-only education programs defines these programs but does not define abstinence itself.17 Some abstinence-only programs have developed their own definitions of the kinds of sexual activity that should be avoided until marriage. Others do not define the term, believing that identifying the behaviors to abstain from would violate children's innocence and provide them with a "how-to" manual of sexual activity.18
But studies from a number of countries suggest that without such information, young people may conclude that vaginal intercourse is the only sexual behavior that is risky. They may then engage in other sexual activities that can put them at some — if not heightened — risk of contracting HIV and other STIs.
Young women interviewed for a study in Mauritius described a practice known as dans bords (light sex), which involves rubbing the penis against the vagina and some penetration, but is not considered sexual intercourse because it does not cause bleeding or pain. In focus group discussions and interviews conducted in Brazil and Guatemala, young people reported that some of their peers practice anal sex to protect a girl's virginity and prevent conception.19 A number of surveys have found high rates of heterosexual anal sex among young people, from 9 percent to 38 percent among female adolescents in low-income, urban areas in the United States, to 12 percent among female college students in Togo, to 44 percent among sexually active, male college students in Puerto Rico. Studies of heterosexual HIV transmission have identified anal sex as the most predictive risk factor for becoming infected with HIV.20
Unlike anal or vaginal sex, oral sex presents very little risk for HIV transmission.21 However, other STIs, including human papillomavirus, herpes simplex virus, hepatitis B, gonorrhea, syphilis, and chlamydial infection, can be transmitted orally.22 Data on oral sex among youth are scarce. The only nationally representative study to look at this question found no increase in reported experience with oral sex among U.S. adolescent males ages 15 to 19 years from 1988 to 1995.23 But largely anecdotal reports suggest that U.S. adolescents are engaging in oral sex at earlier ages.24
From controversy to consensus
Facilitator's manual for a curriculum about youth's reproductive health, produced by Jamaica's Ashe Caribbean Performing Foundation and FHI.
Talking to young people about non-vaginal sexual intercourse can be controversial worldwide. In Jamaica, for example, opposition to the definition of sexual intercourse used in the facilitator's manual for a curriculum developed by the Ashe Caribbean Performing Foundation and FHI threatened a promising family life education program in the schools. Some religious and community leaders feared that including anal intercourse in this definition of sexual intercourse promoted homosexuality.
In response, the Ministry of Education brought together political and religious leaders, educators, child development specialists, and representatives of nongovernmental organizations to review and revise the facilitator's manual. After many discussions, the group agreed on a definition that still included anal sex but was also sensitive to local concerns, emphasizing that many people define sex as vaginal intercourse.
This consensus-building process had positive consequences for youth reproductive health programs in Jamaica, says FHI's Hally Mahler, who edited the manual and participated in the review meetings. Mahler is the youth involvement and behavior change communication coordinator for YouthNet, a program supported by USAID and coordinated by FHI to improve reproductive health and prevent HIV/AIDS among youth.
"In hindsight, it was the best thing that ever happened to the program," she says. "A multisectoral coalition of influential people confronted the risks facing young people in Jamaica and came to consensus that with HIV in the world, and with young people defining sex in many different ways, you cannot ignore anal sex."
Offering options
The word "abstinence" sometimes has negative connotations, in part because many of those who advocate abstinence before marriage also oppose any discussion of contraception, condom use, or alternatives to intercourse, such as masturbation. However, abstinence can be an important, empowering concept when framed in the context of several options for protecting reproductive health in an intimate relationship.
The Jamaican manual helps facilitators guide discussions about ways of showing affection in a relationship, from holding hands and kissing to sexual intercourse. Urging young people to wait until they are physically and emotionally prepared to be sexually active, it describes three options: abstinence, protected sexual activity, and "reclaiming" one's virginity.25
"Some people think that once they start having sex, they cannot stop," explains Ashe Director Joseph Robinson, who wrote the facilitator's manual. "We tell them, 'Yes, you can stop.'"
Dr. Cynthia Waszak, a researcher with the YouthNet Project, says that "abstinence is a very important message, particularly for girls. Girls need to understand that abstinence is their choice if they do not feel comfortable having sex. And that message should be just as applicable to boys and to all young people who are already sexually active."
On the other hand, programs need to recognize that abstinence is not always an option for youth. "Many girls are caught in situations where they are physically coerced to have sex or have no choice but to do so because of economic pressures," Dr. Waszak notes.
— Kathleen Henry Shears
References
Green E. What are the lessons from Uganda for AIDS prevention? What Happened in Uganda? [panel discussion]. U.S. Agency for International Development, Washington, February 5, 2002.
Grunseit A, Kippax S, Aggleton P, et al. Sexuality education and young people's sexual behavior: a review of studies. J Adol Res 1997;12(4):421-53; Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy. Washington: National Campaign to Prevent Teen Pregnancy, 2001.
Rivera R, Cabral de Mello M, Johnson SL, et al. Contraception for adolescents: social, clinical and service-delivery considerations. Int J Gynaecol Obstet 2001;75(2):149-63.
Green.
Okware S, Opio A, Musinguzi J, et al. Fighting HIV/AIDS: is success possible? Bull WHO 2001;79(12):1113-20.
Green.
Green.
World Bank. Uganda: The Sexually Transmitted Infections Project. Findings. Washington: World Bank, 1999.
Asiimwe-Okiror G, Opio AA, Musinguzi J, et al. Change in sexual behaviour and decline in HIV infection among young pregnant women in urban Uganda. AIDS 1997;11(14):1757-63.
Green.
Uganda Bureau of Statistics, ORC Macro. Uganda Demographic and Health Survey 2000-2001: Final Report. Calverton, MD: Uganda Bureau of Statistics and ORC Macro, 2001.
Dailard C. Abstinence promotion and teen family planning: the misguided drive for equal funding. Guttmacher Rep 2002;5(1):1-3.
Kirby.
Devaney B, Johnson A, Maynard R, et al. The Evaluation of Abstinence Education Programs Funded under Title V Section 510: Interim Report. Princeton: Mathematica Policy Research, Inc., 2001; Kirby; Satcher D. The Surgeon General's Call to Action to Promote Sexual Health and Responsible Sexual Behavior. Rockville, MD: Office of the Surgeon General, 1991.
Devaney.
Grunseit; Kirby.
Sonfield A, Gold RB. States' implementaton of the Section 510 abstinence education program, FY 1999. Fam Plann Perspect 2001;33(4):166-71.
Remez L. Oral sex among adolescents: is it sex or is it abstinence? Fam Plann Perspect 2000;32(6):298-304.
Weiss E, Whelan D, Rao Gupta G. Gender, sexuality and HIV: making a difference in the lives of young women in developing countries. Sex Rel Ther 2000;15(3):233-45.
Halperin DT. Heterosexual anal intercourse: prevalence, cultural factors, and HIV infection and other health risks, part I. AIDS Patient Care STDs 1999;13(13):717-30.
Dailard.
Edward S, Carne C. Oral sex and the transmission of non-viral STIs. Sex Trans Inf 1998;74(1):6-10; Edwards S, Carne C. Oral sex and the transmission of non-viral STIs. Sex Trans Inf 1998;74(2):95-100.
Gates GJ, Sonenstein FL. Heterosexual genital sexual activity among adolescent males: 1988 and 1995. Fam Plann Perspect 2000;32(6):295-97, 304.
Remez.
Robinson J. Preparing for the VIBES in the World of Sexuality (revised). Kingston, Jamaica: Ashe Caribbean Performing Foundation, 2001.
As girls begin to initiate sexual activity earlier and marry later in many countries, they are exposed longer than ever to the risk of unplanned pregnancy and sexually transmitted infections (STIs).1 Given the public health consequences of this increasing vulnerability, many experts say reproductive health programs should make adolescents' needs a priority.
Data on 10- to 19-year-olds in developing countries are not reliable enough to draw firm conclusions about trends in their sexual behavior before marriage.2 But Demographic and Health Survey results show an increasing gap between age at first sexual intercourse and age at first marriage in 32 of 37 countries surveyed in every region of the developing world, suggesting that premarital sex is rising throughout sub-Saharan Africa and in most countries of other regions.3 In the United States, the gap between sexual initiation and marriage widened by almost 30 percent during the 1980s.4 Women in the United States now typically begin sexual activity about seven years before marriage and are sexually active for almost one quarter of their reproductive lives before giving birth.5
Beginning sex at earlier ages increases the risk of STIs for young women and men because the longer a person is sexually active before marriage, the more partners he or she is likely to have.6 Marrying later can open educational and vocational opportunities to young women,7 but later marriage combined with increasing premarital sex among adolescents puts them at greater risk of unplanned pregnancies, unsafe abortions, and STIs, including HIV.8
Most people worldwide have their first sexual experiences — which can have lifelong effects on their sexual and reproductive health — before reaching age 20.
Sexually active adolescents' risk of pregnancy and STIs is already high. They are less likely than adults to use condoms and other contraceptives and more likely to experience contraceptive failures.9 (They are also more likely to resort to unsafe abortion if they decide to terminate unplanned pregnancies.10) Adolescent girls are at greater risk for STIs than older women because of specific biological characteristics that make them more susceptible to such infections and because they are less likely to be able to refuse unwanted or coercive sex or to negotiate condom use.11
Serving adolescents with differing needs
Most people worldwide have their first sexual experiences — which can have lifelong effects on their sexual and reproductive health — before reaching age 20.12 Dr. Malcolm Potts, FHI president emeritus and Bixby Professor at the University of California, Berkeley, USA, and his colleagues write that the earliest stages of men's and women's reproductive lives are so important for public health that countries with scarce medical resources should devote most of those resources to protecting young people's sexual and reproductive health. They propose that public reproductive health programs focus on providing education, counseling, and other services to adolescents and young adults at two distinct stages of their reproductive lives: when they are not yet sexually active, and when they are sexually active but do not yet wish to have children. Meanwhile, social marketing programs and private providers would be expected to meet the needs of most women at two other stages of their reproductive lives: when they plan to have a child or more children, and while they are fertile but do not want more children.13
Just as adults' priorities for contraception and STI protection change over the course of their reproductive lives, young people's reproductive health needs differ as they move through adolescence. Ten-year-olds need information about the changes they will face with the onset of puberty, while older adolescents may need protection against unplanned pregnancy and STIs.
Adolescents are not a homogeneous group. Thus, experts suggest tailoring education, counseling, and other reproductive health services to address the needs of young people with different kinds of experiences. Two young women in a market in Guatemala City, Guatemala.
Recognizing that adolescents are not a homogeneous group, Jane Hughes of the NewYork- based Population Council and Dr. Anne McCauley of the Washington-based International Center for Research on Women have suggested tailoring programs to meet the needs of young people with three different kinds of experiences: those who are not yet sexually active, those who are sexually active and have experienced no unhealthy consequences of their sexual activity, and those whose sexual experiences have resulted in unhealthy consequences, such as abortion complications or STIs. Noting that most providers primarily serve young people in the latter group, Hughes and Dr. McCauley point to the need to put more emphasis on reproductive health education, counseling, and services for adolescents in the first two groups.14 This approach is supported by research that shows that family life education and other programs to prevent teenage pregnancy and STIs are most effective when they reach young people before they are sexually active.15
— Kathleen Henry Shears
References
Mensch B, Bruce J, Greene M. The Uncharted Passage: Girls' Adolescence in the Developing World. New York: Population Council, 1998.
Mensch.
Blanc AK, Way AA. Sexual behavior and contraceptive knowledge and use among adolescents in developing countries. Stud Fam Plann 1998;29(2):106-16.
Forrest JD, Cates W. Stages of women's reproductive life: impact on contraceptive choice. In Hazeltine FP, LaGuardia K, eds. Opportunities in Contraception: Research and Development. Washington: American Association for the Advancement of Science, 1993.
Forrest JD. Timing of reproductive life stages. Obstet Gynecol 1993;82(1):105-11.
Alan Guttmacher Institute. Into a New World: Young Women's Sexual and Reproductive Lives. New York: Alan Guttmacher Institute, 1998.
Singh S. Adolescent childbearing in developing countries: a global review. Stud Fam Plann 1998;29(2):117-36.
Population Reference Bureau. The World's Youth 2000. Washington: Population Reference Bureau, 2000.
Blanc.
Ipas. Children, Youth and Unsafe Abortion. Chapel Hill, NC: Ipas, 2001.
Alan Guttmacher Institute.
Mensch.
Potts M, Rooks J, Holt BY. How to improve family planning and save lives using a stage-of-life approach. Int Fam Plann Perspect 1998;24(4):195-97.
Hughes J, McCauley AP. Improving the fit: adolescents' needs and future programs for sexual and reproductive health in developing countries. Stud Fam Plann 1998;29(2):233-45.
Frost JJ, Forrest JD. Understanding the impact of effective teenage pregnancy prevention programs. Fam Plann Perspect 1995;27(5):188-95; Grunseit A, Kippax S, Aggleton P, et al. Sexuality education and young people's sexual behavior: a review of studies. J Adol Res 1997;12(4):421-53; Kirby D. School-based programs to reduce sexual risk-taking behaviors. J School Health 1992;62(7):280-87; Stanton B, Li X, Kahihuata J. Increased protected sex and abstinence among Namibian youth following a HIV risk-reduction intervention: a randomized, longitudinal study. AIDS 1998;12(18):2473-80.
YouthLens: HIV Counseling, Testing Expanding for Youth
Many young people in countries where HIV prevalence is high want to know their HIV status, recent studies indicate, and experts see voluntary counseling and testing (VCT) services for youth as a useful way to address their HIV prevention and care needs. However, such services are limited and more research is needed to determine their impact.
With as many as one of every two new HIV infections occurring in some countries among young people,1 it is important to focus on youth, says Deborah Boswell, an FHI expert on HIV/AIDS care and support services who helped develop VCT services in Zambia. "Some countries are trying to implement and expand VCT services for youth. To ensure quality, counselors and other staff must be trained to work with young people and to be discreet, confidential, and nonjudgmental. Also, care and support services must be available, including direct referral to supportive clinicians and options after testing for those who test either positive or negative."
Working on behalf of the United Nations Children's Fund, Boswell and colleagues at FHI recently compiled a reference guide on VCT and the needs of young people, children, pregnant women, and their partners.2 Among key issues involving young people are the level of their demand for VCT services, the impact of VCT on their behavior, and programmatic challenges that include legal and ethical concerns, adequate counseling, and ongoing support.
Demand for services
In Demographic and Health Surveys in Kenya and Zimbabwe, more than 60 percent of some 6,000 males and females ages 15 to 19 years who had not undergone VCT reported that they would like to be tested.3
In another survey of males and females ages 14 to 21 years, about 90 percent of 210 Ugandans and 75 percent of 122 Kenyans who said they had not received VCT services reported that they wanted to be tested.4 However, in these and other studies, some young people feared testing. Some worried that their test results would be positive. Others were concerned that their test results would not remain confidential, that they might lose their partners, and that the services would be costly or be provided in inconvenient locations.
In a Ugandan study of 369 young people ages 14 to 21 years who had sought VCT, young women who decided to get tested tended to do so if they were about to be married, enjoyed their partners' support, and knew their partners were willing to pay for the service. Nearly two of every three girls said their partners encouraged them to be tested. In contrast, boys were more likely to decide on their own to be tested and to pay for testing themselves. A third of boys said their decision to seek VCT testing was influenced by partners; a third, by friends; and another third, by no one.5
Impact of VCT
It appears that VCT can help young people adopt safer sexual practices and even reduce their rates of sexually transmitted infections (STIs), but more research is needed. In a randomized trial involving some 4,000 adults in Kenya, Tanzania, and Trinidad, reduction of unprotected intercourse with non-primary partners was significantly greater among individuals who received VCT than among individuals who received only basic HIV prevention information.6 The impact of VCT on behavior by age was not reported. But in an analysis of a subgroup of study participants, a third were 22 years or younger and nearly half were 25 years or younger.7
In the survey conducted in Uganda and Kenya, most of the 240 who had been tested said they intended to adopt safer sexual behaviors such as sexual abstinence, monogamy, use of condoms, and reduction in number of sexual partners.8 This study did not measure the impact of VCT on HIV infection rates, but a study in the United States involving more than 4,000 males and females ages 15 to 25 years found that incidence of STIs decreased for those testing negative for HIV. (It did not change for those testing positive.)9
Reaching out to youth
Over the last 10 years, a growing number of VCT programs for adults have been established and have dealt with such challenges as recruitment, confidentiality, stigma associated with testing positive, testing procedures, and the importance of pre- and post-test counseling. Some of these programs have also begun to focus on youth.
One example is the AIDS Information Center (AIC) in Uganda, which originally offered VCT services with adults in mind. It now has a clinic area specifically designated for young people and has developed a curriculum for youth counseling. The change came after the center analyzed its client data and found that many young people were seeking VCT services. "We began asking questions about how to be more responsive to the challenges that youth face," says Jane Harriet Namwebya, VCT technical officer at FHI, who directed the AIC project in Uganda before moving to FHI's Kenya office. "Do we need to train youth counselors? What are the challenges youth have in accessing the services? How can we support them after they have been tested?"
HIV testing can be quick, with a finger prick providing blood that is analyzed in 15 minutes.
Similarly, in Kenya, the International Centre for Reproductive Health (ICRH), in collaboration with the Kenyan Ministry of Health and FHI, originally set up nine VCT centers in Mombasa, offering a quick, confidential HIV test. (A finger prick is used to obtain blood, and a rapid assay test yields results in 15 minutes.) Realizing that they needed to do more to reach youth, project managers established three other counseling centers where trained community peer educators provide youth with HIV information. Trained counselors then work with the young people for referral to VCT testing centers, if appropriate, says Dr. Mark Hawken, ICRH project coordinator.
Existing youth-oriented projects are also beginning to offer VCT services. In Uganda, for example, the Naguru Teenage Information and Health Center, which runs a large outreach effort through radio, expanded its existing youth reproductive health services by adding the laboratory equipment and training needed to offer VCT as well.
Programmatic challenges
In these expanded efforts to provide VCT services to young people, key programmatic challenges are confidentiality, parental consent, adequate counseling, and ongoing support. Unless VCT is strictly confidential, young people (especially women) run the risk — as do adults — of being stigmatized, suffering violence, and being disowned by family members or partners.
One of the key challenges for programs is deciding whether to involve a youth's parents in the VCT process, gaining approval for testing and reporting of results. Ideally, each country would determine informed consent procedures for using VCT. In Kenya, national VCT guidelines issued in 2001 advise that "mature minors" do not need parental consent. "Mature minors" include those individuals younger than 18 years who are "married, pregnant, parents, engaged in behavior that puts them at risk, or are child sex workers."10
In countries where such formal guidelines do not exist, agency policies and individual counselors use various approaches to determine whether parental permission is needed. "Before HIV testing is done, it is important for counselors to establish the degree of maturity of the youth in terms of ability to handle the HIV test results," says Namwebya. "A lot is left to the counselor's judgment." Effective pre-test counseling would explore such issues as youths' support systems, whom they have told they might get tested, and with whom they would share the results. Youth deemed to have the maturity to accept test results are given the opportunity to learn their HIV status and obtain support and counseling without having to tell their parents and risking negative consequences.
Counseling young people, in general, requires special skills. And counseling youth about HIV testing is even more challenging. It is important to be nonjudgmental, establish rapport, and instill hope in young people, particularly those testing positive. "Counselors have to be trained to handle young people's needs, which differ from those of adults," says Namwebya. "Young people who are HIV positive still have their dreams and many years ahead. What will happen to their dreams? How long can they sustain behavior change? We should be able to help them cope."
— William Finger
William Finger works on information dissemination for YouthNet, a five-year program coordinated by FHI and funded by the U.S. Agency for International Development to improve reproductive health and prevent HIV/AIDS among young people. YouthLens is an activity of YouthNet.
References
AIDS Epidemic Update. December 2001. United Nations Programme on HIV/AIDS.
Boswell D, Baggaley R. Voluntary Counseling and Testing: A Reference Guide — Responding to the Needs of Young People, Children, Pregnant Women and their Partners. Arlington, VA: Family Health International, 2002.
Kenya Demographic and Health Survey 1998. Calverton, MD: National Council for Population and Development and Macro International, Inc., 1999; Zimbabwe Demographic and Health Survey 1999. Calverton, MD: Central Statistical Office and Macro International, Inc., 2000.
Horizons Program. HIV Voluntary Counseling and Testing among Youth: Results from an Exploratory Study in Nairobi, Kenya, and Kampala and Masaka, Uganda. Washington: Population Council, 2001.
Juma M, McCauley A, Kirumira E, et al. Gender variations in uptake of VCT services among youth in Uganda. The XIV International Conference on HIV/AIDS, Barcelona, Spain, July 7-12, 2002.
The Voluntary HIV-1 Counseling and Testing Efficacy Study Group. Efficacy of voluntary HIV-1 counselling and testing in individuals and couples in Kenya, Tanzania, and Trinidad: a randomized trial. Lancet 2000;356(9224):103-12.
Sangiwa MG, van der Straten A, Grinstead OA, et al. Clients' perspectives of the role of voluntary counseling and testing in HIV/AIDS prevention and care in Dar Es Salaam, Tanzania: the Voluntary Counseling and Testing Efficacy Study. AIDS Behavior 2000;4(1):35-48.
Horizons Program.
Chamot E, Coughlin SS, Farley TA, et al. Gonorrhoea incidence and HIV testing and counseling among adolescents and young adults seen at a clinic for sexually transmitted diseases. AIDS 1999;13(8):971-79.
Kenya Ministry of Health, National AIDS and STD Control Programme. National Guidelines for Voluntary Counseling and Testing. (Nairobi: NASCOP, 2001)5.
