I'm delighted to have online Dr Susan Kassite who is a senior specialist and team leader in HIV prevention whose based at UNICEF headquarters in New York. Susan thank you so much for participating in our MOOC on Global Adolescent Health. As an HIV/AIDS specialist, I am really keen for our students to hear a little bit of your perspectives. And I'm interested in the fact that we know that it is a relatively small number of countries that are experiencing a disproportionate burden from HIV/AIDS, which we know can be transmitted sexually, from injecting drug use and from perinatal infection. Can you share with us a little of the current context of HIV/AIDS in young people around the world. >> Sure, Susan, thank you very much for the question. And thank you especially for inviting me and inviting UNICEF to join this MOOC and to share some of what we know and are doing about the HIV epidemic in adolescents. So, what we know right now, and we're very fortunate to have the regular updated data on the global academic, from UN AIDS. In recent years, with UNICEF support we've been able to refine and support generation of data on adolescents. Specifically, something that is really a response to a growing global call for better, for partners everywhere, and governments everywhere to take a closer look at data on adolescents. So what we know is that by the end of 2014 there were about 2 million adolescents age 10 to 19 living with HIV globally. We also know that six countries account for nearly half of all those adolescents living with HIV. South Africa being the country with the largest, contributing the largest number of adolescents with HIV, they account for 13% of just over one in ten of all adolescents living with HIV. Nigeria account for 10%. Kenya accounting for about 8%. India accounting for six, Mozambique, six. And Tanzania 6%. So those six countries, a we said a small number contributing to 50% of all the adolescent infections. But we know as well that adolescent girls accounted for about 60% of all the new HIV infections in 2014 amongst adolescents age 15 to 19. So those are the years when the sexual behaviors and injection drug use behavior do tend to begin. And this, and globally what we see is 60% of the new infections are in adolescent girls. But that being said, that means a whole 40% of those infections were in adolescent boys. When we look at the global epidemic, what we've been seeing is in many countries, rising numbers of new infections in adolescent key populations. These are populations of adolescents that are critical to the epidemic in each of these countries. They include adolescents who sell sex and they may be girls, and boys, adolescents who inject drugs and adolescent males who have sex with other males. So we're seeing in some countries, disturbing trends of increasing numbers of the infections among these particular adolescents, and adult key populations as well. And we know that this is a reflection, not of our inability to prevent new infections, but more our ineffectiveness at using the technology, and the evidence, and the capacities that we have to translate the evidence into more effective programs. In terms of deaths due to HIV, what we've seen over the last few years is also very interesting. We've seen phenomenal progress in preventing AIDS related deaths in children ages zero to four. We've seen about a 10% decline in AIDS related deaths in children in that first five years of life really attributable to the investment and consistency of the programming and improvements in programming in convention mothers to child transmissions programs globally. So that 10% of decline a huge story of success. We've seen relative success in terms of decline in age related deaths in children aged five to nine and in young people, age 20 to 24. Again, beneficiaries of what has been significant investment in state offered treatment programs. Those two age bands have seen about a 4% to 5% decline in age related deaths since 2001. In adolescents the picture is quite different. We're not seeing declines, and if anything we see a hint of increases in age related deaths. And again, that's reflective not of our ability to program to prevent these deaths. But our ineffectiveness in focusing on this age group and it's special needs for prevention, treatment and care. >> Thank you very much for such a beautifully detailed overview. I think that's really helpful in terms of so capably setting the scene. We know that there is a declining prevalence of HIV aids in some countries. And presumably, that's also the case in adolescents as well. What have these countries been able to do that has helped reduce this Incidents? >> I think that if I can point to things. It is different things in different places, but there are some critical building blocks that have contributed to success. The first thing that I mention is leadership. And leadership at multiple levels, because it takes leadership to drive investments and the kinds of investments and quality of programs and attention to priorities that can deliver impact. And so where we have seen significant changes and successes in the HIV response, it has been because of an exercise, a persistent and sustained exercise of leadership. Political leadership, as well as technical leadership, community level leadership, and a partnership across different sectors to just get the job done with the resources and the evidence that we have. So we've seen programs being scaled up, as I mentioned earlier for PMTCT, continually improving those programs to ensure that we get the regiments right, that we build the capacities, we strengthen the systems, and build the ability of systems to deliver sustained programs. And to establish a level of quality and understanding the policy required to deliver consistent results. So where we're seeing that, as I've said, we're starting to see the results in terms of declines of HIV transmission in children, the declines in age-related deaths, and we're also starting to see the benefits of that for adolescents. So while we had previously the majority of infections in adolescents attributable to sexually transmitted HIV infections and behavior transmitted HIV we're starting to see a shift right now with a majority of infections in adolescents being attributable to maturing of adolescents coming through the PMTCT program and the Pediatric Care program in other words children surviving longer. And that has implications for needs and demands on programs. But it critically means that we do have to accelerate the capacity, even where these countries have done well. To make sure that they're able to deal with a new generation of issues in terms of caring effectively for adolescents living with HIV and needing transition out of pediatric and adolescent care and out of adolescent care into adulthood. So leadership has been critical. Investment has been critical. Quality of programs have been absolutely critical and engagement of communities and multiple partnerships to establish and sustainable and solid foundation for response across a range of issues. >> Which is fascinating to hear the importance of leadership because I think too often in the global health space I think we are at risk of thinking that there are simple solutions for what we know are incredibly complex problems. And I think what you are very clearly articulating here is that yes, we might have medication available, yes we might have interventions that reduce the likelihood of behavioral factors that increase transmission. But that unless we actually have an integrated system with leadership is an incredibly important part of that. And quality health services as well. Then we're not going to be achieving the gains. So then if we look at those countries where we have not seen that decline in incidence and new onset. Is it the reverse of a failure of leadership? A failure of health services? A failure of investment? Or in addition to that are there also other responsible factors? >> I think it's difficult to say that there are no other factors that can contribute to the failure that we are seeing. But I have to say again that just as those factors those core things, leadership, effective allocation of the investments, the resources that we have to invest in quality programs. And engagement to the different sectors to establish a robust comprehensive response to the epidemic. I have to say those four things still do play critically into the failure that we see in a number of countries to address the challenge of HIV in lessons. I'll give a few examples in terms of investment, we looked at the allocation of resources to the global epidemic. The global adolescent response a few years ago. And we realized that the investments in adolescents in order to be effective we're going to have to increase by more than a 100% within the space of two years. In order for us to start to get the adolescent response on track to achieve the noble targets. In other words, to achieve an equitable pace of progress in dealing with the adolescent academic. So in other words, we are seeing a degree of underinvestment in adolescents, an inadequate investment in adolescence. And unless we see the basic level of investment being placed into the adolescent response we cannot deliver the kinds of results or progress that we need to see to turn the epidemic around. In a number of countries, I've talked about leadership and in a number of countries we're still grappling with failure of leadership to address the basic structural issues that contribute so significantly to vulnerability in adolescent girls for example. Sexual violence. Child marriage. Keeping girls in school. Protection from discrimination. Investment in their capacities to become productive and independent citizens in their community. We are not seeing sustained and adequate degree of investment in these things to create the kinds of changes at the pace that we need to get, you know to establish capacities in these adolescent girls in time. For them to transition through that adolescent period without the degree of vulnerability that they are experiencing. Similarly we're not seeing the kind of leadership being exercised to address barriers that make it impossible for some of the most vulnerable adolescents to access the kinds of services that they need. I'm talking about legislation that basically criminalizes adolescents and other populations based on their own sexuality. That criminalizes sex work and therefore makes it absolutely impossible for effective prevention, care, and support to be provided to the very populations that need it the most. So all of these are examples of critical leadership gaps and opportunities for us to make a significant transformation to the kind of success that can be achieved in the HIV epidemic. So can I just clarify Susan, what you're suggesting, I think, is that among a range of factors, that there has been a relative under investment in the adolescent population. Commensurate with, if you like, the burden of HIV experienced in that population? Is that a critical point you are making? >> That is a critical point that I'm making. Because adolescents account for a significant proportion of the population in need of prevention, of treatment and care. But when you look at the service delivery, the monitoring and the tracking that is done of these programs, adolescents are, for the most part, invisible. Invisible in the data, and as we all know, without a basic understanding of the data for your population in need, for any program, it's almost impossible to plan adequately. And that's what we're seeing in terms of the failure to slow age-related deaths down in adolescents and to stem the infections. In a population that really should be relatively easy to reach, because they are. We know where to find adolescents, we know how to reach them, but we're just not doing that effectively with the tools that we have. >> So what I'm hearing you articulate here is that there is a relative lack of investment in the age population of adolescents. As well as perhaps that failure of appreciation of some of those key social determinants of health that will provide young people with the capabilities to enable them to in a sense move in a more healthy trajectory through adolescence and into adulthood. And so in a sense there's been a failure at two levels both the target of the intervention as well as the amount of that intervention, is that correct? >> That's absolutely right, so it's inadequacy of investments but it's also reflective of the way that the investments are being applied, because investments are being made often with insufficient attention to some areas that can deliver the results. Many of the adolescent programs that we read about, for instance, focus very, very much. Own information, and that's critical, but it is not sufficient for prevention of a new infection in an adolescent. And without adequate investment in commodities for prevention, in sexual and reproductive health programs that reach adolescents effectively, link them to services. We aren't able to see the kind of pace and scale of results that are needed to end the epidemic in adolescence by 2030, which is the global goal. >> Sure, you mentioned that challenge of transition through to adult healthcare for adolescents who are HIV-affected and the risk of dropout of care at this time. We know, in terms of high income countries, in young people with chronic physical and mental health conditions that this is certainly a major challenge for health systems. And I think, in those countries that are carrying a significant burden of HIV AIDS, my senses that the penny has suddenly dropped with an almighty clang around that need to think of how we better orientate health services to the adolescent age group. And it feels to me that the example of HIV/AIDS in a sense becoming one of those inexmplarie conditions of how health services more broadly, not yet sufficiently oriented to young people like challengers and opportunities of working with young people. But the fact that adult healthcare systems typically are not sufficiently engaging of young people. Can you share a little bit more about that challenge? >> And happy to share a bit more about our challenge. We are working right now with a number of countries to try and pinpoint with governments and with their partners just where to begin in addressing the challenge of reaching adolescents better. Preparing the systems better to address this population and their unique needs. But also to engage with them so that our programs are more relevant because they respond to the reality that adolescents themselves are very, very well able to advise gives us some. And so UNICEF and UN Aides and other global partners launched a global agenda, double initiative, which we're calling the All In Initiative. Really reflecting what is needed to create a vigorous response for adolescents, effective responses. For partners to really come together across sectors, across organizations, across government, private sector, and community in order to establish the kind of support and network of opportunities for adolescents to address the complex challenges that they face. So the All In initiative is really aimed to trying to get the adolescents that wants back on track to end the AIDS epidemic by 2013. What that means is that with countries, we're trying to, countries and global partners, we're trying to sharpen ways to engage adolescents in thinking through how to better reach them, how to better engage them in supporting program design and delivery and monitoring. We're working with country teams to look at the data from various program platforms so that we get a better understanding of what actually is happening in terms of service access. Utilization, retention and going further looking at the data at the decentralized level to understand what the critical bottle-necks are that are contributing to under performance in the programs that we have. So we're taking a critical look using the data that is available at facilities and different programs to really get, to take a closer look at what we can do to improve and accelerate the results possible from programs. So that's an opportunity that we're building on. We're working with about 25 countries and it's challenging, but it's exciting at the same time because we're seeing leadership across countries really picking up this challenge. And as you said, using this in response to a concern that is bubbling up everywhere as different sectors recognize the significance of effective investment in this population for long term development in each country. >> Susan, this has been fascinating. Because I think what you're suggesting that we need to be in a sense be paying greater attention to the adolescent population in terms of curbing the global epidemic of HIV/AIDS. And at the same time I think what you have beautifully articulated there and earlier on is the importance of reliable data. Not just obviously incidence and prevalence data at a country and having that age disaggregated so that adolescents the burden of HIV/AIDS in the adolescence in comparison to other age groups can become more visible. But also in relationship to evaluation around health services. Whether that's utilization of health services with that experience of care. So I think that one of the points we've been trying to help our students in this MOOC understand is the importance of evidence-based interventions, on one hand. But at a very simple level, if we do not have data about the extent of the burdens of health issues in populations, in this case in HIV. Then we are completely blind in terms of how individual countries and with how within individual regions we might need to respond. I think you've beautifully articulated some of those challenges globally. Thank you so much for joining with us today. I wish you and your colleagues in UNICEF, and UNA, and WHR the best of luck and hard work in terms of coping this epidemic. Thank you, Susan. >> Thank you, Susan. Thank you for having me.
