Implementation guidance for health providers and planners

Key populations

Ending the AIDS epidemic will depend on greater efforts to reduce new HIV infections and prevent AIDS-related deaths among key populations at highest HIV risk. These groups are disproportionately affected by HIV, even in high prevalence settings, and they experience higher rates of mental health issues, substance use and suicide as a result of chronic stress, estrangement (actual or feared) from families and lack of social support, and disconnection from health and support services.

Key populations are ‘key’ to both the dynamics of and the response to the epidemic, yet few programmes have focused on these groups, resulting in low coverage of HIV prevention interventions. Data on adolescent members of key populations in particular are extremely limited; either existing data on these groups are not disaggregated by age, or the research has not been done on adolescent populations, often due to concerns about consent issues or other barriers related to social and legal environments.

However, what is clear is that adolescent members of key populations are more vulnerable than adults in the same groups, with many risks and vulnerabilities overlapping across specific group delineations. They share many of the same characteristics of adolescents who are not living with HIV, such as evolving capacities, higher risk-taking behaviour – which can be particularly dangerous for adolescents who inject drugs and share needles – lower condom use and lower levels of awareness about HIV and other health risks. As they begin to establish intimate relationships, adolescents are still acquiring negotiation skills and learning how to manage unequal power dynamics in sexual decision-making.

Most adolescents are also less experienced in navigating the health system, and they are less willing to seek services; when they do, they may find health workers have unhelpful or judgmental attitudes. Adolescent members of key populations face many additional, rights-related socioeconomic challenges such as lack of adequate housing, education, employment and psychosocial support. At the same time, adolescent members of key populations may not identify themselves as such, leading to a range of denial-associated vulnerabilities.

Key populations, and especially adolescents in these groups, often face significant challenges in accessing care and treatment due to stigma and discrimination from health providers, and ignorance within health systems about gender variance. In many countries where certain sexual identifications and practices are criminalized, additional barriers are created by individuals’ own fears of stigma, abuse, harassment and legal consequences.

With the growing evidence that ART reduces the risk of HIV transmission and has a dramatic impact on quality of life and survival, it is urgent that health services in all epidemic settings prioritize key populations, including adolescents in those groups, for much greater attention and support. Effective interventions that ensure confidentiality will protect the members of these marginalized groups and improve their health and quality of life, while making a major contribution to reducing HIV transmission.

For adolescents, who are often not aware of their rights, policies and laws specifying age-related restrictions and stipulating consent by parents/guardians or spouses add to their fears and deter adolescents who might otherwise seek services. At the same time, such official restrictions create complex dilemmas for providers who want to act in the best interest of their clients but who may have concerns about their own legal liability as well as the safety of their young clients. Until such policies and laws are changed, many adolescents living with HIV in key populations may need legal support following HIV testing and counselling services.

More specifically, for adolescent males who have sex with men and for transgender adolescents, the normal exploration of sexuality that takes place during adolescence may be more complex. This may expose them to additional risks, due to a transitional stage during which sexual questioning and experimentation with partners of both sexes is not uncommon and may take place before consistent sexual identification as gay or bi-sexual. Additional pressures of ‘coming out’ or disclosing their emerging, possibly confusing or upsetting sexual identification to family members and peers can add to an adolescent’s vulnerability; ‘sexual silence’, when one’s sexual orientation is not discussed with partners, friends or providers, also increases the risk for HIV and sexually transmitted infections.

Interventions and services for adolescents in key populations should be based on adolescent-friendly principles (as previously addressed in this tool), with particular attention to accessibility issues and the attitudes of staff members. Services that prioritize building trust with young, highly marginalized and stigmatized groups can more effectively reach adolescents in key populations, optimizing the impact on individual lives and on broader HIV prevention, care and treatment efforts. Community-based services are especially well-positioned to break down some of the barriers that exist for adolescents in key populations; creative use of peer outreach and support as well as social media can promote services that are easy to access and provide safe, impartial settings where confidentiality and respect for individuals and their autonomy are assured.

In many communities, adolescents from key populations will feel safer seeking services from organizations that have a special focus on their particular psychosocial and legal needs, along with their health needs. These ‘one-stop shop’ services can provide comprehensive HIV/STI risk reduction and treatment options, as well as services that address the range of other issues key populations face. In some settings where adolescent-friendly services are already established, it may be possible to add services for adolescent members of key populations. Similarly, services for adult members of key populations may consider ways to accommodate the particular needs of adolescents. In either case, it is vital that adolescent members of key populations not feel singled out, set apart or marginalized in any way.

Health providers need support and training to develop a more sensitive and robust understanding of the lives and circumstances of adolescent key populations. They also need to be better prepared to meet the needs of four main groups of adolescent key populations: adolescent males who have sex with men; adolescents under the age of 18 who are being sexually exploited or sex workers 18–19 years of age; adolescents who use injecting drugs; and transgender individuals. Health providers need to make sure that they work in a multidisciplinary way, and that linkage to community-based providers is established to ensure referrals and adequate follow-up care are available for these adolescents.