Our position ‘€“ conditional support

The Children’€™s Rights Centre supports government’€™s intention to extend and improve HIV Counselling and Testing (HCT) for teens as part of the revitalisation of a sustained school health programme to improve the health status and overall wellbeing of teens. We are encouraged by the Minister of Health’€™s emphasis on the ‘€˜bigger picture’€™, rather than targeting numbers for a once off campaign. We are inspired by the transformative vision of health services that includes integrated, comprehensive school and primary health care, including sexual and reproductive health services for teens. However, this support is conditional. We are concerned about the practical challenges of such a programme in school, health and community settings in which teens live and learn, and where rights are either realised or violated. We need to ensure that this vision is not undermined by harm caused by predictable and considerable risks.

HCT – important for teens, important for society

South Africa leads the world in the global HIV burden. We account for less than 1% of the world’€™s people, but experience 17% of the global HIV burden. To turn the epidemic around, we need effective prevention with and treatment for teens with special attention to the realities and needs of girls, their relationships, sexuality and sexual and reproductive health.

In South Africa, teens are a major target of the disease. HIV prevalence spikes between the ages of 15 to 24 years. Thus, these are critical years for intervention, particularly during the high school period. Prevalence starts at low levels in teens. But by age 15, HIV prevalence is twice as high in girls compared to boys. HIV prevalence in girls then rises sharply in every year of age while in boys the increase starts at about age 20. By age 21, women are five times as likely as men to have HIV.  Clearly this is a stage of life that needs special attention, and each age group  is likely to bring forth different issues that require specific responses. This understanding may be one of the keys to turning the tide on the epidemic.

HCT, if handled appropriately, has the potential to provide a gateway to prevention, and to treatment, care and support for all teens. If not, HCT in schools could result in discrimination, mental health problems, family conflict, and failure of health and social services.

The context

The reality is that adolescents are daily dealing with intimate relationships and complex feelings. However this normal sexual, emotional and social development occurs in a context of high levels of bullying, stigma, substance abuse and violence in schools, families and communities. Reports indicate that 1 in 3 girls have experienced sexual violence before the age of 18, which includes unwanted touching, forced sex or being sexually exploited by much older men. While reporting levels are low, 40% of victims who do report rape to the police are girls under 18, and 15% are under 12 years. Orphans and vulnerable children may be especially likely to engage in early sexual activity, due in part to lack of social and economic support. One South African study found that 23% of orphans had sex by age 13, compared with 15% of non-orphans.

Children in South Africa suffer high rates of mental health problems. Such problems are known to dramatically increase following an HIV diagnosis. The manner of disclosing a diagnosis is known to affect the individual’€™s mental health for the rest of their lives. Adults living with HIV are 36 times more likely than the general population to commit suicide. The risk of suicide is influenced by a number of factors including the availability of psychological support. The reality is that mental health and social support systems are weak, fragmented and poorly integrated across the education and health functions. Current HCT provisions require only a single pre- and post-testing counselling session. Psychological and social support systems for teens need to be much more extensive.

Realities of schools pose challenge to rights

The school context poses serious challenges to the essential requirements of HCT: voluntariness, informed choice, privacy and confidentiality. Teens are by nature heavily influenced by their peers, and educator ‘€“ learner relationships are unequal. Thus a learner who is not ready to test may feel pressured to do so, and react badly to the news. Teens who have not been adequately prepared have been found to have a poor understanding of their own risk of being positive, and may be highly traumatised by the results. This could defeat the object of initiating and securing adherence of treatment for teens with HIV. Ensuring privacy and confidentiality needs special attention in testing in schools, given that an upset learner will stand out in a testing setting, and HIV status will be exposed even if there is no technical violation of confidentiality.

What is needed

A thorough and meaningful pre-testing preparation phase is required at school and community level. This should include working with educators and parents to deal with personal issues related to HIV and to teens’€™ sexual and reproductive health rights, and implementing long-term care and support for these issues.

The planning, implementation and monitoring of the testing must be in children’€™s best interests and must fully and meaningfully protect their rights to health, information, care and support, and participation. Learners’€™ involvement should be central to each step.

HCT needs to be integrated into the Life Skills curriculum, and there needs to be effective training for, and attitudinal changes by, educators.

Schools must facilitate teens working with health facilities to become adolescent friendly, and creating an on-going mechanism for adolescent participation in health services.

Post-testing monitoring of stigma, discrimination, mental health and social concerns needs to be carried out at all sites.

High stakes

HCT for Teens is a high-stakes programme that can yield tremendous benefits for individuals, families and the public at large. It can also go hopelessly wrong if not managed carefully. The benefits of testing, if done properly, include opportunities to access health services, information on HIV, sexual and reproductive health; and for teens living with HIV, it can facilitate treatment, care and support. In order to achieve these benefits, adults and learners, government and civil society, policy makers and implementers will all need to work together.

Fact Box

In boys to men aged 15 to 19 years, HIV prevalence is lower than it is in girls, and remains largely unchanged at 2-3%. Girls at age 15 experience higher levels of HIV with 4% prevalence, and the increase in prevalence starts earlier, at age 17 years, rising sharply at age 17 to 6%, at age 18 to 9%, and by age 19 to nearly 14%. By age 21 women have a prevalence of 31% while in the case of men, it is just under 6%. This means that at 15 years, a girl is twice as likely as a boy to have HIV, while by age 21, five times more likely. HIV strikes hard and fast in these critical years.

Cati Vawda is Director of the Children’€™s Rights Centre and Chairperson of the Yezingane Network a national network addressing children’€™s rights in the context of HIV.