Module 2 The Nature of Adolescence and

the Provision of Youth-Friendly

Services

Session 2.1: Stages and Changes of Adolescence

Session 2.2: Adolescent Vulnerabilities, Risk-Taking Behaviors, and Their
Consequences
Session 2.3: Providing Youth-Friendly Services to Adolescents

Learning Objectives
After completing this module, participants will be able to:
• Define adolescence
• Identify some of the physical changes that occur during adolescence
• Define the stages of adolescent development
• Describe how ALHIV are different from children and adults living with HIV
• Discuss the ways in which adolescents are a heterogeneous group
• Discuss risk-taking as a normal part of adolescence as well as the consequence of negative
risk-taking
• Discuss some of the vulnerabilities faced by adolescents
• Describe the characteristics of youth-friendly HIV care and treatment services

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Session 2.1 Stages and Changes of Adolescence

Session Objectives
After completing this session, participants will be able to:
• Define adolescence
• Identify some of the physical changes that occur during adolescence
• Define the stages of adolescent development
• Describe how ALHIV are different from children and adults living with HIV
• Discuss the ways in which adolescents are a heterogeneous group

Who Are We Talking About?

Who are we referring to when we talk about “adolescents?” In general, the term “adolescent”
refers to people in their second decade of life, meaning those between the ages of 10 and 19
years. Other commonly used terms are “youth” and “young people.” These terms have slightly
different definitions (see Table 2.1) but are sometimes used interchangeably with the term
“adolescent.”

Table 2.1: Key definitions

Group Age range
(according to WHO)
Adolescents 10–19 years
Focus of this training
Youth 15–24 years

Young people 10–24 years

Figure 2.1: Young people (age 10–24 years) includes the overlapping categories of
“Youth” and “Adolescents”

Adolescence has many dimensions: physical, psychological, emotional, and sociological.

Adolescence is a phase of an individual’s life that is defined differently across cultures and
communities.

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Key Changes During Adolescence
There are a number of physical and sexual changes that occur during adolescence.

In females: In males:
• Development of breasts • Growth of the penis, scrotum, and testicles
• Appearance of pubic and underarm hair • Appearance of pubic, underarm, chest, and
• Widening of the hips leg hair
• Menarche • Night-time ejaculation
• Development of the vulva and pelvis • Morning erection
• Development of back muscles
In both females and males:
• Accelerated growth
• Increased perspiration
• The presence of acne
• Face has characteristics of young adult
• Change in tone of voice
• Sexual desire activated
• Initiation of sexual activities

The system used most frequently to categorize these physical and sexual changes in girls and
boys is referred to as the "Tanner staging system" (see Appendix 2A: Tanner Staging System). The
first stage represents the pre-pubertal child and the final stage represents the “mature” or adult
stage. The Tanner staging system can be used to determine maturity when deciding whether an
adolescent should receive an adult or pediatric ARV dosing, as discussed in the next module.

There are also a number of psychological and emotional changes that occur during
adolescence:1
• Mood swings
• Insecurities, fears, and doubts
• Behavioral expressions of emotion, which may include withdrawal, hostility, impulsiveness,
and non-cooperation
• Self-centeredness
• Feelings of being misunderstood and/or rejected
• Fluctuating self-esteem
• Interest in physical changes, sex, and sexuality
• Concern about body image
• Concern about sexual identity, decision-making, and reputation
• A need to feel autonomous and independent

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The Stages of Adolescent Development
Adolescence can be categorized into 3 overlapping developmental stages:
• The ages listed are approximate — maturation is more important than specific ages when
discussing adolescent development.
• Maturation occurs in fits and starts and is not always coordinated.
• Growth in each of the categories listed in Table 2.2 can occur at different rates. For example,
an adolescent girl may look like an adult physically (a characteristic of late adolescence), but
may not yet be capable of abstract thinking (a characteristic of early adolescence). Another
adolescent may appear small and stunted, but may demonstrate advanced intellectual or
psychological maturity.
• HIV disease impacts maturation in a number of ways (as discussed in the next section).

Table 2.2: Stages of adolescence

CATEGORY EARLY MIDDLE LATE
OF CHANGE (10–15 years) (14–17 years) (16–19 years)
• Secondary sexual • Has advanced secondary • Physically mature
characteristics appear sexual characteristics
GROWTH OF
BODY • Rapid growth reaches a • Growth slows down;
peak reaches approximately 95%
of adult size
• Thinks in concrete terms • Thinking can be more • Abstract thinking now
COGNITION (i.e. the “here and now”) abstract (theoretical) but established
(ability to get goes back to concrete
knowledge • Does not understand • Plans for the future
how actions affect future thinking when under stress • Understands how current
through
different ways of • Better understands long- choices and decisions
thinking) term results of own actions have an effect on the
future
• Worries about rapid • Has established body image • Plans and follows long-
physical growth and • Thinks about fantasies or term goals
PSYCHO- body image impossible dreams • Has established sense of
LOGICAL
• Has frequent mood • Feels very powerful identity (who he or she is)
AND SOCIAL
changes • May experiment with sex,
drugs, friends, risks
• Still defining comfort • Has conflicts with authority • Is moving from a child-
FAMILY with independence/ figures parent/ guardian
dependence relationship to more
adult-adult relationships
• Peers very important for • Has strong peer friendships • Decisions/values less
development that help affirm self-image influenced by peers and
• Has intense friendships • Peer groups define right and more influenced by
with same sex wrong individual friendships
PEERS
• Has contact with • Selection of partner based
opposite sex in groups on individual choice
rather than on what
others think
• Focus is on self- • Has preoccupation with • Forms stable relationships
exploration and romantic fantasy • Has mutual and balanced
evaluation • Tests how he or she can sexual relations
SEXUALITY attract others • Is more able to manage
• Sexual drives emerging close and long-term
sexual relationships
• Plans for the future
Sources:
WHO. (2003). Orientation programme on adolescent health for health-care providers. Geneva, Switzerland: WHO Press.
WHO. (2010). IMAI one-day orientation on adolescents living with HIV. Geneva, Switzerland: WHO Press.

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Effects of HIV Infection on the Changes of Adolescence2
Growth:
HIV affects growth in adolescents who are perinatally infected with HIV. The following section
is not meant to pertain to ALHIV who were infected as adolescents, as they have typically
already reached their adult height by the time they are diagnosed with HIV. Even in perinatally
infected children, the physical effects of HIV may be minimized through the use of effective
ART.
• If HIV disease is fairly advanced, an adolescent may experience delays in physical
development, including delays in the physical changes of puberty (for example, delayed or
irregular menstrual cycles in girls). As a result, ALHIV may appear younger and smaller than
other adolescents because they have not yet begun the physical process of becoming adults.
• ALHIV may be shorter than their peers, either because of stunting early in life or slowed
growth throughout childhood and adolescence. This may lead to a negative self-image and
may also affect how other people view the adolescent (e.g. as sick and younger than his or
her actual age).
• ALHIV may experience drug-related side effects, including those that change physical
appearance, like lipodystrophy (changes in fat distribution on the body).

Cognition:
• Adolescents perinatally infected with HIV may experience neurological consequences of
longstanding HIV infection. The result may be developmental delays and learning problems.

Psychological and social effects:

• ALHIV are very likely to experience emotional difficulties. These difficulties may not
necessarily be due to health status, but rather to the pressures of life and a history of loss
(including the loss of parents and home).
• Illness may prevent ALHIV from going to school regularly, from making friends, and from
learning sports and hobbies. Due to illness, ALHIV may miss out on activities that help
define adolescents’ identities. 3
• HIV can bring with it concerns about prognosis; body image; stigma and isolation; fear of
disclosure; and having to take multiple medications. These concerns may affect ALHIV’s
mental health and their sense of fitting in with peers.
• Many ALHIV live with either one or neither birth parent. Although they may be living with
extended family, in some cases these adolescents may not feel “attached” or like they are a
part of their adopted home. This can lead to a sense of isolation or a sense that “nobody
loves them.”

Peers:
• ALHIV may experience peer problems, which can be exacerbated by the stigma associated
with HIV.
• ALHIV may have to regularly miss school to attend clinic appointments. This may impact
their educational attainment and their sense of fitting in with peers.
• In some places, few ALHIV attend school. This suggests that the school environment is not
supportive of ALHIV’s needs, which further alienates them from their school-attending
peers.4
• If adolescents feel different from their peers, they have a harder time bonding with them.
This can have an adverse effect on the attachments of ALHIV, making it difficult for them
to separate from their parents or caregivers.

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No Longer Children, Not Yet Adults5
There are a number of characteristics that distinguish adolescents from both children and adults.
As these are generalizations or even stereotypes, however, they are not applicable to every
adolescent client. Distinguishing characteristics of adolescents may include:
• Energetic, open, spontaneous, inquisitive
• Unreliable and/or irresponsible
• Moody
• Desire independence
• Influenced by friends
• Less influenced by family
• Looking for role models (often outside the family)
• Embarrassed to talk to adults about personal issues
• Desire to be different from parents and previous generation in general

HIV prevention, care, treatment, and support services need to be tailored to meet the needs and
characteristics of adolescent clients. Services that are tailored in this way are referred to as
“youth-friendly services” and are discussed further in Session 2.3.

Exercise 1: Adolescents: Not Big Children or Little Adults: Small group work and large
group discussion
Purpose • To understand some of the important things health workers
should consider about the special needs of adolescent clients
• To understand how and why adolescents are a heterogeneous
(diverse) group and what implications this has for their care
While working in small groups, participants will be asked to discuss 1 of the following
questions:
• What are some of the special characteristics of adolescents that health workers need to
consider when providing them with HIV care and treatment?
• How and why do the needs of adolescent clients differ from those of pediatric and adult
clients?
• Adolescents are a heterogeneous/diverse group. What are some of the differences health
workers may see among different adolescent clients? What are the implications of these
differences for their HIV care?

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Special Considerations for Adolescent Clients2
Adherence to medicines:
• Although younger adolescents may still rely on a parent or caregiver to remember to take
their medicines, older adolescents need to take some or all of the responsibility for taking
their medicines every day and as directed by the health worker.
• Often, adolescents struggle with adherence at various points in their development, as they
strive to form their own identity and to fit in with peers.
(Adherence to medications is discussed further in Module 8.)

Adherence to care:
• Adolescent clients often have less disciplined or structured lives than adults. They may also
have less stable relationships outside of the family. These factors make adherence to care and
treatment more difficult.
• Adolescent clients are more likely than adults to lack the skills to negotiate health services
and to understand side effects, treatment options, and regimen requirements.
• Outreach is more difficult with adolescents because they are scattered and it is harder to
bring them into care (while children are accessible through their parents and caregivers).
• Adolescents can become lost in the system when in transition from pediatric to adult HIV
services. (Transition is discussed further in Module 13.)
(Adherence to care is discussed further in Module 8.)

Stigma and discrimination:

• Blame is often placed on adolescents living with HIV (especially those who acquire HIV
behaviorally) because of an assumption that they were infected after voluntarily engaging in
“risky behavior.” This blame — often misplaced and always oversimplified — results in
stigma and discrimination.
• The stigma and discrimination associated with HIV prevents many adolescents from
disclosing their HIV-status. This may be a particular issue when adolescents decide to
become involved in a sexual relationship.
(Stigma and discrimination is discussed further in Module 5.)

Counseling adolescents:
• Adolescents’ cognitive abilities and skills are different from adults. They require both
different counseling approaches and, in many cases, more extensive and intensive counseling
sessions.
• Conflicts between cultural or parental expectations and adolescents’ emerging values can
present serious challenges for adolescents.
• Adolescent clients often depend on their parents or caregivers (for example, for money and
housing) and can therefore not always make independent decisions.
• Adolescent clients have a range of future decisions to make, like whether to have children,
whether to get married, etc.
• Adolescents face strong peer pressure and tend to be dependent on peers for lifestyle
guidance.
(Counseling is discussed further in Module 4.)

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Safer sex:
• Adolescents may not understand risk-taking behavior or the importance of risk reduction.
This makes them vulnerable to unintended pregnancy and sexually transmitted infections
(STIs).
• There is a widespread belief that adolescents living with HIV are “not supposed” to be
having sex. As a result, they often hide their sexuality.
• Adolescents may have limited access to condoms and other contraceptives. Even when they
do have access to contraceptives, they may lack the skills to use them correctly and/or
negotiate their use.
• For young women living with HIV, gender inequality may further reduce their ability to
negotiate condom use.
(Safer sex is discussed further in Module 10.)

How Adolescents Differ from One Another

Adolescents are a heterogeneous group. By definition, they range in age from 10 to 19 years. The
personality and expectations of a person who is 10 years old is very different from that of a 19-
year-old, even though both are adolescents.

Adolescents differ according to their stage of development; gender; sexual orientation; home and
family situation; and educational level. Some come from well-off families, others come from
poor families; some are from urban areas while others are from rural areas. Some adolescents are
in a relationship, some are married, and others have yet to have a romantic relationship. Some
adolescents know their HIV-status while others do not; some have never experienced stigma or
discrimination while others may face it every day.

Health workers need to assess each adolescent client’s care, treatment, and support needs. They
must also ensure that the adolescent’s care and treatment plan is tailored to meet these unique
needs. In particular, counseling and education need to “meet the adolescent where he or she is.”
(Sexual orientation is discussed further in Module 10.)

ADOLESCENT HIV CARE AND TREATMENT – PARTICIPANT MANUAL MODULE 2–8

Session 2.2 Adolescent Vulnerabilities, Risk-Taking
Behaviors, and Their Consequences

Session Objectives
After completing this session, participants will be able to:
• Discuss risk-taking as a normal part of adolescence as well as the consequences of negative
risk-taking
• Discuss some of the vulnerabilities faced by adolescents

Risk-Taking As a Normal Part of Growing up

Risk-taking is simply part of an adolescent’s struggle to test out an identity that provides self-
definition and separation from others, including the adolescent’s caregivers. Adolescents must
attain social autonomy during their second decade of life and this often involves moving away
from dependence on their family. As the influence of their family decreases, new social
relationships — especially with peers — begin to gain greater importance. Adolescents’ peers
often influence their risk-taking.

Risk-taking can be healthy or unhealthy. Healthy-risk taking provides important

opportunities for growth, whereas unhealthy risk-taking involves activities that are dangerous.
• Healthy risk-taking includes participating in sports, developing artistic and creative abilities,
traveling, making new friends, and contributing constructively to one’s family or community.
• Curiosity, sexual maturity, a natural inclination toward experimentation, and peer pressure
can lead to unhealthy or negative risk-taking (risk-taking that can be dangerous). This
includes drinking, smoking, using drugs, driving recklessly, unsafe sexual activity, self-
mutilation, running away, and stealing.
• A sense of powerfulness, feelings of invulnerability, and impulsiveness can lead to a lack of
future planning and can compromise protective behavior.
• Sometimes, unhealthy risk-taking is caused by a lack of knowledge about life’s risks. For
example, adolescents may know little about STIs, may find it difficult to use condoms
consistently and correctly, or may lack communication and negotiation skills. As a result, they
may not use condoms during sex.
• In some cultures, young men are encouraged to take risks as a way of proving their
masculinity.

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Health workers should:
• Encourage and help adolescents to find healthy risks, which may prevent unhealthy risk-
taking.
• Help adolescents evaluate risks, anticipate the consequences of their choices, and develop
strategies for diverting their energy into healthier activities when necessary.
• Share lessons learned from their own histories of risk-taking and experimenting.
• Advise adolescents to seek additional help if they are:
• Experiencing psychological problems (such as persistent depression or anxiety that goes
beyond more typical adolescent "moodiness")
• Having problems at school
• Engaging in illegal activities
(Psychosocial support and mental health issues are discussed further in Modules 5 and 6.)

Types and Consequences of Unhealthy Risk-Taking Behavior1,2,6

Unhealthy risk-taking can result in:
• Poor adherence to ART or HIV care and treatment, resulting in a drop in CD4 count,
disease progression, opportunistic infections (OIs), a greater chance of passing HIV to sexual
partners, and drug-resistance
• Unprotected sex, resulting in putting partners at risk of HIV infection and resulting in a risk
of unwanted pregnancy, unsafe abortion, and contracting STIs (including re-infection with
different strains of HIV)
• Experimentation with substances, such as alcohol and marijuana, resulting in short- and
long-term consequences:
• Substance use and abuse can interfere with judgment and adherence; poor medication
adherence will cause a decline in immune-system function.
• Alcohol use can suppress the immune system, can lead to increased susceptibility to
opportunistic infections, and can compromise the body’s response to AZT.2
• Many illicit drugs, including nicotine, can reduce the functioning of the immune system,
which may strengthen the virus.2
• For adolescents on ART, substance use and abuse can adversely interact with HIV
medications, causing illness.2
• Like many ARVs, illegal substances are often processed through the liver. Combining
illegal substances with ARVs can lengthen the time that illegal substances stay in the
bloodstream, thus increasing toxicity and the chance of overdose.2
• Alcohol reduces inhibitions and affects decision-making. Alcohol can also cloud people’s
judgment and give them the “courage” to do things they would not normally do. A study
from Botswana (the study focused on people age 15–49, but findings are most likely
applicable to adolescents) found that people who drink heavily were more likely to have
unprotected sex, to have multiple partners, and to pay for sex with money or other
resources. 6 Intergenerational sex was also strongly associated with heavy drinking.
(Substance abuse is discussed further in Module 9).

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Physical Vulnerabilities1,7
• Young people are more vulnerable to STIs than adults for many reasons (see next section).
• Young women are particularly susceptible to STIs because the cells that line the inside of
the normal adolescent cervical canal are more vulnerable to infections than the cells that
line the mature cervical canal of an adult.
• The prevention and early treatment of STIs in people living with HIV is important to
reduce the risk of both STI and HIV transmission to sexual partners (and babies), as well
as to prevent the long-term health consequences of STIs.
• Adolescence is a time of rapid growth and development, creating the need for a nutritious
and adequate diet. ALHIV, like all people living with HIV, are particularly vulnerable to
nutritional and caloric deficiencies, due to the increased energy demands that HIV imposes
on the body.
• HIV can contribute to compromised physical and psychological development, including
stunting and slower than normal growth.

Social, Psychological, and Emotional Vulnerabilities1

• Psychological factors that put many adolescents at increased risk of physical harm (e.g. of
having an automobile accident or getting an STI) include a general sense of invulnerability,
the desire to try new things (including drugs and alcohol), and a willingness to take risks (e.g.
having unsafe sex, changing sexual partners often, or having a partner who has multiple
partners).
• Adolescents may be living in family situations where there is little social and material/
financial support.
• Mental health problems can increase during adolescence, due to the hormonal and other
physical changes of puberty and changes in adolescents’ social environment. (Mental health
issues of ALHIV are discussed further in Module 6.)
• Adolescents often lack assertiveness and good communication skills, which can make them
unable to articulate their needs and withstand pressure or coercion from peers or adults.
• Adolescents may feel pressure to conform to stereotypical gender roles.
• Often, there are unequal power dynamics between adolescents and adults (adults may still
view adolescents as children).
• Adolescents are more vulnerable than adults to sexual, physical, and verbal abuse because
they are less able to prevent these shows of power.
• Adolescents may lack the maturity to make good, rational decisions.

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Socioeconomic Vulnerabilities1
• During adolescence, young people’s need for money often increases, yet they typically have
little access to money or gainful employment. This may lead adolescents to steal or take work
in hazardous situations. Girls, in particular, may be lured into transactional sex.
• Poverty and economic hardship can increase health risks, particularly if accompanied by poor
sanitation, lack of clean water, or an inability to afford/access health care and medications.
• Adolescents are more likely to experiment with drugs and alcohol, and disadvantaged
adolescents are at greater risk of substance abuse.
• Young women often face gender discrimination that affects food allocation, access to health
care, adherence to care, the ability to negotiate safer sex, and opportunities for social and
economic well being.
• In many societies, a girl’s status is only recognized when she marries and has a child. Some
young women marry very young to escape poverty and, as a result, may find themselves in
yet another challenging situation.
• Many young people are at risk due to other socioeconomic and political reasons. These
especially vulnerable youth include street children, sex workers, child laborers, refugees,
young criminals, those orphaned because of AIDS or other circumstances, and other
neglected and/or abandoned youth. (Most-at-risk adolescents are discussed further in
Module 5.)

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Session 2.3 Providing Youth-Friendly Services to
Adolescents

Session Objective
After completing this session, participants will be able to:
• Describe the characteristics of youth-friendly HIV care and treatment services

Characteristics of Youth-Friendly Services

Table 2.3: Characteristics of youth-friendly services

Health worker Health facility
Program design characteristics
characteristics characteristics
• Specially • Separate space for • Youth involvement in program design and
trained/oriented young people monitoring
staff* • Special times when • Drop-in clients welcomed
• All staff display young people can • Short waiting times
respect for youth receive services • Set up to provide chronic disease management,
• All staff maintain • Convenient hours including multiple appointments and medications
privacy and • Convenient location • Appointment systems in place as well as tracking
confidentiality • Adequate space and systems for clients who miss appointments
• Enough time for privacy • Affordable rates or no fees for services
health worker- • Comfortable, youth- • Publicity, marketing, or recruitment materials
client interaction friendly surroundings that inform and reassure youth
• Peer Educators • Friendly to both male and female clients
available • Wide range of services available —“1-stop
shopping”
• Referrals available to clinical and community-
based services
• Youth-friendly educational materials available to
take away
• Youth support groups
• Peer Educators available
* Including training in the following areas:
• Clinical HIV care for adolescents
• How to build trust with and counsel adolescents
• Providing psychosocial support to adolescents
• Mental health assessment, counseling, and referrals
• Disclosure counseling
• Adherence counseling
• Positive living counseling
• Sexual and reproductive health counseling and services
• Preparing adolescents for the transition to adult care
Adapted from: Senderowitz, J., Solter, C., & Hainsworth, G. (2004). Comprehensive reproductive health and family planning
training curriculum. 16: Reproductive health services for adolescents. Watertown, MA: Pathfinder International.

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Organizing Youth-Friendly Services
There are many things health workers, health facility managers, and youth can do to improve the
youth-friendliness of comprehensive HIV care and treatment services. Sometimes even the
smallest adjustments or changes can help — without necessarily creating additional workload or
incurring any additional costs. A step-by-step guide for making services more youth-friendly is
provided in Table 2.4. In addition, a sample of a client satisfaction survey for youth is provided
in Appendix 2C. Please note that the topics of program modification and quality improvement
will be discussed further in Module 14.

Table 2.4: Making services more youth-friendly

Step How
• Conduct an assessment using a tool such as the one included
in Appendix 2B: Checklist and Assessment Tool for Youth-Friendly
HIV Care and Treatment Services.
• Ask clients what they like about the clinic and what needs
improvement.
• Interview clients who have dropped out of care — ask
them why they decided not to come back and what could
Assess clinic needs: be done to make the clinic more youth-friendly.
figure out what needs to be
done to make services • Ask parents what could make services more welcoming for
more youth-friendly. their children.
• Ask colleagues what needs to change in order to ensure that
services are accessible and meet the needs of young people.
• Review national or local reports on the topic or review
manuals from other clinics or programs to find out what
others have done to attract and retain young people.
• Visit a neighboring clinic that has been very successful in
welcoming youth.
• Based on interviews and research done during the assessment
phase, list the areas that need improvement and how they can
Design an action plan be improved.
that will respond to the • For example, if several clients mentioned that they are
needs identified in the scared of the receptionist because she is rude, one of the
assessment. This plan areas for improvement might be: “Ensure that receptionist
should list the most makes clients feel welcome.” Then suggest ways to address
important activities first. this need; for example, by providing one-to-one training
For each activity, it should and support for the current receptionist, by relieving the
include a timeline and list receptionist of other duties so that he or she can focus
the person responsible for solely on welcoming clients, by recruiting a new
that activity. receptionist, etc. Be sure to include the date by which this
activity should be completed and the person who is going
to make it happen. (See Module 16 for a template.)
Identify the needed • If an activity requires funds, identify the budget where these
human and material funds could come from. Remember that making services
resources. youth-friendly does not need to be expensive.

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 Step How
• To gain general agreement and support for the action plan,
first present it to the manager/supervisor.
• Work with others in management to ensure that the needed
support exists to implement the recommended changes.
Present the action plan to
stakeholders. • The action plan may need to be revised several times to
incorporate the suggestions of those in management and
ensure their support.
• Once management has approved the plan, present it to the
health workers and youth that will be involved in the program.
• Start implementing the activities in the action plan.
• Provide support to the people responsible for each activity.
Implement, monitor, and • Revisit the action plan monthly at first to see what progress
evaluate the planned has been made and where adjustments are needed.
activities. • Six months to a year after implementation, evaluate: find out if
the action plan has had an effect on the number of clients
retained in care by comparing the present year’s figures with
those of the previous year.

Remember that setting up youth-friendly HIV care and treatment services is a start, but in order
to really meet the needs of adolescent clients, quality, evidence-based HIV care must be
provided within the context of youth-friendly services.

Exercise 2: Making Services Youth-Friendly: Small group work and large group discussion
Purpose • To learn more about the characteristics of youth-friendly HIV
care and treatment services
• To begin to assess gaps and challenges, and to start planning
next steps for providing youth-friendly HIV care and treatment
services at participants’ health facilities
Refer to Appendix 2B: Checklist and Assessment Tool for Youth-Friendly HIV Care and
Treatment Services when working in small groups.

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 Module 2: Key Points

• Adolescence, the years between the ages of 10 and 19, is characterized by rapid growth and
development as well as significant psychological and emotional changes.
• During adolescence, social relationships move from being family-centered to being more
peer- and community-centered. It is also a time when new skills and knowledge are acquired
and new attitudes are formed.
• ALHIV may experience adolescence differently. Most notably, long-standing HIV infection
and/or advanced HIV disease may affect ALHIV’s expected physical and emotional
development. Social development may be atypical as well, particularly if the adolescent has
been ill for significant periods of time or if he or she has felt alienated from peers because of
HIV-related discrimination or because he or she feels different from peers.
• As part of growing up, adolescents take risks. Risk-taking is the tool adolescents use to define
and develop their identities. Healthy risk-taking is a valuable experience.
• Unhealthy risk-taking, however, can sometimes have lifelong consequences. For ALHIV,
such consequences can include poor adherence to medications or the discontinuation of
care. ALHIV may also take sexual risks, which can lead to the further spread of HIV.
• Health workers should remember the reasons that clients may be vulnerable as well as the
ways these vulnerabilities relate to risk-taking behavior and their participation in and
adherence to HIV care and treatment. An understanding of their adolescent clients’ lives can
help health workers work with ALHIV to transition safely into adulthood.
• In order to serve adolescent clients with HIV-related health services, clinics and programs
must be able to attract, meet the needs of, and retain these clients.

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Appendix 2A: Tanner Staging System
Girls — breast and pubic hair development
Pubic hair
Stage Breast development development
Description
1 Breasts: pre-pubertal, no breast
tissue with flat areola. No pubic
hair.

2 Breast budding with widening of

the areola. Small amount of long
hair at base of female labia majora.

3 Larger and more elevated breast

extending beyond the areola.
Pubic hair: moderate amount of
curly and courser hair extending
outwards.
4 Larger and more elevated breast;
areola and nipple projecting from
the breast contours. Pubic hair
resembles adult hair but does not
extend to inner surface of thigh.
5 Mature stage: breast is adult size
with nipple projecting above
areola. Pubic hair: adult type and
quantity extending to the thigh
surface.
Female Tanner staging image by Michał Komorniczak, medical illustrations. Poland.

ADOLESCENT HIV CARE AND TREATMENT – PARTICIPANT MANUAL MODULE 2–17

Boys — development of external genitalia and pubic hair
Development of Testicular
Stage external genitalia and volume in ml, Description
pubic hair* length in cm
1 Genitals: pre-pubertal, testes small in size
with childlike penis. No hair.

2 Testes reddened, thinner, and larger

(1.6–6cc) with childlike penis. Small
amount of long hair at base of male
scrotum.

3 Testes larger (6cc–12cc) and scrotum

enlarging; increase in penile length.
Moderate amount of curly and courser
hair extending outwards.

4 Testes larger (12cc–20cc) with greater

enlargement and darkening of the
scrotum; increase in length and
circumference of penis. Pubic hair
resembles adult hair but does not extend
to inner surface of thigh.
5 Testes over 20cc with adult scrotum and
penis. Pubic hair: adult type and quantity
extending to the thigh surface.

* Note that a circumcised penis is depicted here — an uncircumcised penis would look slightly different.
Male Tanner staging image by Michał Komorniczak, medical illustrations. Poland.

ADOLESCENT HIV CARE AND TREATMENT – PARTICIPANT MANUAL MODULE 2–18

Appendix 2B: Checklist and Assessment Tool for Youth-Friendly HIV Care and Treatment
Services
Facility name: Type of facility/clinic:

Questions to Assess Youth-Friendliness Answer Comments/Recommendations

Location
How far is the facility from public transportation?
How far is the facility from places where adolescents spend
their time?
How far is the facility from local schools?
Facility hours
During what hours is the clinic open?
Does the clinic have separate hours/days for youth?
Is there a sign listing services and clinic working hours?
What times are convenient for adolescents to seek services?
Facility environment
Does the facility provide a comfortable setting for young
clients?
Does the facility have a separate space to provide services to
adolescent clients?
Does the facility have a separate waiting area for adolescent
clients?
Is there a counseling area that offers both visual and auditory
privacy?
Is there an examination room that provides both visual and
auditory privacy?
Are both young men and women welcomed and served at the
clinic?

ADOLESCENT HIV CARE AND TREATMENT – PARTICIPANT MANUAL MODULE 2–19

Questions to Assess Youth-Friendliness Answer Comments/Recommendations
Staffing
Are all health workers trained in pediatric HIV care and
treatment?
Are all health workers trained in adolescent HIV care and
treatment?
Have all staff members (including data clerks, pharmacists,
receptionists, etc.) received orientation about adolescent
services?
Do health workers show respect for adolescent clients during
counseling sessions and group sessions?
Are there job aides available to help health workers in their
daily work with adolescents?
Services provided
Is 1-stop shopping provided to adolescent clients? Describe.
Are the following services provided to adolescent clients
directly (note if through referral):
• HIV testing and counseling
• Comprehensive care, including the prevention and
treatment of OIs
• Malaria prophylaxis and treatment
• ARVs/ART
• Adherence preparation
• Ongoing adherence assessment & counseling (at each
visit)
• Pregnancy testing, antenatal care, and PMTCT
• Sexual and reproductive health counseling
• Condoms and water-based lubricant
• Contraception (which methods?)
• STI screening and treatment
• Positive prevention counseling
• Psychosocial counseling and support

ADOLESCENT HIV CARE AND TREATMENT – PARTICIPANT MANUAL MODULE 2–20

Questions to Assess Youth-Friendliness Answer Comments/Recommendations
• Nutrition counseling
• Laboratory tests (CD4, other HIV tests)
• PEP, as per national guidelines
Are there outreach services, especially targeting most-at-risk
adolescents? Explain.
Do adolescent request services other than the ones offered?
Which ones?
Is there a formal referral system for services not provided at
the clinic?
Is there a formal referral system for services required by most-
at-risk adolescents (sexual abuse counseling and treatment,
drug/alcohol rehabilitation, support for youth-heads of
household, etc.)? Which ones?
Is there a tracking and follow-up plan in place for clients who
do not return?
Peer education and counseling
Is a peer education program available?
How many Peer Educators are working at the facility?
How many hours/days per week do Peer Educators work at
the facility?
What are the roles and responsibilities of Peer Educators?
How are the Peer Educators trained?
Is there a system for supervising and monitoring Peer
Educators?
Educational activities
Are educational/information materials available? Which ones?
Are there educational posters displayed?
Are there posters or brochures that describe clients’ rights?
Are there materials for adolescent clients to take home?
In what languages are the materials?

ADOLESCENT HIV CARE AND TREATMENT – PARTICIPANT MANUAL MODULE 2–21

Questions to Assess Youth-Friendliness Answer Comments/Recommendations
Are group education sessions held with younger adolescents?
Describe.
Are group education sessions held with older adolescents?
Describe.
Are group education sessions held with parents/caregivers?
Describe.
Are adolescent support groups held (with younger
adolescents)? Describe.
Are adolescent support groups held (with older adolescents)?
Describe.
Are there ways for adolescent clients to access information or
counseling off-site (via a hotline, etc.)?
Youth involvement
Are adolescents involved in decision-making about how
programs and services are delivered?
What ways are there for adolescents to give feedback to clinic
staff?
How could adolescents be more involved in decision-making at
the facility?
What other roles could adolescents play in clinic planning,
operations, and evaluation?
Supportive policies
Do clear, written guidelines or standard operating procedures
(SOPs) exist for adolescent services?
Do written procedures exist for protecting client
confidentiality?
Are records stored so that confidentiality is ensured?
Is parental/guardian/spousal consent ever required? In what
cases?
Is there a minimum age required for adolescents to receive
HIV testing?
Is there a minimum age required for adolescents to receive
contraceptives?

ADOLESCENT HIV CARE AND TREATMENT – PARTICIPANT MANUAL MODULE 2–22

Questions to Assess Youth-Friendliness Answer Comments/Recommendations
Are there policies or procedures that pose barriers to youth-
friendly services?
Administrative procedures
Is the registration process private so that others cannot see or
hear?
Can adolescent clients be seen without an appointment?
How long do adolescent clients normally have to wait?
What is the average time allotted for client/health worker
interaction?
Publicity/recruitment
Does the clinic publicize the services available to adolescents,
stressing confidentiality?
Are there staff or volunteers who do outreach activities?
Describe.
Fees
Are adolescents charged for any services? If so, which ones
and how much?
If there are fees, are they affordable to adolescent clients?
OTHER?

Adapted from: Senderowitz, J., Solter, C., & Hainsworth, G. (2002). Clinic assessment of youth friendly services: A tool for assessing and improving reproductive health services for youth. Watertown,
MA: Pathfinder International.

ADOLESCENT HIV CARE AND TREATMENT – PARTICIPANT MANUAL MODULE 2–23

Appendix 2C: Sample Client Satisfaction Survey for Youth
Clinic/Facility: _______________________
Lead physician or nurse (if applicable): _________________
Your name (optional): ____________________ Date: _________________

Please help us improve our services by answering some questions about the services you
received.

We are interested in your honest opinion — whether positive or negative. Your answers
will be kept confidential.

1. The staff at the clinic communicated clear information to me.

1 2 3 4 5
Strongly Disagree Somewhat Agree Agree Strongly Agree
Disagree

2. People at the clinic included my opinions when making decisions.

1 2 3 4 5
Strongly Disagree Somewhat Agree Agree Strongly Agree
Disagree

3. The staff at the clinic listened to me.

1 2 3 4 5
Strongly Disagree Somewhat Agree Agree Strongly Agree
Disagree

4. The staff at the clinic involved my family/caregivers in my care.

1 2 3 4
More than I About the Less than No involvement,
wanted right amount I wanted which is what I wanted

5. I am satisfied with the progress I have made toward my treatment goals (taking
medication/adherence, participating in psychosocial support activities, etc.)

1 2 3 4 5
Strongly Disagree Somewhat Agree Agree Strongly Agree
Disagree

ADOLESCENT HIV CARE AND TREATMENT – PARTICIPANT MANUAL MODULE 2–24

6. The staff at the clinic worked well together.

1 2 3 4 5
Strongly Disagree Somewhat Agree Agree Strongly Agree
Disagree

7. The staff at the clinic spent enough time with me.

1 2 3 4 5
Strongly Disagree Somewhat Agree Agree Strongly Agree
Disagree

8. The staff at the clinic treated me with respect.

1 2 3 4 5
Strongly Disagree Somewhat Agree Agree Strongly Agree
Disagree

9. The staff at the clinic gave me support.

1 2 3 4 5
Strongly Disagree Somewhat Agree Agree Strongly Agree
Disagree

10. I would recommend this clinic/program to a friend who needed similar help.

1 2 3 4 5
Strongly Disagree Don’t Know Agree Strongly Agree
Disagree

11. On a scale from 1-10, how would you rate the care you received?

1 2 3 4 5 6 7 8 9 10
WORST BEST

12. Is there a staff member who worked especially well with you? If yes, can you explain why?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

13. Comments? (Please use the back of this page if necessary)

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Thank you for helping us improve the quality of our services. Your opinion is important to us!

Adapted from: Foster Family-based Treatment Association. Sample TFC youth satisfaction survey (2008) and Customer satisfaction survey,
Child version (2007).

ADOLESCENT HIV CARE AND TREATMENT – PARTICIPANT MANUAL MODULE 2–25

References

1 Senderowitz, J., Solter, C., & Hainsworth, G. (2004). Comprehensive reproductive health and family planning training
curriculum. 16: reproductive health services for adolescents. Watertown, MA: Pathfinder International.

2 Baylor International Pediatric AIDS Initiative. (2010). HIV curriculum for the health professional. Houston, TX: Baylor

College of Medicine.

3Usitalo, A. Psychiatric issues in adolescents with HIV/AIDS. PowerPoint presentation for the Florida/Caribbean AIDS
Education and training Center, May 13-14, 2011 in Orlando, Florida.

4 Obare, F., van der Kwaak, A., et al. (2010). HIV-positive adolescents in Kenya: access to sexual and reproductive health services.

KIT Development Policy and Practice, Bulletin 393. Amsterdam: KIT Publishers.
5 WHO. (2010). IMAI one-day orientation on adolescents living with HIV.

6Weiser SD., Leiter K., Heisler M., McFarland W., Percy-de Korte F., et al. (2006). A population-based study on alcohol
and high-risk sexual behaviors in Botswana. PLoS Med, 3(10): e392. Available at:
[Link]

7Hsu, JW., et al. (2005). Macronutrients and HIV/AIDS: a review of current evidence: consultation on nutrition and
HIV/AIDS in Africa: evidence, lessons and recommendations for action. Durban, South Africa: WHO, Department of
Nutrition for Health and Development.

ADOLESCENT HIV CARE AND TREATMENT – PARTICIPANT MANUAL MODULE 2–26