Implementation guidance for health providers and planners

Service delivery

HIV has become a manageable condition, and effective, ongoing care for adolescents living with HIV must be based on broad support from their communities and health care providers. Health care planners and providers can adapt current service delivery models, taking advantage of integration, decentralization and community-based approaches to provide a range of opportunities for prevention, early identification of health, emotional and social issues and timely interventions.

Depending on the setting, one of the key challenges with decentralization and reliance on community-based services will be developing some degree of capacity at peripheral facilities to handle the array of HIV-related services required by adolescents.

Integration of services. Service integration involves blending either some of the elements of, or all aspects of one service into the regular functioning of another service, allowing a person to access as many services as possible in one place. This is a big advantage for adolescents living with HIV, minimizing clinic visits and the time they have to spend attending clinic and waiting for services.

Integration makes it easier to deliver comprehensive care and support – not just related to HIV. When services are integrated, it can also help to reduce missed opportunities for initiating ART and other interventions, enhancing long-term adherence support and optimizing patient retention in care. Effective integration of services also makes optimal use of human and financial resources, improves coordination along the continuum of care and facilitates the transition of adolescents into adult HIV services.

HIV services for adolescents are currently delivered in many clinical settings including primary health care, antenatal care (ANC), maternal and child health (MCH) services, and special services for key populations. These clinics should be mindful of the unique needs of adolescents living with HIV. Likewise, HIV care settings serving adolescents should consider how to incorporate SRH, ANC, PMTCT and TB services.

Multiple services can be provided for adolescents at a single clinic visit through: 1) satellite clinics from other services (e.g., a family planning provider holds a clinic session on designated day within the ART service, or an HIV provider offers ART care within an antenatal setting); or 2) task shifting and increasing the scope of work of providers through appropriate training. When it is not possible to deliver services in one location, it is important to establish systems to share information between clinics, service delivery points and individual providers.

For detailed principles and practical suggestions related to integration, please refer to the Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection.

Decentralization. Decentralizing ART to more accessible settings for adolescents eases the burden on other parts of the health system. More importantly for adolescents with busy lives, decentralization brings services closer to home and reduces waiting times. This may increase the likelihood that they will use services and stay engaged in care. Decentralization may also improve equity by facilitating access to ART in places that are easier for adolescents to reach in terms of logistics and cost, and are more reassuring in terms of confidentiality and safety.

For all decentralized services, links to the supply of diagnostics and medicines, services, training and supervision of health workers are needed to maintain the quality of care.

For detailed principles and practical suggestions related to decentralization, please refer to the Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection.

Community-based approaches. Community-based services foster long-term relationships between formal health services and local support groups. They are particularly useful in reaching those infected during adolescence, as this group is inadequately tested in both generalized and concentrated epidemics.

Community-based approaches to service delivery increase accessibility in terms of distance and cost, while allowing for closer partnership between health providers, support groups, clients and their families. Community-based programmes can also refer to those that serve the needs of specific communities with common characteristics or challenges, most importantly key populations.

There may be limitations to the scope of services that community-based providers can offer. In some cases, complex health issues may be harder to address in community-based settings, e.g. cardiac, lung, cognitive and pubertal delay issues as well as annual monitoring of ART patients for long-term toxicity and co-morbidities. It is important to note that in some cases, the 'familiarity' aspect of community-based services may be a disincentive for adolescents due to concerns about confidentiality.