SAFEGUARDING THE FUTURE: GIVING PRIORITY TO THE NEEDS OF ADOLESCENT AND YOUNG MOTHERS LIVING WITH HIV DECEMBER 2021 TECHNICAL BRIEF HIV SERVICE DELIVERY
SAFEGUARDING THE FUTURE: GIVING PRIORITY TO THE NEEDS OF ADOLESCENT AND YOUNG MOTHERS LIVING WITH HIV Safeguarding the future: giving priority to the needs of adolescent and young mothers living with HIV ISBN (WHO) 978-92-4-003989-6 (electronic version) ISBN (WHO) 978-92-4-003990-2 (print version) © World Health Organization and the United Nations Children’s Fund (UNICEF), 2021 This joint report reflects the activities of the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. 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Design and layout by ACW Cover image: © UNICEF Malawi iii Acknowledgements ............................................................................................................................................... iv Background .................................................................................................................................................................. 1 A call to action ........................................................................................................................................................... 2 Giving priority to services for adolescent and young mothers living with HIV .............. 3 The time to act is now ...........................................................................................................................................15 References ..................................................................................................................................................................16 CONTENTS iv Safeguarding the future: giving priority to the needs of adolescent and young mothers living with HIV ACKNOWLEDGEMENTS This technical brief is the result of collaborative work between the Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, WHO and the Eastern and Southern Africa Regional Office, UNICEF. The development of this brief was coordinated by Wole Ameyan, Global HIV, Hepatitis and Sexually Transmitted Infections Programmes WHO and Alice Armstrong, UNICEF Eastern and Southern Africa under the guidance of Rachel Baggaley and Marco Vitoria and overall leadership of Meg Doherty, Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, WHO. Judith Sherman, Consultant, UNICEF wrote the manuscript. WHO and UNICEF thank the following for their expertise, inputs and feedback: Elise Akwara (Consultant, WHO, Kenya), Cathrien Alons (Elizabeth Glaser Pediatric AIDS Foundation, USA), Venkatraman Chandra-Mouli (WHO Switzerland), Lastone Chitembo (WHO Zambia), Lucie Cluver (University of Cape Town, South Africa), Carrie Cox (Baylor College of Medicine Children’s Foundation, Malawi), Augustina Delaney (United States Centers for Disease Control and Prevention, USA), Alison Groves (Drexel University, USA), Laurie Gulaid (UNICEF, Kenya), Luann Hatane (Paediatric-Adolescent Treatment Africa, South Africa), Christina Laurenzi (Stellenbosch University), Christine Kisia (WHO Kenya), Nomthandazo Lukhele (WHO Eswatini), Frank Lule (WHO Regional Office for Africa), Thithili Makhesi (Baylor College of Medicine Children’s Foundation, Lesotho), Otty Mhlongo (Health Department, KwaZulu-Natal, South Africa), Lynne Mofenson (Elizabeth Glaser Pediatric AIDS Foundation, USA), Busisiwe Msimanga-Radebe (WHO South Africa), Eve Mtetwa (Africaid Zvandiri, Zimbabwe), Lynette Mudekenye (Regional Psychosocial Support Initiative, South Africa) Morkor Newman (Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, WHO), Ishmael Nyasulu (WHO Malawi), Phoebe Nyasulu (Baylor College of Medicine Children’s Foundation, Malawi), Martina Penazzato (Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, WHO), Natella Rakhmanina (Elizabeth Glaser Pediatric AIDS Foundation, USA), Agnes Ronan (Paediatric-Adolescent Treatment Africa, South Africa), Lineo Thahane (Baylor College of Medicine Children’s Foundation, Lesotho), and Elona Toska (University of Cape Town, South Africa). The following members of the WHO adolescent HIV service delivery working group (ASDWG), adolescent and young people representatives and organisations made available their expertise in structuring the document, providing information, feedback and external review: Nadia A. Sam-Agudu (Institute of Human Virology, Nigeria), Cindy Amaiza (Young People Living with HIV Y+, Kenya) Ruby Fayorsey (ICAP, Columbia University, USA), Jane Ferguson (Independent Consultant, Switzerland), Susan Hrapcak (United States Centers for Disease Control and Prevention, USA), Peggy Kuchocha (Africaid Zvandiri, Zimbabwe), Eleanor Namusoke Magongo (Ministry of Health, Uganda), Daniella Mark (Paediatric AIDS Treatment for Africa, South Africa), Immaculate Mutisya (Centers for Disease Control and Prevention, Kenya), Helena Nangombe (Young Women Empowerment Network, Namibia), Diane Nguyen (Baylor College of Medicine International Pediatrics AIDS Initiative, USA), Kathrin Schmitz (Mothers to Mothers, South Africa), Teresa Steffy (Baylor College of Medicine Children’s Foundation, Lesotho), Denis Tindyebwa (African Network for Care of Children Affected by HIV/AIDS, Uganda), Damilola Walker (UNICEF, USA), Christine Wambugu (Ministry of Health, Kenya), Brian White (Elizabeth Glaser Pediatric AIDS Foundation, USA), Nicola Willis (Africaid Zvandiri, Zimbabwe). 1BACKGROUND Adolescent girls and young women (15-24 years old) represent one in five of the adults acquiring HIV globally and 30% of the people acquiring HIV in sub-Saharan Africa. Globally, an estimated 260 000 adolescent girls and young women acquired HIV in 2020, with sub-Saharan Africa representing 85% of the people acquiring HIV in that age group (1). According to UNAIDS 2021 epidemiological estimates, about 300 000 adolescent girls and young women living with HIV became pregnant in 2020 in sub-Saharan Africa. Adolescent and young mothers are disproportionately represented among the people acquiring HIV. Although 26% of pregnant women living with HIV were 15-24 years old, 42% of the pregnant and breastfeeding women acquiring HIV were in this age group (2,3). Adolescent and young mothers (pregnant and parenting women 15-24 years old) living with HIV risk falling between the cracks of primarily adult-oriented maternal care and the prevention of mother-to-child-transmission of HIV. They require targeted services and support to prevent maternal and newborn illness and mortality and enjoy good health and well-being. Although some adolescent pregnancies are planned, at least half are unintended, reflecting a high unmet need for effective contraception (4). Adolescent girls 15-19 years old have higher rates of pregnancy and childbirth complications than women 20-24 years old (4,5), and maternal conditions are the leading cause of death among adolescent girls 15-19 years old globally. Infants born to adolescent and young mothers are at increased risk of dying in their first month of life, especially when born to young women who have experienced multiple births (6). Adolescent and young mothers are more likely to have a repeat pregnancy within a year of giving birth, placing both themselves and their children at risk for negative health outcomes (7). Adolescent pregnancy also has implications for the mother’s mental health outcomes, and poor maternal health is, in turn, a risk marker for the development of the child (8). Many adolescent and young mothers, especially those who are unmarried, are vulnerable to the negative social and economic effects of early pregnancy, including stigma, rejection, violence, inadequate social support and reduced educational and economic opportunities (9,10). Having HIV adds another layer of complexity. Adolescent and young mothers living with HIV have multi-layered issues to manage, including pregnancy, childbirth and parenting, alongside lifelong antiretroviral therapy (ART), preventing HIV transmission to their infant, potentially caring for a child with HIV, mental health challenges and often HIV- associated stigma and discrimination (11). Adolescent and young women may attend antenatal care but often only late in their pregnancies and for fewer than the WHO-recommended number of 4-8 minimum visits (12). In addition, they are often unable to access the specialized, adolescent-friendly care that is vital to their continued engagement in maternal services, including postnatal care (12,13). Limited antenatal care and postnatal care attendance represent missed opportunities to receive testing and treatment services for HIV and other sexually transmitted infections, alongside contraceptives and other support essential for maternal and child health. ©UNICEF Lesotho 2 Safeguarding the future: giving priority to the needs of adolescent and young mothers living with HIV A CALL TO ACTION Global recognition has increased in recent years that early motherhood and HIV are inextricably linked to the overall health and broader well-being of adolescent girls and young women. The Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-2030) (17) aims to achieve “a world in which every woman, child and adolescent realizes their rights to physical and mental health and well- being, has social and economic opportunities, and is able to participate fully in shaping prosperous and sustainable societies.” The Global Accelerated Action for the Health of Adolescents translates the Global Strategy into action by offering guidance for country implementation. The Global AIDS Strategy 2021-2026: End Inequalities, End AIDS calls for “tailored, integrated and differentiated vertical transmission and paediatric service delivery for women and children, particularly for adolescent girls and young women in locations with high HIV incidence”(18). The Strategy proposes new targets, including ensuring that 95% of women of reproductive age have their HIV and sexual and reproductive health service needs met. These achievable goals will not be reached without giving priority to and investing in health, social protection and education, including for adolescent and young mothers living with HIV. The learning session (19) convened by WHO and the CCABA in 2019 in Geneva, Switzerland brought together global, country and community stakeholders from the HIV, sexual and reproductive health, early childhood development, poverty reduction, human rights, sexual and gender-based violence and mental health sectors. The learning session identified gaps and consolidated key scientific and programmatic evidence on the scale and nature of the needs of adolescent and young mothers living with HIV and their children and proven solutions to addressing them. There have been tremendous efforts to reduce the number of children acquiring HIV. Nevertheless, in 2015, 190 000 children 0-14 years old acquired HIV by vertical transmission worldwide. Available evidence indicates that adolescent and young mothers living with HIV and their infants have lower uptake and higher attrition of services to prevent the mother-to-child transmission of HIV, including delayed treatment initiation, especially before conception, and lower retention of mother-infant pairs, contributing to higher rates of mother-to-child transmission of HIV versus adult pregnant and breastfeeding women living with HIV (14). Although some adolescent and young mothers may already know their HIV status and be receiving treatment, others first learn of their HIV status at antenatal care when confirming their pregnancy, increasing the risk of vertical transmission during pregnancy. HIV infection during pregnancy or breastfeeding reflects the gap in HIV prevention for adolescent girls and young women and results in a heightened risk of mother-to- child transmission of HIV (15). Population-based surveys in several countries in sub-Saharan Africa indicate that adolescent girls and young women living with HIV have lower rates of suppression of viral loads than women 25 years and older (16), increasing the risk of poor maternal health and horizontal and vertical transmission. Low rates of suppression of viral loads also suggest that receiving ART might not be enough—adolescent girls and young women living with HIV require additional care and support to ensure adherence to treatment and retention in care. In 2019, WHO and Coalition for Children Affected by AIDS (CCABA) convened a learning session of scientific and programmatic experts to consolidate the evidence on why HIV-affected adolescent mothers and their children are being left behind and to deliberate on the multiple-level changes needed to improve their outcomes. This technical brief is a follow on from that learning session and will be useful to HIV programme managers in health ministries and other adolescent- and youth-linked line ministries, especially those in in sub-Saharan Africa, in implementing, monitoring and evaluating adolescent and youth-responsive and -friendly health services for young mothers living with HIV. The publication will also be a valuable resource for healthcare workers and will assist international organizations, nongovernmental organizations and other implementing partners in better contextualizing, planning and delivering youth friendly health services for young mothers living with HIV. It begins with a call to action with alignment to key global maternal, adolescent and child strategic documents, identifies key strategic actions with implementation case examples from available models, and ends with some key multi-sectoral actions with alignment from the learning session. ©Africaid Zvandiri 3GIVING PRIORITY TO SERVICES FOR ADOLESCENT AND YOUNG MOTHERS LIVING WITH HIV A central task of the learning session was to develop this technical brief to inform global dialogue and accelerate action on giving priority to services and support for adolescent and young mothers living with HIV (19). The following strategic actions (Figure 1) reflect current learning and provide examples from programmes across sub-Saharan Africa that demonstrate how governments, health facilities, social services, communities, families and adolescent and young mothers are working together to bridge the gap between adolescent- and adult-focused HIV and maternal health services. Whilst outcome data are not as robust in general, the programme examples provided here serve to highlight potential and ongoing lessons in countries. Fig. 1.4. Key strategic actions for improving services for young mothers living with HIV 1. INTEGRATE Integrate adolescent-friendly health services for adolescent and young mothers to improve the quality of life 2. STRENGTHEN Strengthen adolescent-responsive prevention of mother-to-child transmission of HIV, sexual and reproductive health and maternal and child health services with adolescent and young mothers living with HIV at the centre of their own care 3. PROTECT Protect the right to education among adolescent mothers living with HIV 4. ENGAGE Engage the sexual partners of adolescent and young mothers living with HIV 5. ESTABLISH Establish familial and social support networks 6. PROVIDE Provide screening, referral and support for shared vulnerabilities 7. ADDRESS Address social, economic and legal barriers to accessing health and social services STRATEGIC ACTIONS 4 Safeguarding the future: giving priority to the needs of adolescent and young mothers living with HIV STRATEGIC ACTION 1. INTEGRATE ADOLESCENT-FRIENDLY HEALTH SERVICES FOR ADOLESCENT AND YOUNG MOTHERS TO IMPROVE THE QUALITY OF LIFE Sexual and reproductive health rights encompass physical, mental and social well-being as they relate to the reproductive function (20). For adolescent and young mothers living with HIV, this means having a fulfilling sex life, control over fertility decisions and access to safe and respectful maternal and newborn care. However, to achieve their sexual and reproductive health rights, adolescent and young mothers living with HIV must navigate multiple services, including sexual and reproductive health, maternal, newborn and child health, nutrition and HIV care and treatment. Fragmented health services contribute to the likelihood that adolescent and young mothers living with HIV will fail to access all the services they need. Integrating sexual and reproductive health and HIV with other services creates a higher potential that adolescent and young mothers living with HIV will receive comprehensive care and support. Integrating services may not mean offering all services in one place by a single provider, but it does mean that adolescent and young mothers living with HIV know what services are available to them, where they are located and how much they cost. Facilities need sufficient commodities, health-care provider capacity and clear guidelines for referrals and links to appropriate services. Including community health workers and peer supporters in service delivery can help lessen the burden of care on health-care providers. Peer supporters, for example, are well positioned to work alongside health-care providers and share information, provide screening and follow-up referrals and accompany adolescent and young mothers on their visits. Although there are several models of integrated services, at minimum, adolescent and young mothers living with HIV require a person-centred, differentiated plan that eases their navigation within and between facilities, links them to community resources and helps them feel confident in interacting with different service providers. Three areas of integration with HIV care stand out for adolescent and young mothers: sexual and reproductive health (including screening for and treating sexually transmitted infections and providing contraceptives), mental health and early childhood development. WHO guidance highlights integrating sexually transmitted infection and contraceptive services within HIV care settings (21) and providing contraceptive services within HIV treatment programmes (22). Studies have indicated that integrated contraceptive service delivery is both cost-effective and improves the uptake of modern contraceptive methods (23). HIV services should offer contraception, including dual protection, and screening for sexually transmitted infections and cervical cancer, while contraceptive services should offer HIV and sexually transmitted infection testing, ART referrals and adherence counselling. Both HIV and sexual and reproductive health services should provide screening and referral for sexual and gender-based violence and mental health. ©REPSSI 5The Baylor International Pediatric AIDS Initiative provides support throughout sub-Saharan Africa to children and adolescents living with HIV, including adolescent and young mothers. In Malawi, health-care providers have been trained on providing integrated HIV and sexual and reproductive health services during young motherhood clinics, while peer supporters (adolescent and young women living with HIV) are providing adolescent and young mothers at antenatal care and postnatal care clinics with health education, information on HIV testing and partner testing, HIV prevention and treatment and sexual and gender-based violence awareness and services. The peer supporters also assist adolescent and young mothers living with HIV with access to ART and viral load testing during antenatal care and postnatal care days, support clients with adherence and retention and flag clients’ specific challenges to the clinical team. Despite good progress, the impact of COVID-19 on services is noted. As of August 2021, among 84 adolescent and young mothers reached with integrated services and peer support, ART adherence was 62%, a decline from 78% in September 2019. The percentage of HIV-exposed infants with a negative dried blood spot result also decreased, from a high of 98% to 75%. Baylor has noted the challenges of following up mothers during the COVID-19 pandemic, especially in hard-to-reach areas with limited mobile phone and internet connectivity. Uptake of modern contraceptive methods, in contrast, increased from September 2019 to August 2021 from 43% to 63% (24). Adolescent and young mothers are at increased risk of mental health challenges (25), including those related to HIV (26,27). Current intervention strategies are wide- ranging, encompassing support for HIV status disclosure, peer-led group sessions and support, use of lay counsellors, problem-solving therapy, economic empowerment and family strengthening (28). Integrating mental health interventions and referrals into HIV and/or maternal care settings may increase the likelihood that adolescent and young mothers living with HIV will experience increased adherence to treatment and remain in care. Given the nascent nature of integration, conducting implementation research for these interventions is necessary to identify the most promising practices. Paediatric-Adolescent Treatment Africa’s Ask-Boost-Connect-Discuss programme (29), currently being implemented in Kenya, Malawi, Uganda, United Republic of Tanzania and Zambia, is a mobile tool designed to improve mental health among adolescent and young mothers living with HIV. The easy-to-use app, used by trained peer supporters (young people living with HIV), draws on WHO’s Thinking healthy manual (30) and includes psychosocial support modules that are used in group sessions with young mothers. It also contains supplementary resources about HIV, early childhood development and help-seeking. The initial pilot in four countries with 147 young mothers found that integrating this tool into existing adolescent health services expanded reach and coverage of mental health support. Health-care workers reported improved knowledge and skills in identifying and referring common mental health concerns and increased adherence and retention among adolescent and young mothers (29). Early childhood development refers to the first three years of a child’s life, a critical time for a child’s health and development (31). Although the benefits of integrating early childhood development into HIV clinical care and parenting programmes are clear, numerous challenges remain (32). Few programmes have explicitly included adolescent and young mothers living with HIV, yet they are likely to need support to fulfil all the components of early childhood development, such as providing good nutrition, a secure home environment, responsive caregiving and opportunities for early learning, alongside those that are specific to HIV, such as administering antiviral prophylaxis to their children to prevent HIV, following safer infant feeding practices, seeking HIV testing for early infant diagnosis, and in the case of having children living with HIV, further support to ensure ART adherence. Health facility and community-based services, such as maternal and child health and HIV settings, are an opportunity to provide adolescent and young mothers living with HIV with knowledge and skills for early childhood development and access to early childhood development centres (33). ©UNICEF Lesotho 6 Safeguarding the future: giving priority to the needs of adolescent and young mothers living with HIV The Regional Psychosocial Support Initiatives (REPSSI) provide holistic psychosocial care and support for children and adolescents in 13 countries in sub-Saharan Africa. From 2017 to 2019, on behalf of the Government of Zimbabwe, REPSSI responded to the acute needs of adolescent and young mothers, including those living with HIV, in 24 districts. REPSSI established a peer mentor mother and peer mentor father programme and facilitated collaboration with social workers, health-care providers, village health workers and community childcare workers to coordinate support for HIV services, infant and young child feeding, nutrition, water, sanitation and hygiene and child protection. Reached through antenatal care, postnatal care and maternity waiting homes, adolescent and young mothers and fathers were supported with training in positive parenting and counselling on healthy relationships. At the end of 18 months, 1083 health-care providers in 337 health facilities and 2962 village health workers and community childcare workers had improved skills in integrating early childhood development into their work; 118 district stakeholders were trained as master trainers for early childhood development; 28 581 adolescent and young mothers were reached with holistic care and support; 14249 adolescent and young mothers participated in 839 peer support groups; and 9233 children received child protection services (34). ©Africaid Zvandiri 7STRATEGIC ACTION 2. STRENGTHEN ADOLESCENT-RESPONSIVE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV, SEXUAL AND REPRODUCTIVE HEALTH AND MATERNAL AND CHILD HEALTH SERVICES WITH ADOLESCENT AND YOUNG MOTHERS LIVING WITH HIV AT THE CENTRE OF THEIR OWN CARE Most HIV and sexual and reproductive health programmes for adolescent girls focus on preventing pregnancy and HIV, rather than on their sexuality, fertility preferences and desire for relationships (11). Respecting sexual and reproductive health rights requires changing the discourse from equating pregnancy and HIV with failure to understanding and responding to adolescent and young women’s goals, aspirations, and wants. Qualitative research indicates that unplanned does not always equal unwanted; adolescent and young mothers living with HIV want to have children (35). However, they require conception support and contraceptive methods, especially dual protection, that will help them control the timing of pregnancy, are appropriate to their circumstances and will minimize the risk of mother-to- child HIV transmission. Adopting a positive approach to conception, improving health-care providers’ knowledge and skills to provide evidence-informed, confidential services and establishing supportive guidelines, such as promoting birth companionship, may increase the likelihood that adolescent and young mothers living with HIV will fully engage in sexual and reproductive health, maternity and prevention of mother-to-child transmission of HIV services. The WHO recommends integrating ART into maternal and child health services, pointing to evidence of improved uptake of and adherence to ART, reduced HIV-related stigma, better client experiences and increased efficiency (36). Although integration has increased, in many instances, neither antenatal care, postnatal care nor ART services are responsive to the various needs of adolescent and young mothers. For example, some women have been recently diagnosed with HIV and need special support to safely disclose their HIV status to their partner and family and to develop an ART adherence plan. Other adolescent and young mothers who are already receiving ART may be engaged in peer support that is essential to maintain despite transitioning to a different service delivery point. ART services can feel especially stigmatizing to adolescent and young mothers who are already self-conscious about early motherhood and being diagnosed with HIV. The timing of referrals from prevention of mother-to-child transmission of HIV to adult ART clinics needs to be flexible, so maternal and child health settings can support adolescent and young mothers’ readiness and prepare them for transition to chronic HIV care settings. ©m2m. Mentor Mother Christine Wandawa Bugweri Busesa Health Center 8 Safeguarding the future: giving priority to the needs of adolescent and young mothers living with HIV In South Africa, mothers2mothers (38) recruited mentor mothers (women living with HIV who have experience with preventing the mother-to-child transmission of HIV) in KwaZulu-Natal. In 2021, m2m’s mentor mothers reached 25 288 adolescent and young mothers in 61 health facilities with a comprehensive package of support, including health education, psychosocial support, screening and referrals for sexually transmitted infections, TB, sexual and gender-based violence and mental health, couples counselling and support groups. A total of 98% of adolescent and young mothers were tested for HIV; of those testing positive, 98% initiated treatment. Following treatment initiation, the average viral suppression among enrolled mothers at six months was 95%, and ART retention at 12 months was 89%. The Department of Health has expanded the programme by hiring mentor mothers in Gauteng Province and employing community health workers and lay counsellors in four additional provinces. The national Department of Health has commissioned an evaluation of the project with support from UNICEF, with an aim to scale up throughout the country (39). Many countries are expanding differentiated HIV service delivery, recognizing that people have different needs at different times. Extending differentiated ART services to adolescent and young mothers is especially important for retaining them in lifelong care and treatment. Both flexibility and an understanding of their service delivery preferences are required. For example, some adolescent and young mothers might appreciate community-based ART services, limiting interactions to a single trusted provider, while others might prefer the anonymity of centralized, higher-volume facilities. In all cases, health-care providers require training, supervision and support to identify risks, provide responsive care and support and make referrals as needed. In addition to protecting women’s health, continuing care and treatment throughout pregnancy and breastfeeding is vital to reduce the probability of mother-to-child HIV transmission. This includes providing routine viral load testing and enhanced adherence counselling if necessary. WHO recommends that all mothers and newborns receive postnatal care within 24 hours of childbirth, regardless of where the birth occurs, and at least three additional postnatal care visits (37). Tailoring postnatal care visits for adolescent and young mothers living with HIV would include counselling for exclusive breastfeeding, infant care, ART adherence, administering prophylactic antiretroviral drugs to the infant to prevent HIV transmission, early infant diagnosis, contraceptives, including dual protection, and early childhood development. ©UNICEF Malawi 9Keeping girls in schools through the secondary level strengthens the likelihood that they will participate in the formal labour market and provide better health care and education for their children (40). However, the right to access education often disappears when girls become pregnant, since school policies are mostly punitive. At the least restrictive, policies compel girls to leave school until after childbirth; at worst, they deny adolescent mothers any return to school. After childbirth, adolescent mothers face numerous challenges to resume formal education, such as financial barriers, lack of childcare, social constraints and stigma. Pregnant adolescents leave school to “hide” their pregnancies from their peers and others (41). Although several countries have adopted more inclusive policies, entrenched social norms keep adolescent mothers away from education (42), making them less likely to find employment and more likely to fall into or remain in poverty. Adolescent mothers who remain enrolled in school need additional support, since they tend to have higher absenteeism and lower educational attainment than their peers (43). Supporting adolescent mothers living with HIV to remain in or return to school includes: flexible policies that enable girls to maintain school attendance both during pregnancy and after childbirth; sensitizing teachers to be supportive and address any stigma related to both motherhood and HIV; modifying rules about uniforms that restrict attendance; providing in-school counselling, social and financial support and a conducive environment for breastfeeding, especially for those who choose to return in the first six months (44), and improving access to childcare (45). If returning to school is not possible, adolescent mothers living with HIV need access to continuing education at venues and times that are convenient for them. STRATEGIC ACTION 3. PROTECT THE RIGHT TO EDUCATION AMONG ADOLESCENT MOTHERS LIVING WITH HIV As part of the pilot Mentoring Adolescent Mothers at School programme, supported by Drexel University, 68 adolescent mothers (14-19 years old) in South Africa attended group sessions led by mentor mothers (women 20-24 years old who had completed secondary education after having a child). Implemented throughout 2017-2018, the 10 sessions, offered biweekly between six weeks and six months postpartum, covered a range of topics, including the right to education, the benefits of staying in or returning to school, how to access available resources, increased information on HIV, sexual and reproductive health and sexual and gender-based violence, and psychosocial support. The young mothers reported that the sessions prepared them to return to school, provided useful parenting skills, and helped them to access the government’s child support grant. Mothers who attended one or more sessions were significantly more likely to return to school postpartum than those who attended zero intervention sessions (adjusted odds ratio: 3.4; 95% CI: 1.1, 10.8, P = 0.04) (46). ©UNICEF Malawi 10 Safeguarding the future: giving priority to the needs of adolescent and young mothers living with HIV STRATEGIC ACTION 4. ENGAGE THE SEXUAL PARTNERS OF ADOLESCENT AND YOUNG MOTHERS LIVING WITH HIV Male engagement in sexual and reproductive health and maternity services and in championing supportive fatherhood can enhance maternal health outcomes for women and children (47,48). Involving male partners in preventing the mother-to-child transmission of HIV has demonstrated improved maternal ART adherence and timely early infant diagnosis (49). However, scant attention has been paid to the sexual partners of adolescent and young mothers living with HIV. Programmes are using a range of approaches that support adolescent and young mothers in disclosing their HIV and pregnancy status to their male partners safely, including encouraging them to attend HIV testing and counselling, antenatal care and postnatal care. These visits are also an opportunity for education and counselling on pregnancy, childbirth, infant and young child feeding, contraceptives and early childhood development and to engage boys and men in improving their own health, including mental health. Since more than 50% of young men living with HIV in sub-Saharan Africa have unsuppressed viral loads (16), they require adherence counselling and support. If HIV negative, they would benefit from being offered pre-exposure prophylaxis (PrEP), condoms and voluntary medical male circumcision. In both cases, support can be given for young, first-time fathers’ psychosocial concerns, such as becoming a parent, providing childcare support, early cohabitation or marriage, leaving school and entering the workforce. Whether through facilities, communities or peers, promoting boys and men’s involvement as sexual partners and fathers can foster better couple communication and decision- making, ultimately contributing to healthier relationships. Nevertheless, some strategies that aim to promote male engagement can have unintended negative effects, especially for adolescent and young mothers who may not be in a supportive relationship (50). For example, antenatal care policies that give preference to pregnant women with partners or require women to obtain a waiver from a community leader may deter adolescents from attending. Engaging partners also becomes challenging when relationships are inequitable or violent. Adolescent girls and young women may be in fluid relationships, have multiple sexual partners or be engaged in transactional sex. Health, education, child and social protection services need to be tailored for adolescent and young mothers living with HIV and their children who live in a range of circumstances. The supportive role of health-care providers, families, peers and community members is essential to establishing an environment that does not tolerate abuse, exploitation or violence against women and girls and supports the safety of adolescent and young mothers and their children. ©m2m Mentor Mothers e-Services Girls4Change Programme 11 Operation Triple Zero (zero missed appointments, zero missed drugs, zero viral load) Plus clubs in Kenya, housed in antenatal care and postnatal care clinics, support adolescent and young mothers living with HIV with treatment literacy; education on sexual and reproductive health services and infant and young feeding; access to child welfare clinics; cervical cancer and sexual and gender-based violence screening and referrals; and links to child protection. The clubs also provide HIV testing for sexual partners and oral PrEP for those who test negative. Young fathers, regardless of their HIV status, have expressed that they enjoy being part of Operation Triple Zero Plus club activities (51). In Zambia, the Operation Triple Zero Plus (OTZ Plus) project which was adapted from Kenya aims to empower Adolescents Living with HIV (ALHIV) with information, skills and tools for better health outcomes i.e., zero viral load, zero mother-to-child transmission (MTCT) among pregnant and breastfeeding adolescent girls, and zero teen pregnancies. The OTZ Plus Project’s objective is to recruit ALHIV from within the Ministry of Health facilities into OTZ clubs and deliver a HIV literacy package to enhance their ability to participate in the management of their own health for better results. In addition to the OTZ clubs, the project also provides a mobile application (OTZ App), providing a platform where adolescents can obtain quick information on HIV, Sexual and Reproductive Health Rights, chat with a counsellor, and other topics of interest such as healthy diet plans, job opportunities and internships, training opportunities, quizzes, and entertainment updates (52). ©UNICEF Lesotho 12 Safeguarding the future: giving priority to the needs of adolescent and young mothers living with HIV Adolescent and young mothers living with HIV face a broad range of vulnerabilities and risks that are unique or greater than those of adult women. The support of families and peers can be fundamental to overcoming the challenges of early motherhood and living with HIV. This is especially important when male partners deny involvement and full responsibility for the pregnancy and childbearing is assigned to the girl (53). Programmes need to build on existing competencies while also providing information, resources and skills to support adolescent mothers’ pregnancies and parenting, including early ART initiation and retention in treatment, promoting exclusive breastfeeding, determining childcare responsibilities and facilitating return to school. For example, sessions with caregivers can be effective in fostering better communication between them and adolescent and young mothers. In addition, peer support networks are an opportunity for adolescent and young mothers to share experiences, guidance and emotional and practical support such as shared childcare. Some adolescent and young mothers living with HIV may live independently or in households with unsupportive caregivers. Identifying other sources of emotional, social and material support, such as extended family members and peer groups, becomes even more urgent, as does ensuring the safety of the mother and her children. STRATEGIC ACTION 5. ESTABLISH FAMILIAL AND SOCIAL SUPPORT NETWORKS Adolescent and young mothers participating in Baylor Lesotho’s health facility-based support groups reported that counselling has improved their communication with caregivers (parents and guardians) about their pregnancies and felt that belonging to a peer group provided essential social support. Caregivers felt better equipped to accept and cope with the adolescent and young mothers’ pregnancies and HIV status, including preventing the mother-to- child transmission of HIV. All participants delivered healthy babies and had an undetectable viral load at delivery, including those who began their pregnancies with a high viral load (54). ©REPSSI 13 STRATEGIC ACTION 6. PROVIDE SCREENING, REFERRAL AND SUPPORT FOR SHARED VULNERABILITIES Ensuring the health and well-being of adolescent and young mothers living with HIV and their children requires addressing their multiple risks and vulnerabilities, including poverty, nutrition and food security, mental health, violence, substance abuse and education needs. A multisectoral approach is key, including fostering a team approach and collaboration among various stakeholders and sectors providing services for adolescents and young women. HIV, sexual and reproductive health and maternal health settings are entry points for screening for shared vulnerabilities and making the appropriate referrals, with bidirectional links to social services and educational institutions. Health-care services require standard operating procedures for individualized needs assessment and care and treatment plans. To ease the burden on health-care providers, referral pathways can be supported by community workers, patient navigators and peer mentors who coordinate care, conduct screening and referrals and monitor follow-up. Linking and enrolling adolescent and young mothers living with HIV and their infants into social protection programmes can provide case management, psychosocial support and economic strengthening. Cash transfer programmes, for example, have been found to improve food security and positively affect the sexual risk behaviour of adolescent girls and young women (55). In Zimbabwe, 72 young mentor mothers from Africaid Zvandiri, an organization that supports children and adolescents living with HIV, work alongside health-care providers in 38 health facilities and social welfare officers in 17 districts to support adolescent and young mothers at health facilities and within communities. Through engagement at health facilities, home visits and digital health, the young mentor mothers provide adherence counselling, follow up missed appointments, send reminders for early infant diagnosis, conduct couples HIV counselling and perform screening and referrals for nutrition, mental health and social protection. As of July 2021, 97% of the 1671 mothers participating in the programme had achieved viral suppression, and the rate of mother-to-child-transmission of HIV was less than 2%. Although not measured at the same points in time, the mother-to-child transmission rate is well below the national average of 5% at six weeks and 8% at 24 months (56). Most sexual partners were mobilized to learn their HIV status; 99% of the partners testing HIV positive initiated treatment, and 84% of those testing negative were linked to PrEP (57). ©UNICEF Lesotho 14 Safeguarding the future: giving priority to the needs of adolescent and young mothers living with HIV STRATEGIC ACTION 7. ADDRESS SOCIAL, ECONOMIC AND LEGAL BARRIERS TO ACCESSING HEALTH AND SOCIAL SERVICES Respecting the right of adolescent and young mothers living with HIV to good health and well-being requires governments to ensure that laws, policies and programmes support access to comprehensive HIV, sexual and reproductive health and maternal health care. For example, this might entail changing or harmonizing age-of-consent policies that restrict adolescent mothers from knowing their HIV status, starting ART and accessing contraceptives, all of which deprive them of appropriate care and treatment. Health-care providers need to be aware of the relevant laws and policies and to be both supported and held accountable to act in the best interests of adolescent and young mothers, regardless of their age and HIV, income or marital status. Although many countries in sub-Saharan Africa have removed user fees for maternal care, fees for complicated pregnancies and out-of-pocket costs for supplies and transport may prevent adolescent and young mothers living with HIV from seeking skilled care. Supportive legislation and policies alone are not sufficient. Programmes need to be adequately resourced, tailored and implemented to reach the adolescent and young mothers who are most in need. Help Lesotho has been working with government ministries and community structures to reduce stigma surrounding adolescent and young mothers living with HIV and increase their access to ART, sexual and reproductive health, nutrition and sexual and gender-based violence services, reintegration into formal education and vocational training, early childhood development, birth registration and income generation. As of September 2021, 83% of 433 adolescent and young mothers had received support from caregivers and/or partners, 62% had returned to school and 62% had increased their financial independence thanks to income generation starter kits. Most young mothers reported improved understanding of maternal and reproductive health and expressed increased hope for their future. Dialogue sessions in all participating communities resulted in increased knowledge and commitment to prevent sexual and gender-based violence against girls and women (58). ©UNICEF Malawi 15 THE TIME TO ACT IS NOW Adolescent and young mothers living with HIV are at the intersection of two overlapping vulnerabilities—HIV infection and motherhood. The challenges they face are significant but not insurmountable. Success requires government leadership and commitment, allocating adequate resources, tailored programming and collaboration among sectors. Failure to respond to their needs will have severe repercussions across their lifetime and that of their children and impede realization of the Sustainable Development Goals. The following actions are suggested to support adolescent and young mothers living with HIV to access the knowledge, skills, resources, services and support necessary to realize their vision of the best life possible for themselves and their children. Call to action for programmes, donors, policy makers and civil society Participation • Support the meaningful engagement of adolescent and young mothers living with HIV, in all their diversity, in policy dialogue and development and at every stage of programme design, implementation, monitoring and evaluation, beginning with identifying their own needs and aspirations. • Place adolescent and young mothers at the centre of service delivery, enabling them to make decisions regarding their own care. Resources • Give priority to adolescent and young mothers living with HIV and their children in donor strategies, grant applications and programme indicators across a range of outcomes. • Allocate funding to reach the most marginalized adolescent and young mothers living with HIV at the right service delivery points. • Require integration and multisectoral collaboration in funding applications and progress indicators. Policies • Reform policies that limit or restrict adolescent and young mothers living with HIV from further schooling and/or accessing HIV, sexual and reproductive health services, sexual and gender-based violence and social protection services. • Strengthen accountability through integrated scorecards, national indexes and other tools that reflect data from a range of sources, including from adolescent and young mothers themselves. • Tackle stigma surrounding adolescent and young mothers living with HIV at all levels and in all forms, including advocacy and capacity building for using the People Living with HIV Stigma Index (59). Programmes • Promote comprehensive, multisectoral programming that strengthens the integration of health services and person-centred service delivery and facilitates access to other social services. • Include adolescent and young mothers in programmes that target adolescent girls and young women. • Engage young men in learning and championing new modes of positive masculinities, equality in power dynamics within relationships and supportive fatherhood. • Foster collaboration, learning and sharing between sectors, stakeholders and settings. This includes sharing data systematically and generating data in areas where there are gaps. • Deepen understanding of service uptake and health outcomes by disaggregating data by age (15-19 and 20-24 years old). ©UNICEF Lesotho 16 Safeguarding the future: giving priority to the needs of adolescent and young mothers living with HIV REFERENCES 1. AIDSinfo [online database]. 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