March 21, 2012 — Reaching youth where they live and socialize appears to be a critical component in improving testing and treatment for HIV, sexually transmitted infections, and unwanted pregnancy, according to a study published online March 20 in the Journal of Adolescent Health.
Donna M. Denno, MD, MPH, associate professor, Pediatrics, and clinical assistant professor, Global Health, University of Washington, Seattle, and colleagues conducted an extensive review of the research literature from multiple databases in an attempt to identify effective innovations in confronting risks to sexual and reproductive health among marginalized 10- to 24-year-olds.
Among the successful approaches uncovered were mail-based chlamydia screening in the Netherlands and Denmark, street distribution of condoms in Louisiana, home-based HIV counseling and testing in Malawi, and promotion of over-the-counter access to emergency contraceptives (ECs) in a number of countries.
The 20 studies selected from the 13,552 studies retrieved initially included promotion of such things as birth control and ECs and clean needle or needle-exchange programs. To meet inclusion criteria, the interventions had to take place outside of traditional health facilities. The interventions could take place in pharmacies, jails or detention centers, the street, parks, and community centers. The authors also looked for studies that were randomized and controlled, quasi-experimental, observational with a control group, or included time-series analysis. All studies were published before March 2010.
Nonprescription Emergency Contraception
Despite a lack of what the authors term "rigorous studies" on nonclinic access to HIV and reproductive health services for youth (only 1 of the trials they found was randomized), this literature review indicates that nonclinic interventions "offer promise to reach those who cannot or will not be reached by traditional health facility-based approaches," the authors write.
They point to studies in France and British Columbia, Canada, that showed an increase in emergency contraception when contraceptives could be obtained directly from pharmacies without a prescription. In France, EC acquisition increased by 17% among those younger than 25 years, and in British Columbia, the increase was by 51.9% (ages 10 - 14 years), 54.9% (ages 15 - 19 years), and 83% (ages 20 - 24 years). Despite readily available ECs, the number of prescriptions for ECs remained unchanged in these studies.
Although 1 trial in the United Kingdom showed that a steady increase in nonprescription ECs at pharmacies was accompanied by a corresponding decrease in prescriptions, a second UK study showed that, with the availability of nonprescription ECs at pharmacies, the interval between unprotected sex and the acquisition of ECs fell from a median of 41 hours among those obtaining ECs from a clinic to a median of 16 hours when ECs were obtained over-the-counter from a pharmacy, which is a statistically significant difference (P < .001).
Community Outreach
A study in urban Monterrey, Mexico, showed that adding a youth center with education, recreation, and reproductive health services to ongoing community outreach not specifically directed at the young brought a 44% increase in contraceptive use among 15- to 22-year-olds who had never before used contraceptives. Even more successful, and less expensive, was the use of youth promoters providing community-based reproductive outreach targeting youth. In that instance, contraceptive use increased 98%.
Interventions by mail also proved an effective method of increasing chlamydia screening in both the Netherlands and Denmark. In the Danish study, young men mailed a test kit for chlamydia were 60% more likely to be screened for the sexually transmitted infection than those mailed an invitation to request a screening kit. A study in Rotterdam showed screening rates of 40% in their mail-based program.
A Louisiana street-outreach condom distribution effort in neighborhoods with a high prevalence of injection drug use gave out nearly half a million condoms in 2 years. People in this neighborhood were 37% more likely to use condoms than those in a control neighborhood without the outreach program.
In a study on Likoma Island, Malawi, in which HIV counseling and testing was offered during home visits to people aged 18 to 35 years, 66.9% received the counseling and testing. More than half of the study participants were younger than 25 years, and among those younger than 20 years, 79.4% agreed to counseling and testing; among those aged 20 to 24 years, the rate was 72.5%.
Limitations of the review include the inability to pool data, not contacting experts and agencies in the field of adolescent health, and "the heterogeneity of interventions, outcomes, and populations" in the studies evaluated.
Adolescence and young adulthood "represent a time of increasing mortality worldwide," the authors state. In this combined age group, HIV/AIDS is the sixth leading cause of death, accounting for 142,000 (6%) of deaths. Maternal deaths, especially resulting from hemorrhage and abortion-related deaths, are responsible for an even larger proportion of deaths among young women, the authors note.
"[T]his review suggests that out-of-facility approaches can be important avenues to reach youth," the authors conclude. "Continued evaluation is necessary to better understand specific approaches that can successfully deliver health services."
The study was supported by the Departments of HIV and Maternal Newborn Child and Adolescent Health, World Health Organization.
J Adolesc Health. Published online March 20, 2012. Abstract
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Cite this: Outreach Critical for Youth Reproductive and Sexual Health - Medscape - Mar 21, 2012.
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