Studies focusing on young people most at risk in developing countries

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While there is a wealth of information from cross-sectional studies conducted among at-risk young people, there are few published evaluations of interventions targeting these groups in developing countries. No studies were found in peer-reviewed journals, and the 11 studies that were identified were all in programme reports or other grey literature. Three of these were from Africa, two from Asia and six were from Latin America. Target groups included sex workers (5 studies), men who have sex with men (1 study), injecting drug users (3 studies) and youths living on the street (2 studies). Unfortunately, only four ofthese studies met the inclusion criteria (Table 9.1). The studies that met the inclusion criteria came from Africa (1 study) and from Latin America (3 studies). One of the Latin American studies examined interventions directed to sex workers; one examined interventions targeted at men who have sex with men; and two examined interventions targeted at street youths.

9.3.2.1 Sex workers

Interventions targeting young sex workers were identified in Brazil, Ethiopia and Nicaragua (24). The Ethiopian programme, run by the Organisation for Social Services for AIDS, and the Brazilian "Sidewalk Girls" programme both used older peer educators who met with younger sex workers in an attempt to teach them how to reduce their risk of becoming infected. Unfortunately, no evaluations of these interventions were found. A second intervention by the Instituto Centroamericano de la Salud in Nicaragua provided all sex workers in Managua with vouchers that entitled them to receive a standardized package of free sexual and reproductive health treatment (study D) (24, 25). The project started in 1996 and for eight years afterwards distributed more than 30 000 vouchers and provided more than 12 000 consultations, during which a large number of STIs were treated among female sex workers (25). A substudy among 114 sex workers who also sniffed glue showed decreases in the prevalence of gonorrhoea (13.7% to 8.6%, not significant), syphilis (15.6% to 8.0%, not significant) and trichomoniasis (22.1% to 12.4%, P < 0.01) (24).

9.3.2.2 Injecting drug users

Interventions for young injecting drug users were identified in Argentina, India and Kenya (24). The Kenyan centre trained 54 volunteers in counselling and HIV prevention, and it provided counselling and detoxification services for 20 young injecting drug users. In Argentina, HIV testing, safer sex workshops and a drug users' network were provided; in India a drop-in centre provided counselling and HIV testing as well as support groups for more than

4 000 drug users. Unfortunately, none of these interventions provided evaluation data.

9.3.2.3 Men who have sex with men

Only one project was identified that specifically targeted men who have sex with men who were also sex workers. "El Salon" in Costa Rica provided a safe place in the form of a home at which young male sex workers could access counselling, education and support (study B) (24). The evaluation of the intervention showed an increased use of condoms and the formation of support groups among the target group (24).

9.3.2.4 Street youths

Evaluations of interventions targeting youths living on the street were also included because this group frequently becomes involved in sex work and drug use. Studies of interventions were identified in Brazil and Uganda (26, 27). In Uganda, services provided information and counselling and increased access to condoms (147 000 condoms distributed) and STI treatment (29 000 adolescents treated for STIs from April 2002 to March 2004). Unfortunately no denominators were available (study C) (26). In Brazil, the intervention aimed to increase knowledge about HIV prevention through the use of videos, comic books and drama groups (study A) (27). Cross-sectional surveys among 400 young people carried out before and after the interventions demonstrated significant changes, with the interventions resulting in increased levels of knowledge about HIV transmission and decreased levels of misconceptions about HIV/AIDS.

Table 9.3 summarizes the studies that met the inclusion criteria according to typology (whether the interventions were outreach-based and/or clinic-based and whether they included information and/or services). Only one project that met the inclusion criteria was identified as a type 1 intervention (providing only information through an outreach programme). No studies of type 2 interventions (information and services provided through an outreach programme) had sufficient details on either the content or the evaluation. For interventions based only in facilities, (type 3 interventions), one programme for male sex workers was identified. Two studies of type 4 interventions were identified; these provided facility-based services as well as outreach activities. One worked with street children and sex workers and the other worked only with sex workers.

Table 9.3, Table 9.4 and Table 9.5 include studies focusing on the main target group of this review, namely young people in developing countries who are most at risk of becoming infected with HIV. Table 9.4 describes the evaluation designs for each of the studies, and Table 9.5 summarizes the studies according to the level of evidence of effectiveness that could be derived from the studies.

Table 9.3

Description of the interventions by study

Study and location Target population and primary objectives Description

Intervention type 1 (information only provided through outreach programme)

> Primary objectives: to prevent HIV/AIDS transmission in the target group

> Target groups: Young women vulnerable to sexual violence, youths living on the street

Intervention type 2

No study met the inclusion criteria Intervention type 3

• Multicomponent programme consisting of education about sexuality and HIV/AIDS; training in HIV/AIDS prevention skills; sensitization of educators and institutional directors to the need to support vulnerable youths

•After formative research, educators were trained with a manual and through meetings. The intervention produced a video and a comic book that were distributed among the target group and staged group discussions, role-plays and theatre activities. Sessions were conducted in 10 institutional settings and 125 outreach activities were implemented

• Scale of project: information not available (information and services provided through an outreach programme)

(facility-based information and services)

• Primary objective: not stated

• Target groups: young people involved in sex work, injecting drug use and/or young male sex workers living on the street

1 Multicomponent programme consisting of a safe place to spend time off the streets in project house and education about HIV/AIDS prevention

1 Counselling and support provided for alcohol-related and drug-related problems

1 This intervention started with a thorough situation analysis

1 Emphasis placed on creating a safe space for vulnerable youths

• Approach is confined to the locality of the centre

• Scale of project: 1 house Intervention type 4 (facility-based information and services with an outreach component)

> Primary objective: to reduce prevalence of STIsa and HIV among vulnerable youths; to increase access to youth-friendly health services

'Target groups: children and adolescents living on the streets and sex workers

1 Primary objective: to provide STI services for young female sex workers > Target groups: All sex workers and their clients

> Multicomponent programme consisting of drop-in health centres and mobile clinics for youth for treatment and counselling and testing; training of peer providers for socially marketed contraceptives and STI kits; training of health-care providers in youth-friendly services; close involvement of community leaders

> After determining the size of the target group and informing community leaders about the programme, 5 youth-friendly drop-in clinics and 17 mobile clinic outreach posts were opened around Kampala

> 100 peer providers were trained to distribute socially marketed condoms and STI kits

> Drama and film shows provided information to the target group

> Scale of intervention: throughout capital city

> Not a multicomponent intervention

> Treatment vouchers distributed to be used at various health-care providers (public, nongovernmental and private sector)

> Providers contracted on a competitive basis

> Each voucher provided treatment for STIs, safe sex counselling and educational material

> Target group involved in designing treatment vouchers and accompanying handbooks that were distributed among female sex workers, their clients and young people who sniffed glue

> Service providers were given an updated STI treatment plan and introduced to the programme

> Scale of intervention: throughout capital city a STIs = sexually transmitted infections.

Table 9.4

Description of outcome evaluations by study

Study Design and sample size

Evaluation results

Strength of evidence for effect

Intervention type 1 (information provided only through outreach programme)

A (27) Design: pre-test and post-test "Significant" changes both in increased levels of evaluation; no comparison group knowledge about HIV transmission as well as in

Sample size: random sample of 400 youths decreased levels of misconceptions interviewed 10 months apart Intervention type 2 (information and services provided through an outreach programme) No study met the inclusion criteria

Intervention type 3 (facility-based information and services)

B (24) Design: pre-intervention and post- • Increase in reported use of condoms among intervention evaluation male sex workers

• Increase in number of support groups Intervention type 4 (facility-based information and services with an outreach component)

C (26) Design: service utilization statistics

D (24, 25) Design: pre-test and post-test evaluation in a subsample of target population (females who sniff glue)

• 29 564 treatments provided in VA years at

6 369 drop-in centres and 23 195 outreach sites

• 1 291 referrals (mainly for blood tests for sexually transmitted infections)

• 215 counselling sessions plus testing provided

• 21 664 young people received condoms (10 079 females and 11 585 males)

• 15 000 vouchers distributed in 8 years, 40% leading to medical consultations

• Gonorrhoea prevalence reduced from 13.7% to 8.6%

• Syphilis prevalence reduced from 15.6% to 8.0%

• Trichomoniasis prevalence reduced from 22.1% to 12%

Weak

Limitations: tests for statistical significance not available

None Weak

Limitations: no comparison group; no denominator

Weak

Limitations: no denominators provided

Weak

Limitations: no comparison group

Table 9.5

Strength of evidence of effectiveness for each intervention type

Intervention type and study design

Positive effect

No significant effect

Negative effect

Evidence

Statistically Statistical significant significance not known

Type 1 (information only provided through outreach)

(1 evaluation)

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