The World Health Organization estimates that more than 30% of all new seroconversions are among 15 to 25 year olds. Young women are at even greater risk: Their rate of HIV acquisition is 60% higher than that of young men, explained Heather Ingold, M.P.H., of Unitaid at the "Reaching Young People Where They Are" satellite symposium during the recent 10th International AIDS Society Conference on HIV Science. One way to stem this tide is to provide teenagers and young adults with access to pre-exposure prophylaxis (PrEP).
Maeve B. Mello, Ph.D., of the Pan American Health Organization suggested at the symposium that programs used to popularize oral contraception among young people could be adapted for biomedical HIV prevention. However, people younger than 18 years may need a parent's permission to access HIV testing or other sexual health care, and in some countries, providers are required to report to parents if a teen is sexually active, she noted. Financial considerations -- for example, in the U.S., where medications are not free -- can impede adherence among those without an income of their own. She recommended that PrEP be integrated into other services geared toward youth to make it more accessible.
A youth-led approach to popularizing PrEP was presented by Elmari Briedenhann and Letitia Rambally Greener, M.S.Sc., of Wits Reproductive Health and HIV Institute (Wits RHI) in South Africa and Laio Magno, Dr.P.H., of Universidade do Estado da Bahia in Brazil. Their Project PrEP includes not only fun, sexy online and offline activities, but also giveaway items, such as a scarf/balaclava, and a mascot, PrEPPO, as well as a mobile PrEP support app and the world's first transgender chatbot, Amanda Selfie. The app includes a gamification feature, and the chatbot answers questions in a nonjudgmental, slightly slangy tone. "We need to make PrEP famous," Elmari Briedenhann concluded in their presentation.
Amanda Selfie is based on artificial intelligence and uses the Facebook Messenger platform, explained Maria Inês Costa Dourado, M.D., Ph.D., of Universidade Federal da Bahia, Brazil. Amanda has their own Facebook page, as well as a Twitter handle. The profile "picture" makes it clear that they aren't human, and this is also emphasized in Amanda's own introduction. Thus, everyone knows that they are communicating with a bot. Nonetheless, Amanda has appeared in person at youth venues, in the form of someone dressed as an Amanda Selfie mascot. Word about Amanda is also spread via digital influencers, Dourado said.
Saiqa Mullick, M.B.B.Ch., M.P.H., Ph.D., of Wits RHI, drew lessons from Project PrEP in South Africa. These include the need for a combination of HIV prevention strategies integrated into sexual and reproductive health services, especially for adolescent girls and young women who may also need services addressing gender-based violence or mental health issues. Confidence in using condoms correctly, as well as a menu of strategies for addressing barriers to adherence, must also be developed. Barriers include some teens' fear of a community member seeing them enter the clinic. "Get out of the clinic!" Mullick advised. Her project has a mobile unit that can serve as a one-stop shop for HIV prevention, contraception, and other sexual health services.
To engage young women in HIV prevention, you need to "start with what's important to them," Nina Hasen, Ph.D., of Population Services International, a U.S. organization working in southern Africa, among other locations, said during the "New Developments in Pediatric and Adolescent Care" panel at the conference. Motherhood is important to many young women, but they also want economic security, she explained. Her program frames sexual health services in this context: Using contraception now helps you establish economic stability before becoming a mother. One way to implement this approach is an intervention for young married couples that starts with a financial planning session before introducing health extension workers.
Undetectable Equals Untransmittable (U=U), the insight that people who are on effective ART and whose viral load is undetectable cannot pass on HIV sexually, is another way to keep adolescents from seroconverting, Lee Fairlie, M.B.Ch.B., D.C.H., M.Med., of Wits RHI noted during the panel. The U=U message can motivate youth to get tested and start and stay on treatment. However, young people must engage with this cascade in the first place, which requires youth-friendly services and changes to some health care workers' attitudes toward teen sex, Fairlie noted: "As a health care system, we fail our adolescents, and we fail them at different points."
To reduce seroconversions among adolescents and young people, we need to meet them where they are, have nonjudgmental providers deliver youth-friendly services -- not necessarily in clinics -- and come up with innovative ways for reaching this population, presenters agreed.