In the Asia Pacific (AP) region as of 2010 (excluding Central and Western Asia, Australia, and New Zealand), there were over 668 million adolescents aged 10–19 years and over 360 million young people aged 20–24 years.1 Young people aged 10–24 years comprise around 17% of the total population of the region.1 In 2012, an estimated 690,000 young people (aged 15–24 years) in AP were living with HIV.2 New infections among adolescents in South Asia and East Asia and the Pacific were estimated to be 58,000,3 21% of all estimated new infections in the same region,4 while globally young people aged 15–24 years accounted for 39% of all new infections.5
Asian HIV epidemics are concentrated in key populations, namely males who have sex with males (MSM), people who inject drugs, and sex workers (SW), whereas clients of SW are the largest population at risk in AP.2 The modeled assumption is that 95% of new HIV infections in young people in AP are among young people from these key populations.6 To date, available data cannot tell us the specific risk profiles of adolescents and young people or conversely the specific risk profiles of adolescents and young people within key populations. Age of consent still prohibits some countries from including adolescents aged <18 years in targeted studies or routine surveillance. Collecting programming data is also an issue as adolescents aged <18 years cannot access programmes without consent and or do not for fear of legal repercussions given the criminal of the nature of their risk behaviors.7,8 Since 2005, several countries in AP have included adolescents aged <18 years in at least 1 kind of survey, however, data are generally reported aggregated and within subpopulations, for example, in national Global AIDS Response Progress Reports.9
This review was initiated to identify, through peer-reviewed literature, interventions in the region with demonstrated impact for young key populations (YKP) as part of a larger review undertaken by UNICEF and partners in the region. Looking at individual and structural factors, findings from the review underscore the opportunity for social and programmatic enablers to increase the efficacy and efficiency of high-impact interventions and for synergistic development activities to mitigate structural drivers of HIV vulnerability for YKP whose behaviors are stigmatized and criminalized.
The focus of the organization of the review and subsequent analysis was on prevention interventions that worked, didn't work, or implications from research interventions on what could work, looking at individual and structural factors and the interplay between them to identify opportunities to improve the accessibility and delivery of high-impact HIV prevention interventions for YKP in AP. The focus of the review was prevention as only 1 article related to treatment was found through the primary search chain (Fig. 1). Journal articles in PubMed, Cochrane Library, Cochrane DARE, EMBASE, PsycINFO, CINAHL, and Web of Science databases were searched for intervention-related information. Surveillance data and non–peer-reviewed literature were not included in this review but are included in the larger review undertaken by UNICEF and partners. Search terms represent those found only in international literature and are not necessarily inclusive of local terms. Although some articles reviewed discussed children younger than 18 years engaged in selling sex, none made reference to sexual exploitation or child protection responses.
Over 1000 articles were found, and 37 ultimately selected. As the focus of the search was strategic information on interventions, studies of all sample sizes were included. Only articles published in English were included. Articles were then reviewed for reported or indicated impact at the individual, community, and structural levels. Where warranted, articles cited within the 37 articles were reviewed. Finally, separate supportive data searches were conducted for background epidemiological and environmental information or to confirm or expand on information provided in the 37 articles.
Our search found high-impact programme intervention information on condom utilization, testing uptake, information/education (peer, sexuality, life-skills), and biomedical interventions.
In nearly all the studies reviewed, condom use among MSM, transgenders, SW, and their clients was low or inconsistent and associated with younger ages and lower education. Low perceptions of risk, including trusting the partner, were the most often cited individual factors impacting condom use for both MSM10 and female sex workers (FSW) including migrant FSW.11 Lower condom use was associated with FSW desiring to be seen as trustworthy or build trust with clients who may become potential partners,11,12 deciding a client “looked clean” or if regular and client partners claimed, they were uninfected.13 Similar subjective risk reduction strategies were found in 2 studies with young clients (aged 15–24 years) of FSW in 9 hotels in Dhaka, Bangladesh, including perception of trust (inconsistent condom use with frequently visited FSW), general cleanliness (clean perceived as uninfected), perceived social status (dark skin equated with lower class and therefore fewer clients), and anal sex (perceived low risk of infection).14,15 Finally, alcohol and drug use, especially among younger risk populations, were determinants of individual behavior negatively associated with condom use.16 As with FSW and MSM, people who inject drugs also were found to have a low perceived sense of risk.17,18 Structural level factors associated with condom negotiation and use in articles reviewed included economic hardship,10,11,16 knowledge of HIV10,19 (closely related to individual factors of risk perception and self-risk assessments), violence and trafficking, peer education and peer influence, availability of condoms and support of the brothel or entertainment venue managers, and cultural norms.
Sexual coercion, forced sex, and trafficking were key factors in lower condom utilization among FSW.16,20 Approximately 40% of FSW worldwide have entered the sex trade before the age of 18.21 Trafficked girls in the Philippines (n = 791) were found to be 12 times more likely not to negotiate condom use, and condom use was lower overall in younger SW. In the same study, among the adolescents selling sex, only 32% always used male condoms during vaginal sex compared with 50% among those aged 19–25 years,22 confirming findings from other studies from Asia reporting higher-risk sexual behaviors among young FSW compared with older FSW.23,24 Decker et al25 documented violence toward SW compromised condom use due to fear of abuse. In another study, Decker et al found that 1 in 7 FSWs (n = 815) studied in Thailand experienced violence in the week before the study survey, and that victimization was significantly associated with recent condom failure, client refusal of condoms, and sexually transmitted infection (STI) symptoms.26 Respondents aged <18 years were at greatest risk (25.0% affected) compared with those aged 18–25 years (17.7%). Chemnasiri et al20 found in Thailand ever been sexually coerced was significantly associated with inconsistent condom use with male sex workers.
Regarding peer influence, 2 studies among clients of FSW in Bangladesh found that peers first brought respondents to buy sex, pornographic materials influenced their decision to purchase sex, and that viewing pornography was promoted by peers who introduced them to the sex industry.14,15 Among FSW themselves, Rogers et al27 found that the more FSW were involved in the development of HIV prevention messages and method of delivery, the more likely they were to communicate it to their peers when they move establishments.
Several studies in the Philippines confirmed the association of work place policies in venues catering to SW with safer sex.16,19,28,29 Ang and Morisky19 found that FSW who worked in an entertainment venue with a mandatory condom use rule (46.6% had rule) had a higher level of condom use. Condom availability in a venue was also associated with use,16,28 and Haseen et al15 found that young male clients of FSW were more likely to use condoms if use was negotiated by the FSW. Maher et al found that in Cambodia, entertainment venues were high risk for FSW because they were unable to mediate violence and interactions with police as there was no managerial support. In addition, they were reluctant to offer condoms given the antitrafficking law introduced in 2008 and subsequent policing.29 In 2009, 96% of FSW were non–brothel based.30 Finally, Mansergh et al31 found unprotected sex among MSM associated more with recruitment from parks compared with saunas, which indicated lack of protective structural support, a finding that was similar between brothel- and street-based FSW.
Expectedly, social factors were also found to influence condom use. For transgender, condom negotiation was more difficult given their female gender–based identity and socially constructed deferent role in society (including anal receptive sexual role).32,33 YMSM at a consultation in Bangkok in 2012 identified that some young transgendered people had unprotected penetration to “validate” their gender identity.7 Among hijras (transgendered people) in Pakistan, median 24 years, 83% had never asked a client to use condoms.34 Eight out of the 11 articles about MSM mentioned males who have sex with males and women (MSMW). Guo et al35 looked specifically at bisexual behavior and associated sociodemographic and behavioral factors among young migrant MSM, mean age 23.7 years, finding MSMW had higher rates of HIV, were less likely to have tested for HIV and to participate in HIV prevention activities, and were less knowledgeable about condom use and HIV (11.2% vs.12.4%). All but one of the studies from China mentioned bisexual sex. In 1 study in China, 83% (25/30) respondents said they would marry because of social pressure although 66.7% of the respondents identified as homosexual,10 however, consistent rates of bisexuality and pressure to marry reported across the studies may be related to China's 1-child era, started officially in 1979, and a cultural norm to carry on bloodlines.35
Three of the 12 MSM studies reviewed looked specifically at testing uptake. At an individual level, factors impeding testing uptake included not knowing where to get tested and low perception of risk, whereas structural factors included perceived stigma and related to the services and facility.36 The only study that looked specifically at testing behaviors of (migrant) YMSM aged 18–29 years in Beijing,37 found while 72% had ever had an HIV test, testing was lowest among 18–19 year-olds (7.7%) compared with 20–24 year-olds (59.5%).37 The most common barriers reported were perceived low risk of infection, not knowing where to take the test and fear of being stigmatized (Table 2).
Two articles looking at voluntary counseling and testing (VCT) among drug users both reported the key structural barrier to returning to pick up the test result were that it either took too much time or the facility was too far away, pointing to the critical need for point of care rapid testing, both at the facility level and in the community.18,38
The Internet was shown to be an underutilized effective means by which to increase VCT uptake. In an innovative study from China, Zou et al36 used the Internet to facilitate VCT uptake in 2 cities using active recruitment through instant messaging (1 of 4 went for VCT), online gay chat rooms (1 of 6), mobile phones (1 of 10), e-mail (1 of 140), and passive recruitment through placement of banners on front pages of 3 major Chinese gay Web sites (42.9% of study participants were aged 18–24 years; total reported uptake 12.87%). Active recruitment was more successful with younger MSM. Factors that could impact future Internet prevention interventions included the desire for a peer professional to facilitate (38.6%) and for the intervention to take place in the evenings when youth had time and privacy. The potential to reach out to YFSW through the Internet was also found to be significant. Multivariate analyses showed that willingness to participate in online prevention programmes was significantly associated with higher Internet use and younger age (20–30 years).39
In a large study from Hong Kong (n = 8039), Wong et al reviewed the overall effectiveness of school-based and doctor-based delivery of HIV/sex education to students aged 15–18 years from 21 secondary schools. Of the study participants, only 4.7% had ever had sex, but a significant amount of them reported forced initiation of sex, both female and male. Multiple logistic regression showed students who had received school-based HIV/sex education were less likely to have sexual intercourse in the past 3 months or use drugs or alcohol before intercourse and were twice as likely to discuss emotional or puberty issues.40 Sex education by family doctors in the same study was not statistically significant. Sutcliffe et al conducted a randomized behavioral trial with 18- to 25-year-old methamphetamine users in Chiang Mai comparing the efficacy of a peer educator intervention with a life-skills curriculum (non-peer) on methamphetamine use and sexual behaviors. Despite pedagogical differences, both approaches were associated with reductions in methamphetamine use [at month 12, only 53% used, down from 99% at baseline (P < 0.0001)] and increases in condom use over 12 months [from 32% at baseline to 44% (P < 0.0001)].41
Biomedical Prevention Interventions
Only 1 study looked at biomedical prevention interventions. In northern Thailand participants, 56.1% of whom were gay men, 18.5% bisexual men, and 25.4% transgender persons, were recruited through the PIMAN Center to look at HIV incidence, risk factors, and motivation for biomedical interventions. Around 70% of the participants screened were aged ≤24 years, with a mean age of 23.9 years.32 Of the 468 clients assessed for willingness to participate in biomedical HIV prevention trials, 86.3% reported interest in oral pre-exposure prophylaxis (PrEP) trials, 69.7% in HIV vaccine trials, and 29.9% in male circumcision trials. Evidence about the efficacy of antiretroviral therapy (ART) was found to elicit complacency regarding risk perception in 1 study among MSM in Bangkok: 34% were not at all concerned about becoming infected with HIV, and 57% with an STI. Only 21% of the study population had heard about effective HIV treatments but of those who had, 44% believed that HIV was less serious now with available treatment and 36% reported having increased their risk behavior with the availability of treatment.31
The Futures Institute and UNICEF suggest that effective programming for adolescents should customize existing interventions to meet the specific needs of young people and pursue an intersectoral approach that stresses the important preventative role played by interventions that address structural vulnerabilities.42 Although there is little research on the impact of interventions for adolescents and young people at risk for HIV in AP, there is some evidence for how individual and structural factors influence the success of high-impact programmes, for example, condom use and testing uptake. We found that except for those forced to engage in unsafe behaviors such as those coerced or trafficked into sex, individual decisions regarding safe behavior and testing uptake are mediated by structural level factors. Condom use and testing uptake are low among young key risk populations, often due to low perceptions of risk, but there are potential interventions that could and do work in Asia to address individual and structural risk factors in HIV acquisition and transmission. Critical enablers such as the design and delivery of services, peer education, and condom policies support uptake of high-impact interventions, and synergistic development interventions such as sexuality education in secondary school, rights-based enforcement of antitrafficking laws, and addressing violence and abuse can mitigate vulnerability to HIV. Although evidence found through this review on what works or could work in Asia focused primarily on MSM and FSW, interventions should ultimately be directed toward the populations most at risk who need them most.43 In Asia, this means MSM, including MSMW, male sex workers, and transgenders.6
Interventions that attempt to reduce risk at the individual level often fail because they do not consider the role that structural factors play in an individual's willingness or ability to exercise safe decisions to reduce risk, which is closely tied to the perception of risk. Perceptions of risk may reflect general cultural norms rather than subcultural sexual partnering, for example, a man who does not consider himself gay may not perceive himself at a higher risk, if engaging in MSM sex or entertainment-based SW may not consider themselves as SW and therefore not conform to occupational norms of SW such as condom use.29 Also from the literature reviewed, transgendered persons are more likely to practice anal sex. Prevention information has to be tailored to individual perceptions and constructions of self and the interplay between subcultural roles and behaviors and normative societal behavior. For MSMW, an effective prevention message may be one that helps him perceive his risk as impacting his desire to adhere cultural norms of marriage and family. A clear understanding of where males and transgender persons fit on the sexual orientation continuum is critical before planning effective prevention and testing uptake interventions with YMSM. Addressing key factors in risk reduction such as motivation and intention, self-stigma, self-esteem and depression, intimacy, and self-efficacy is critical20 given trust of partner and need for intimacy were common individual factors associated with low-risk perception and lower condom use.11 In the report of the above-mentioned regional YMSM consultation in Bangkok in October 2012, it was mentioned that “within the context of a relationship, that is, allowing unprotected penetration as a sign of trust or desire for love, relationship, and connectedness. Some may see condoms as undermining intimacy during the sex act. Low self-esteem can lead to the feeling of insecurity in relationships, which in turn could compromise condom use”.7 Helping YMSM and YSW to understand their risk with both casual and steady partners, especially in the context of trust building, while emphasizing pleasure, intimacy, and sexuality positively can support self-efficacy in condom use more successfully than a public health approach has been able to do to date.
ART and biomedical interventions were associated in 1 article with a reduced perception of risk. Given recent evidence that ART lowers viral load and makes transmission more difficult,44 the raising of the recommended ART initiation threshold,45 and promoted scale up of biomedical interventions such as PrEP, information on strategic use of ARVs should be built into both prevention and testing promotion messages, including limitations of ART, to mitigate complacency in risk perception. Interest in trials was greater among MSM and TG32 and needs to be explored specifically with YMSM as more evidence comes to light on the efficacy of biomedical interventions for MSM.46
Service providers need to be sensitized, and services need to consider geographical and operational preferences, be free and anonymous, offer condoms and lubricants on-site, be available for migrants, and finally be promoted and available where SW and clients are able to reach them. Point of care testing must be available in communities and facilities where testing is available.47 As preferred service delivery points and mechanisms vary,48 formative assessments should be undertaken first to ascertain preferences of the clients of different risk populations and the potential for peer delivery. The influence of peers was a critical factor in both condom use and dissemination of information and found to be most effective when messages were not defined by the work itself but by shared beliefs, norms, and practices.49 Peers are in a unique position to build awareness, promote condom use, and implement a behavior change communication strategy. Where peer interventions were found in the articles reviewed, they were positively associated with increased knowledge and condom use.
Work place policies supporting condom use and availability of condoms in venues can be a critical structural factor in ensuring safer sex for both SW and clients. Establishment managers were reported to be an effective means of information dissemination and condom distribution.14 Decriminalized sex work and 100% condom use policies across all establishments where sex takes place (reinforced by general legislation) can help to ensure the compliance of hotel managers and mitigate the opportunities for clients to offer more money for unprotected sex. Mandatory 100% condom use policies have contributed to a decline in HIV incidence among SW in Thailand and Cambodia.50 Although policies may be easier to implement in a closed brothel setting, there is a need to work with entertainment venue managers (eg, at sauna, bathhouse, and other MSM venues) to develop work place polices to promote norms of nonviolence and condom use. Stronger enforcement of rights-based antitrafficking legislation is also needed to help prevent girls entering the sex industry, women entering by force, and to ensure those trafficked are able to leave. Managers can play a role by linking with Child Protection and Social Welfare programmes for children aged <18 years engaged in the sex industry and targeting clients.14,15
The Internet is a popular means by which key populations socialize or access health information. Utilization can be strengthened to increase VCT uptake and related self-risk identification and information dissemination. Given the positive utilization association with a younger age, it is currently underutilized to reach YMSM and other adolescent and young subpopulations that may be difficult to identify, such as YMSMW and those living in rural or remote areas, as well as freelance SW or those who have been trafficked.51,52 It is anonymous, has broad accessibility, easy quality control, and is cost effective.39,53 China and Thailand are perhaps Asian with the greatest potential to use the Internet given their large populations of MSM and FSW coupled with current Internet penetration.54 Studies in these countries showed the potential of outreach for service uptake especially through instant messaging and online chat rooms though, the potential of reaching risk populations through e-mail still needs more research. The success of outreach and HIV testing uptake in China through online chat rooms and mobile phones is a significant opportunity given the number of MSM, potentially up to 24,000,000.36 Finally, more research is needed to understand the use of Internet cafes for potential structural interventions, as well as the norms and values of virtual subcultural contexts with which YKP identify to ensure the relevant perspective and messaging for active and passive outreach and recruitment into services.
Several of the studies pointed out the opportunity and the need to strengthen sex education in schools. Although the education levels were found to be lower in South Asia, almost all populations had at least a primary education and most a secondary school education. Although sexuality education at the primary level may not be possible in religiously or culturally conservative countries, it should at the least be provided in middle and secondary schools. In addition to focusing on contraceptive methods and STI/HIV prevention, given the serious issue of coercion or rape found in this review,40 information and skills to empower adolescents against forced sex should be integrated into ongoing and future school-based HIV/sex education programmes. Finally, as the fastest-growing HIV epidemics in the region are among MSM, most of whom are younger, sexuality education should include alternative sexuality including male to male and transgender intimacy and risk reduction.
In conclusion, there is a dearth of implementation research on adolescents and young people. Even with the rather broad search criteria for this review, the yield was only 37 articles, with none specifically on adolescents and only 6 looking specifically at <25 years. Despite evidence that structural factors around service delivery and engagement of entertainment venue managers yielded higher impact results related to preventative behavior, it is impossible to generalize from these studies any specific conclusions regarding interventions that work for adolescent and YKP across Asia. To identify opportunities to implement effective high impact programming, more qualitative research is needed on individual and structural drivers of HIV vulnerability, especially variables that are important in self- and group-risk assessments.
The review is a component of a more comprehensive review UNICEF East Asia and the Pacific Regional Office and partners of the AP IATT on YKP are undertaking to answer specific questions about the HIV risk profiles of adolescent and YKP in AP.
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