Implementation guidance for health providers and planners

Providing information and creating discussion

For adolescents living with HIV, knowledge about sexual and reproductive health is critical to their ability to protect their health and to live positively with hope for the future. Sharing information and open discussion supports the evolving capacities of adolescents, especially their increasing capacity to make decisions autonomously. Many adolescents seek and welcome the opportunity to use SRH information to help them to fully enjoy their emerging sexuality as well as to protect themselves and to avoid transmission of HIV to others. At the same time, many adolescents living with HIV have a number of unanswered questions that they may not feel comfortable enough to bring up on their own.

Providing information should always be a continual process, not something that can be considered accomplished in one consultation. Information that has been shared should be revisited and built upon during each interaction with the adolescent client. Providing information during a SRH consultation needs to be a discussion and exploration of the issues with the adolescent, not just a one-way transfer of information. Leaflets and other printed materials should be reviewed together with the adolescent to allow for good understanding and opportunities for questions, and adolescents should be encouraged and given the time to raise any questions or concerns they may have, or if further information is needed. Additionally, links should be provided to other services or internet and mobile information sites so that the adolescent knows that there are other sources of information and support.

In resource-constrained environments group education activities, peer support groups and other community-based approaches may be suitable to provide information regarding sexual and reproductive health to adolescents living with HIV. However it is important to recognize the sensitive nature of SRH issues and the importance of privacy and confidentially for adolescents, which may be difficult in a group setting. Again, such sessions do not remove the responsibility of the health providers to strive to meet the sexual health and reproductive needs of adolescents living with HIV.

Please refer to the section on Living Positively and additional sources of support for more detailed information and examples of peer support.

Health providers are responsible for providing accurate and practical information. It is their role to help adolescents understand the transmission risk of certain types of sex and to provide guidance to help them reduce risk-associated behaviour, to maintain good SRH, and to prevent new HIV infections. It is also important for providers to initiate discussions regarding SRH, allow time for adolescents to ask questions and check their understanding. In order for these discussions and information sharing to be effective, adolescents need to feel that health providers are knowledgeable, comfortable and supportive when discussing any topic, regardless of how difficult or sensitive it may be. A one-way conversation where health providers share their own moral guidelines or assume the role of a parent will prevent open communication, cause the adolescent to disengage from care and may compromise decisions made by the adolescent concerning his or her sex life.

All adolescents living with HIV, whether sexually active or not, need information that goes beyond sexual abstinence. The most important emphasis is full, accurate and non-moralistic information for adolescents for the protection of their health and well-being as they become more sexually active. Key topics include transmission risks and types, strategies to reduce risk, signs and symptoms of STIs, and critical information on contraception (dual methods) and conception (how to have a child in a way that is safe for the mother, her partner and their baby) for both males and females.

SRH service providers should encourage clients to bring their partners for a joint consultation, if appropriate and feasible. These are ideal opportunities to discuss many topics that concern both partners and to nurture openness and honesty. Couples can be offered joint testing and counselling, support for disclosure to each other and to others, information on post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP), and advice on transmission risk and safer sex. The WHO Guidance on couples HIV testing and counselling – including antiretroviral therapy for treatment and prevention in serodiscordant couples – offers recommendations for couples.

Please refer to the Disclosure section for more detailed information and guidance on HIV disclosure to sexual partners.

If an adolescent reports that s/he is not sexually active, the discussion should not stop there. For many adolescents, the first sexual experience is unplanned, so it is important to talk about sex and condom use before that first sexual encounter. Broaching the topic of sexual and reproductive health for the first time can be daunting and uncomfortable for both the adolescent client and the provider, and a gradual and sensitive approach can be helpful. If an adolescent reports that s/he is not sexually active, the provider can address related topics of more immediate concern, such as puberty and challenges the adolescent may be facing in establishing their independence from parents or adult caregivers. These topics can serve as a bridge to discussing issues that may be more unfamiliar or worrisome for adolescents, while allowing the provider to develop a comfort level with the client that will facilitate counselling on more complex SRH issues.