In the previous lectures, I've discussed both patterns of sexual reproductive health in adolescence, as well as some of the risk factors that we know to be important. In this lecture, I'll be discussing some of the important clinical and policy responses. In general, effective clinical responses are likely to tie in closely with broader policy actions at a local community as well as national levels. In a previous lecture, I showed this slide to illustrate that these different levels, at which policy and service system responses are needed in relation to maternal health. A similar approach applies to all aspects of sexual reproductive health, where interventions are commonly needed at a structural level, at a community level, and at a health service system level. We previously discussed adolescent contraceptive needs and use. We noted that contraceptive use and levels of unmet need vary between countries, but generally, levels of unmet need are high, particularly in sexually active unmarried adolescents. In general, less than 30% of sexually active adolescents, whether married or unmarried, have their needs for contraception met. When we think of effective modern contraception, we often think about the oral contraceptive or the pill. In adolescents in low income settings, oral contraceptives have some downsides. They are dependent on effective supply. And in some settings, this can not be guaranteed. Moreover, they do require a daily dose, and this can easily be forgotten. For these reasons the pill alone is often not a reliable contraceptive strategy for adolescent girls in a low income country. Alternatives have recently gained attention, including the use of long-acting, reversible contraceptives, and IUD's, or intrauterine devices. Progesterone injections, such as Depo-Provera, are popular, and give a high level of protection against pregnancy for around three months. Progesterone implants In the forearm also have a high level of effectiveness, and lasts for up to three years. Although usage is increasing around the world, uptake in low and middle income countries remains low. Intrauterine devices, or IUDs, are another alternative that are around 99% effective for up to five years in preventing pregnancy. One further alternative is emergency contraception, or the morning after pill. These are generally taken up to three days after unplanned intercourse with the aim of disrupting ovulational fertilization. Although emergency contraceptives are available in many countries, their uptake by adolescents is not high. Many of the health care actions for preventing maternal mortality and mobility are similar to those in other age groups. Engagement in antenatal care is often delayed in adolescence because of adolescents' lack of knowledge, and that of their partners. Antenatal care is particularly important for young women who are malnourished at a time when pelvic growth is continuing. Rates of having a skilled birth attendant is similar for adolescents to that in older age groups. Yet it is particularly important for adolescents, because of the risks of obstructed labor, and the complications that might follow. Postnatal care is also important in the detection and treatment of puerperal sepsis, or birth-related infections, but too often absent for adolescents. Postnatal care should include attention to contraception, to ensure adequate spacing between births, another risk factor for maternal health problems, and particularly common in adolescents compared to older women. Ultimately, every action is dependent on the skill and training of healthcare providers. There are a broader set of actions that are ultimately going to be more effective again in reducing adolescent maternal mortality. Each of these strategies is aiming to delay the onset of pregnancy and childbirth. Education is clearly linked to socioeconomic status and, in turn, linked to early marriage and early fertility. This slide illustrates the inverse relationship between years in education and the total burden of disease from sexual and reproductive health problems in young women. Clearly, education is beneficial for young women's sexual and reproductive health. This slide illustrates some of those interlinked factors that are so essential to achieving sexual and reproductive health in girls. Legislation, such as that designed to prevent child marriage, is important, but often undermined, by conflict with cultural and community values and customary and religious laws. There's certainly scope for ensuring the greater effectiveness of legislation, but this will need to be tied to measures aiming to change some of these historic and cultural values and norms in many low income settings. Education is important, but needs to be linked to access to contraception, and ultimately, to economic empowerment of girls, through having some capacity to contribute to the work force, and have an independent means of income. Turning now to HIV and STI actions. Both in prevention and clinical responses to HIV and other STIs, there is good evidence around effective action. Condoms, when used consistently, bring an 80% reduction in HIV incidence. There is no doubt that social marketing can promote condom use in adolescents. But many adolescents are still failing to use condoms. This is particularly true in parts of central and west Africa. More commonly, condoms are being used for the prevention of pregnancy, rather than prevention of HIV and STIs. There are a range of other approaches to prevention and treatment. There is little doubt that comprehensive sexuality education is effective at increasing knowledge. And is even more effective when combined with action at community or national levels. If coverage is weak in regions where HIV and STI rates are high, the barriers to implementation of sexual education are many, and include this education being out of step with local community values, and a lack of teaching capacity and knowledge about how to go about it. There is good evidence that male circumcision, which reduces risk of HIV transmission to around 25% of that in uncircumcised males. It also reduces the risk of HPV infection. Despite its effectiveness, the uptake in regions where HIV is endemic has remained low. Anti-retroviral treatments both improves health and survival in HIV, as well as reduces the risks for transmission. Yet coverage in adolescents with HIV, in many parts of sub-Saharan Africa, also remains low. Available estimates suggest that less than half of young people with HIV are receiving effective anti-retroviral therapy. This may be one of the reasons why mortality rates for HIV in adolescents have not seen the falls that have taken place in other age groups. Syphilis, once diagnosed, is easily treated with penicillin. Rapid diagnostic tests are available which have meant that screening during pregnancy for women attending antenatal care has now been adopted in many countries where risks are high. There is good evidence that broader approaches that enable adolescents to remain in school have benefits in reducing risks for HIV and other STIs. Some of the clearest examples are around the use of conditional cash transfers in poor settings, with strong evidence both from Malawi and Uganda. Despite this evidence, uptake on a broad scale has remained limited. To be very effective, such measures are best combined with other strategies that promote employment and economic independence after leaving school. Good access to contraception and condoms. The vertical partitioning of health services is probably a further factor that limits good and comprehensive clinical responses to adolescent sexual and reproductive health needs. In addition, there are further barriers to accessing treatment for HIV and STIs in adolescence. Lack of knowledge is still high, even in countries where these infections are endemic. Many STIs, including HIV, are asymptomatic at an early stage, that's true for infections such as chlamydia and gonorrhea. In many settings, adolescents are still unable to access confidential health services, as laws require that their parents are notified. This is obviously a major barrier to health care. In one WHO survey, only four out of 22 countries allowed adolescents to access HIV testing without parental permission. Lastly, adolescents have very few financial means to access health care and systems where there is any significant cost. This is a further major barrier, but one where, for a modest investment, the barrier is easily removed.
