The authors of the original papers that were commissioned for the meeting in Talloires in March 2004 that initiated the "Steady, Ready, Go!" process were asked to give special consideration to young people who are most at risk of becoming infected with HIV. When the papers were reviewed during the meeting, participants recommended that a specific chapter be written focusing on these groups of young people. This is important for two reasons. First, interventions for young sex workers, men who have sex with men, and injecting drug users are likely to be key to decreasing the transmission of HIV in low-level and concentrated epidemics. Second, having the evidence of effectiveness for these interventions is important because they are usually surrounded by controversy, the behaviours that this group participates in are often illegal, and the groups themselves are marginalized and exposed to discrimination.
However, there was uncertainty about whether enough data would be available to allow the interventions to be analysed in the same manner used for other chapters in this series. There was also concern that the evidence for effectiveness would be weak since programmes for groups most at risk often focus more on taking action than finding out whether an action works. This problem has already been described by Myers and colleagues (64) who suggested that part of the reason for the difficulty in finding evaluations of interventions targeting these three groups is the fact that much of the literature has been produced by practitioners rather than researchers. While some of the reservations about writing this chapter were clearly justified, our review has nonetheless enabled us to draw some conclusions and allowed us to identify some important issues that require further attention.
This review set out to assess the level of evidence of effectiveness needed to recommend implementation of interventions targeting at-risk young people in developing countries, in order to achieve the global goals on preventing the spread of HIV. Prior to reviewing the evidence, it was necessary to establish whether young people were actually an important proportion of the group most at risk of becoming infected. Our findings support the conclusions of Monasch and Mahy in chapter 2 that young people make up a significant proportion of the population most at risk from HIV. In addition, data indicate that younger injecting drug users, sex workers and men who have sex with men may be particularly vulnerable.
However, little is known about the specific needs of young people in these groups as opposed to older people. This issue needs to be emphasized in future research, given the fact that a large number of the people most at risk are young, and it will be important to ensure that their needs are adequately met by any programmes that are implemented.
As anticipated, few studies were identified that explicitly focused on at-risk young people in developing countries. However, the fact that so few studies were identified in either the published or the grey literature was surprising in view of the evidence from other areas of programming that young people require specific attention from policies and programmes, and that they may be particularly vulnerable and have specific needs.
Not only was it difficult to identify relevant studies, but those that were identified often did not provide adequate information to allow for comparison among studies or assessments of the studies themselves. In general, studies did not provide sufficient details about the interventions, did not clearly define or measure expected outcomes, lacked information about the impact of the interventions and failed to provide adequate pre-test and post-test evaluations or control groups. Given that young people are at the centre of the epidemic in many developing countries, the lack of well evaluated interventions targeting them is a cause for concern.
Despite the comprehensive strategy used to identify relevant studies for this review, it is possible that studies may have been missed, for example if they were reported only in conference abstracts or in internal programme reports or other project documents. Furthermore, it must be recognized that conducting research with these groups is challenging. Not only do many interventions not consider the specific needs of young people but data collected by studies are often not disaggregated by age. Additionally, researching and evaluating interventions for such marginalized groups may be difficult for both methodological and ethical reasons.
In this review, we did not attempt to identify or analyse studies conducted among the general population of people most at risk and that did not disaggregate data by age with the same systematic rigour that had been used for studies of interventions targeting young people. However, the studies we reviewed provide consistently supportive evidence for the effectiveness of interventions targeting at-risk populations in developing countries in terms of changing knowledge and reported behaviours and even biological outcomes, such as reducing the prevalence of STIs.
Because of the lack of studies, this review did not really benefit from the overall methodology that had been developed for chapters in this series. In addition, while the typology is likely to have some resonance with programme development and delivery staff, it is questionable whether these groups are sufficiently similar enough to warrant being combined, even if there is sometimes overlap between them. It is therefore unrealistic to draw strong conclusions from Table 9.5.
However, as indicated in Table 9.6, this does not mean that we do not have evidence from which to recommend action. What it demonstrates is the need to see the evidence for young people in developing countries within the wider context of evidence for the effectiveness of interventions in developing countries that have been directed at adults and young people (where the data are not disaggregated by age). When the evidence for effectiveness among young people in developing countries is combined with the evidence for general at-risk populations in developing countries and the data from young people in developed countries, it becomes reasonable to move type 4 interventions from "Steady" to "Ready" or even to "Go". The studies that focused on young people in developed countries additionally demonstrate that good research on at-risk young people is possible.
Young people who are at the centre of concentrated epidemics require interventions urgently. Such interventions should be based on good practice (5) and should include facility and outreach components as well as a focus on information and services (Box 9.1); thus, they should be type 4 interventions. However, in recommending the widespread implementation of such interventions it is important to include the caveat that they also should be carefully planned, monitored and evaluated and that an operations research component should be included to provide a better understanding of the mechanisms of action and the interactions between different parts of each intervention.
Recommendations on the strength of the evidence for effectiveness by intervention type
1. Information only provided through outreach
Target group needs to be identified Steady and reached with the information
> This type of intervention is used widely and aims at improving information and skills
> No thorough evaluations have been found
> It is questionable whether educational activities alone can be successful in changing risk behaviour among vulnerable groups without including services that provide condoms, STIa treatment and harm-reduction interventions
2. Information and No study met the inclusion criteria None • No intervention of this type was reviewed in a study that met the services provided inclusion criteria through outreach
3. Facility-based Target group must know about and Steady • All UNGASS goals are addressed by this intervention type: information and want to use the facility, which must information, skills and services are provided in an attempt to services be accessible and provide a decrease risk and ultimately HIV prevalence confidential service • Possible stigmatization must be overcome if the facility-based approach is to work • The one study cited primarily provides safe places for young people most at risk of HIV, but it does not include specific services aimed at reducing HIV transmission (for example needle exchange)
4. Outreach and Good integration of services in facility-based outreach and facility-based activities information and necessary services Information about services must be consistent
All members of target group must have equal access to the intervention
Readyb • All UNGASS goals are addressed by this intervention type: information, skills and services are provided in an attempt to decrease risk and ultimately HIV prevalence
• The outreach component is a crucial aspect, helping to inform the target group about facility-based services
• Both studies in this category were successful in increasing knowledge, improving service utilization and reducing prevalence STIs
' STI = sexually transmitted infection.11 When taking the evidence from adult programmes in developing countries into account.
Recommendations for interventions targeting young people most at risk
• Specific attention needs to be given to young people who are most at risk from HIV, including young injecting drug users, sex workers and men who have sex with men.
• Urgent action must be taken if these young people are to benefit from strategies to meet the global goals on HIV/AIDS and the Millennium Development Goal on AIDS.
• Interventions should be widely implemented for these groups of young people and more emphasis needs to be placed on identifying the specific needs of young people compared with those of adults.
• Interventions should include strong monitoring and evaluation components (an important message for donors as well).
• Interventions to mitigate the vulnerability of young people need to be seen within the broader context of structural interventions being made to decrease their vulnerability.
• When developing interventions for sex workers, injecting drug users, men who have sex with men and other groups at high risk from HIV, it is important to ensure that the specific needs of young people are given adequate attention and that data are disaggregated by age and sex.
• If the global goals on HIV and young people are to be achieved, at-risk young people will need to receive information, skills and services through facilities and outreach strategies.
• Practitioners working with at-risk young people should monitor their interventions and collaborate more closely with researchers from the initial stages of project design in order to better assess the impact of their programmes.
• There is an urgent need to strengthen the evaluation component of interventions for young people most at risk, in order to determine the impact of the intervention and the mechanisms of action.
• There is also a need to be clear about key indicators for monitoring and evaluating programmes to achieve the global goals on HIV among at-risk young people.
• More research is needed to identify the special needs of young people most at risk, compared with the needs of at-risk adults.
Planning, monitoring and evaluating interventions will not only ensure that the evidence base for their effectiveness will be strengthened but it will also contribute to the collective ability to track the achievement of the global goals on HIV among these groups of at-risk young people.
Finally, it needs to be emphasized that stopping the spread of HIV among at-risk young people will depend on interventions that decrease their vulnerability to HIV not those that merely mitigate this vulnerability. Such interventions were beyond the scope of this review, although several studies that attempted to do this were identified (65, 66, 67). Unfortunately their impact is often difficult to assess.
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