1. Expanding Access to RH and Maternal Health Services for Adolescents Girls Living with HIV Harriet Birungi and Francis Obare Reproductive Health Program, Population Council December 3, 2009 Presentation at meeting on Integrating HIV/AIDS and Maternal Health Services, organized by Global Health Initiative

2. Country/year Females (15-19) Kenya (2003)3.0% Lesotho (2004)7.8% Swaziland (2007)10.1% Uganda (2005)2.6% Zimbabwe (2006)6.2%

3.  RH and maternal health services in much of Africa are not adolescent-friendly  Being HIV+ is additional source of discrimination in RH and maternal service provision o providers might not respect their right to intimacy, to love and to have children  Those who desire to have children have additional need for PMTCT services

4.  New studies among adolescents 15-19 years perinatally infected with HIV highlight new needs o Uganda, 2007: 732 adolescents (64% female) o Kenya, 2009: 289 adolescents (66% female)  Objectives of the studies o Assess SRH needs of these adolescents o Identify interventions that integrate these needs within existing HIV/AIDS programs

5.  Participants identified through existing HIV/AIDS programs and over 90% receiving ART  Information from interviews, FGDs and IDIs: o access to SRH information and support services o sexual and RH experiences and intentions o use of maternal health services (Kenya only) o issues of self-esteem, worries and fears in life

7. Females who have… UgandaKenya Ever had sexual intercourse31% (469) 61% (191) Used preventive method at first consensual sex 38%22% Currently using modern contraceptive 41%48% Currently using condoms38%44%

8. Females who have…. UgandaKenya Ever been pregnant41% (144) 64% (117) Mean number of pregnancies per person 1.3 (60) 1.3 (75) Unintended pregnancies__71% Pregnancies resulting in live births73%83% Pregnancies ended/miscarried20%12%

10. Percentage of pregnancies for which the mother… Kenya Received antenatal care at least once76% Received PMTCT services at least once52% Delivered at health facility65% Attended well baby clinic69% Used contraception after delivery43%

11. Females who have been pregnant …. UgandaKenya Having at least one living child67% (60) 81% (75)

12. Kenya Percent Percentage of live births tested for HIV85% (80) Of those tested, mothers willing to share results 99% (68) Of mothers willing, to share results, child is HIV+ 21% (67)

13. Kenya Received PMTCT Did not receive HIV-positive3%48% HIV-negative90%52% Don’t know7%0% N4027

14.  Most HIV+ adolescents are on ART and visit clinics regularly -- opportunity to systematically screen for SRH information and service needs Potential Impact  Expanding access to contraceptive information and services to sexually active HIV+ adolescents  Early identification of pregnant HIV+ adolescents and increased use of MCH services

15.  Counseling not responsive to needs o Often talking to them and not discussing their feelings o No comprehensive sexuality education…information is censored, with warnings against sex and relationships o Sometimes providers talk only to parents/guardians  Counseling only focuses on responsibilities and not their rights and lives  Many adolescents are hesitant to discuss their sexual behavior with service providers 15

16.  ‘Fertility and sexuality desire’ assessment tool for counselors to systematically screen and refer young people appropriately  Counselor’s guidelines on SRH and rights of adolescents living with HIV

17.  Strengthening adolescent preventive information and services within ART programs  Establishing transition clinics - bridge between pediatric and adult care for adolescents  Creating effective linkages between HIV/AIDS centers and MCH clinics  Sensitizing service providers on needs of HIV+ adolescents -- not different from any girl or boy

18. 18  Funding agencies: Ford Foundation USAID  Partners: TASO- Uganda APHIA II partners in Kenya NASCOP and DRH