Chapter 8

Sexually Transmitted Infections

& HIV-AIDS in Adolescent and
Youth

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Chapter overview

• This chapter addresses sexually transmitted

infections (STIs) and HIV/ AIDS; focusing on their
epidemiology, risk factors associated with, and
management approaches in adolescents and youth
giving additional notes on disclosure and
adherence.

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Learning Objective:
• At the end of this chapter, you will be able to:
• Define STI/HIV and AIDS in relation to adolescents
and youth

• Discuss the determinants of prevalence and

incidence of STI/HIV and AIDS among adolescents
and youth
• Describe clinical features, causative agents,
incubation periods and common complications of
STI/HIV and AIDS in adolescents and youth
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Learning objectives…

• List the common STIs affecting adolescents and

youth
• Demonstrate an understanding of management
approaches for STIs
• Explain the rationale for and the advantages and
disadvantages of syndromic STI management.

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Competencies
• Knowledge on epidemiology, causes, modes of
transmissions, prevention, treatment and care of
STI/HIV and AIDS

• Capacity to provide STI/HIV counseling and/or

testing/ diagnosis and management appropriate to
adolescents and youth

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Competencies…
• Ability to make appropriate decisions in the
provision of or referral for PEP, ART, PMTCT, etc.
services
• Ability to provide services on STI/HIV to
adolescents and Youth with respect, free of
judgment
• Willingness to effectively assist clients to address
the consequences of STI/HIV and AIDS

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Basics on Sexually Transmitted Infections in
Adolescents and Youth

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The Burden of STIs
• STIs have public health importance because of their
magnitude, potential complications and their
interaction with HIV/AIDS.

• More than 1 million Sexually Transmitted Infections (STIs) are

acquired every day worldwide.

• Each year, there are an estimated 357 million new infections

with 1 of 4 STIs: chlamydia, gonorrhoea, syphilis and
trichomoniasis.

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Burden of STIs…
• More than 500 million people are estimated to have
genital infection with Herpes Simplex Virus (HSV).

• More than 290 million women have a Human Papilloma

Virus (HPV) infection.

• According to EDHS, 2011, Young people, in the age

group 20-34 years, were highly-affected (68.2%) by STI
and majority were females (61%).

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Factors Contributing to STIs among
Adolescents and Youth
• Young people experiment sexually, indulge in risky
sexual practices
• Sexual practices are often unplanned and sporadic,
and sometimes the result of pressure, coercion or
force.
• Adolescents or youth may feel peer pressure to
have sex before they are emotionally prepared to be
sexually active.

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 Factors contributing…
• Adolescents start sexual activity typically
before they have:
 Adequate information about STIs and how to
avoid contracting STIs
 Experience and skills to protect themselves
 Access to SRH services and supplies such as
condoms

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 Factors contributing…
oYoung girls are more vulnerable than young men and
adults because of biological factors, as well as social,
cultural and economic factors.
oYoung men often feel that they have to prove their
sexual powers.
oSubstance abuse or experimentation with drugs and
alcohol often leads to irresponsible decisions,

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Buzz Group Activity:

Form a group of two members:

Discuss the possible consequence of STI for
adolescents and youth and share with the plenary

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 STI Management in A & Y
• Etiologic: A diagnosis is based on the results of
laboratory tests that can identify the specific
organism causing the infection..
• Clinical: Provider makes a diagnosis (or educated
guess) about which organism is causing infection
based on the patient's history, signs and symptoms.
• Syndromic: The patient is diagnosed and treated
based on groups of symptoms or syndromes, rather
than for specific STIs.

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 Activity 8.3.2. Group Discussions

Instruction: discuss the following point among

yourselves for 10 minutes

What are the advantages and disadvantages of

syndromic management?
What is the actual practice in your health system?

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Group Activity: case study

• Case study
Q. If you were the junior doctor, how would you deal
with this? Discuss among yourselves and provide
your answers

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 Practical Considerations in Managing STIs
among Adolescents and Youth
oEstablishing good rapport
oCarrying out history taking and physical examination
in a sensitive manner
oArriving at the right diagnosis: risk assessment

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 Practical consideration in STI
management …
oCommunicating the diagnosis and its
implications, discussing treatment options and
providing treatment
oLinkage with HIV counseling and testing
oFollow up visits
oPromotion of safer sex

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Basic Facts on HIV/AIDS among Adolescents
and Youth

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The Burden of HIV
• Worldwide, about 2.1 million adolescents aged 10-19 years
are living with HIV.
– 85% of them in sub-Saharan Africa
– and 60% of them girls.
• A minority of these adolescents are aware of their HIV
status or enrolled in a treatment and care programme.
• AIDS related deaths are declining in all age groups except
in Adolescents

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New HIV Infection among Adolescents,
In 2014
 HIV is the leading cause of adolescent
mortality in Africa, especially among young
women
 AIDS related deaths are declining rapidly in all
age groups except adolescents
 25 countries account for 80% of HIV new
adolescent infections (18 countries in Africa)
 The HIV prevalence among girls aged 15-24
years (4.3%), remains very high than among
young men throughout sub-Saharan Africa.
 Only 10% of young men and 15 % young
women aged 15-24 years know their HIV status.
Vulnerability to HIV
• For most young people, the following interventions
will protect them from the risk of HIV:
• delaying sexual debut, reducing the number of sexual
partners, and using condoms correctly and consistently.
• Vulnerability is a measure of an individual’s or
community’s inability to control their risk of HIV
infection.
• Vulnerability recognizes that they may not have a
choice as to whether they engage in behavior that
puts them at risk of acquiring HIV.

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Vulnerability to HIV…

• Vulnerability increases the likelihood of

negative health outcomes.
• There are social and contextual risk factors
that make many young people vulnerable to
HIV infection. These include:
• gender norms, relations between different age
groups, race and other social and cultural norms
and value systems, location and economic
status.
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Combination Prevention Intervention for
HIV/AIDS in Adolescents and Youth

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Case study

• A 14 years old boy with HIV is living with his

younger brother, father and step mother. His step
mother came complaining that he tries to bite his
younger brother and also tried to rape her. He
usually doesn’t want to go to school and mostly
spends his time on Facebook.

• Q. How do you think this case can be managed?

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Comprehensive HIV Testing and
Counseling
• HIV testing and counseling is an entry point to
prevention, care, treatment and support.
• It must only be offered with the 4 Cs:
Confidentiality, informed Consent, Counseling and
Condoms.
• Many people in Ethiopia, including adolescents and
youth, do not know their status.
• Routine HIV testing can increase individuals’
access to HIV testing and know their status

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Voluntary Counselling Testing

• This is client initiated counselling and testing and

these clients are more likely to be asymptomatic.
• The primary focus is on preventing HIV acquisition
through risk assessment, risk reduction, and testing.
• Client-focused counseling is provided usually one-
on-one
• Then, HIV positive clients are referred to medical
care services and other support services, some in
community.

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Provider-Initiated HIV Testing and Counseling
(PITC):
• It is initiated by the service providers usually for
medical reasons as part of regular medical care.
• It is seen as an opportunity for:
• people who have never been tested (or were previously
negative) to know their current status,
• people to discuss options and make choices according
to their status; and
• health workers to provide the best care and prevention
according to the patient’s HIV status.

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Rapid HIV testing
• All patients will be tested for HIV (rapid test) unless
they refuse.

• Rapid HIV testing with results the same day is

recommended for all people, especially young
people.

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Rapid HIV testing…
• Rapid testing ensures that the young person gets
the result and receives counseling immediately.
• If the first test result is positive, another Rapid HIV Test
must be performed (confirmatory test).

• With a second positive result, the patient can be

counseled for a positive result.

• If the second test is negative, then the result is

considered inconclusive and the algorithm is repeated.

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Special Considerations in HIV Testing and
Counseling for Adolescents and Youth
• Do not discount the potential for HIV in young
people

• Take Advantage of your first meeting with a

young person

• Promote beneficial disclosure

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Special consideration in HIV testing…

• Take the opportunity given by a negative HIV

test
• Promote future counseling of client together
with their sexual partner
• Promote safer sex and harm reduction
• Promoting Peer Counseling by their Young
PLHIV

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Management of HIV/AIDS in Young People

The aim of services is to help young PLHIV to:

• Stay healthy and live positively

• Counseling and support can help them to stay
healthy, improve their self-esteem and
confidence,

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Management of HIV/AIDS in adolescent…

• Promote adhere to care and treatment

• Help understand the benefits of disclosing HIV

status to family, sexual partner(s), close friends

• Help cope with stigma and discrimination towards

themselves and their loved ones:

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New WHO Guidelines 2015:
TREAT ALL

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Evidence Supports Initiation of ART in individuals
irrespective of CD4 count, to Prevent Transmission

• Viral load is the single greatest determinant of

HIV transmission

• When viral load is suppressed (undetectable), the

risk of HIV transmission is significantly reduced

• The evidence supports early initiation of ART for

HIV prevention irrespective of CD4 level or stage

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When to initiate ART
• New Recommendation supports ART initiation in
ALL adults, ADOLESCENTS and children with HIV at
any CD4 cell count or disease stage including key
populations

• Efforts should be made to reduce the time between

diagnosis and ART initiation to improve health
outcomes

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Starting ART in adolescents
First-line ART Preferred first-line Alternative first-line regimensa,b
regimens
AZT + 3TC + EFV (or NVP)
TDF + 3TC (or FTC) + EFV
Adults TDF + 3TC (or FTC) + DTG c
TDF + 3TC (or FTC) + EFV400 c d
TDF + 3TC (or FTC) + NVP
AZT + 3TC + EFV (or NVP)
Adolescents TDF (or ABC) + 3TC (or FTC) + DTG c
TDF + 3TC (or FTC) + EFV
TDF (or ABC) + 3TC (or FTC) + EFV400 c d
TDF (or ABC) + 3TC (or FTC) + NVP
• Introducing more potent and tolerable regimens as alternatives
• Simplifying regimens adolescents who started Tx in childhood
• Maintaining harmonisation with adults
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ART monitoring: Viral load
• Viral load is recommended as the
preferred approach to diagnose and
confirm treatment failure

• Viral load failure is defined as

persistent viral load > 1000 copies

• Viral load should be measured at 6M,

12M then every 12M (conditional,
very low)

• Dried blood spots can be used to

determine viral load (conditional, low)

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Summary
• STIs among adolescent are an important public
health problem requiring good clinical management

• Adolescent run special risk of exposure to STIs; it

must be stressed that adolescent girl are especially
vulnerable
• There are three diagnostic approaches to STI
management: etiologic, clinical, and syndromic.
Effective treatment includes contact tracing and
treatment.
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Summary…

• Important issues in A&Y HIV/AIDS include

psychosocial support, adherence and disclosure
• There is a need to prevent defaulter earlier during
pregnancy
• Disclosure of HIV status in adolescence should
consider the cognitive, emotional and sexual
maturity of the child. Timely disclosure is always
beneficial

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