Anamnesi i valoració

Adolescence is the period when many young people begin sexual experimentation and the majority of the millions of those who become sexually active live in countries with a high HIV burden thus increasing their vulnerability. According to UNAIDS (2008) as cited in Jewkes, Dunkle, Nduna and Shai (2010:1) owing to its long latency period, the sexually transmitted epidemic starts among women and men in their teenage years before it manifests as AIDS in later life. The main causes of the transmission of HIV among young people are: unprotected sex with an HIV-positive person or contact with infected blood or other fluids through the sharing of non-sterile injecting equipment. In addition, many adolescents living with HIV were born with the virus (UNICEF 2011a:1, 7).

The rapid roll-out of anti-retroviral treatment programmes has made it possible for perinatally infected infants to live through adolescence and adulthood, thereby engaging in dating and sexual relationships (Edmonds, Yotebieng, Lusiama, Matumona, Kitetele, Napravnik, Cole, Van Rie & Behets 2011:6). However, the sexual and reproductive health needs of this unique and rapidly increasing population are largely unmet. In Uganda, the HIV/AIDS treatment, care and support programmes are still organised around either adult or paediatric care and therefore fail to adequately address the needs of this growing segment of the population that usually falls between these two groups (Birungi, Mugisha, Nyombi, Obare, Evelia & Nyinkavu 2008:1). Therefore, HIV remains a major threat to the reproductive health of young people globally. Yet due to their age, social or economic status the young people may have limited access to information and services (UNICEF 2012:23).

In 2012, it was estimated that 2.1 million (5.9%) of the people living with HIV are adolescents aged 10–19 years in middle and low income countries (UNAIDS 2013:18). HIV-related deaths among adolescents increased by 50%, while the global number of HIV-related deaths fell by 30 percent (WHO 2013c:1). Globally, around 2500 new cases of HIV infections occur among adolescents and youth ages 15–24 every day. Additionally, approximately 712 new cases of HIV are diagnosed each day in children under 15 years of age due to vertical transmission and sexual coercion (WHO 2013b:2) .In the US, 1 in 4 of people aged 13–24 years is living with HIV and is not aware of the infection. It is estimated that in 2009, about 2 million adolescents (aged 10–19) were

living with HIV. Although they are found in countries in all continents, 1.8 million live in sub-Saharan Africa and therefore, young people living with HIV/AIDS are a major African public health problem (UNICEF 2012:23).

Eastern and Southern Africa is home to 2.7 million people aged 15 to 24 years living with HIV, which is more than half of all HIV-positive young people globally. Uganda is one of the twenty Sub-Saharan African countries with the most new infections among young people aged 15-24 years old with an estimated 46,000 new infections annually (UNAIDS 2010 as cited in UNICEF 2011a:6). According to the recent AIDS indicator survey in Uganda 4 percent of the young people age 15–24 years are living with HIV. However, there is a gender gap; HIV prevalence among women age 15–24 years is 5 percent, while among men, it is only 2 percent (UNAIDS 2011:112).Globally, young women aged 15-24, have HIV infection rates twice as high as in young men, and account for 22% of all new HIV infections and 31% of new infections in Sub-Saharan Africa (Cowan & Pettifor 2009:290; UNAIDS 2011:1).

Persistent challenges to effective HIV prevention for adolescents and young people include biological susceptibility due to traumatic injury to the genitalia during sexual intercourse which is high in cases of experience of sexual violence as a child or adolescent and repeated violence (Kerrigan et al 2010 as cited in UNAIDS 2013:7), gender inequalities, gender based violence and forced sex against young women and girls (Jewkes et al 2010:46; UNAIDS 2013:17, 78; Reza, Breiding, Jama, Mercy, Blanton, Mthethwa, Bamrah, Dahlberg & Anderson 2009:1969) undermine their ability to protect themselves from HIV infection and/or to make smart decisions regarding sexual health.

Knowledge of HIV sero status is key to linkages to HIV care and prevention (Tumwebaze et al 2012:1). Access to and uptake of HIV testing and counselling by adolescents is lower than for many other groups leaving them disadvantaged in terms of seeking and being linked to HIV prevention, treatment and care services. In sub- Saharan Africa it is estimated that only 10% of young men and 15% of young women (15–24 years) were aware of their HIV status (WHO 2013b:viii). This is due to inaccessibility and underutilisation of health facilities. In many developing countries young people have limited access to high-quality, youth-friendly HIV and sexual and reproductive health services (WHO 2013b:34). Adolescent services must be confidential

because stigma, perceived and experienced, and inadvertent disclosure of HIV status hampered adolescents from utilising HIV services (Mutwa, VanNuil, Asiimwe-Kateera, Kestelyn, Vyankandondera, Pool Ruhirimbura, Kanakuze, Reiss, Geleen, Van de Wijgert & Boer 2013:3). Furthermore, limited protection for young people’s confidentiality and right to medical privacy presents a barrier to access to service utilisation (Mutwa et al 2013:3; Mbeba, Mkuye, Magembe, Yotham, Mellah & Mkuwa 2012:2).

In many countries, health workers, even those experienced in caring for adults with HIV, are often ill-equipped to support the health-care needs of adolescents. There is little experience with understanding and providing services for the particular needs of adolescents, and judgemental attitudes toward sexually active adolescents which hamper rapport and subsequent care (WHO 2013b:5; Mbeba et al 2012:2). Health care seeking and utilisation by pregnant adolescent girls is often poor (Atuyambe 2008:5). Adolescent girls with HIV have less access to PMTCT interventions than adult women, leading a significant proportion of perinatally infected infants born to adolescents mothers missing early care (Horwood, Butler, Haskins, Phakathi & Rollins 2013:1; WHO 2013b:5).

Adequate information can change attitudes and behaviours related to HIV markedly. However, many young people in Africa still lack comprehensive and correct knowledge about HIV (Oljira, Berhane & Worku 2013:1738). According to UNAIDS, about 60 percent of young people in the age range 15-24 years, are not able to correctly identify the ways of preventing HIV transmission (UNAIDS 2008 as cited in UNICEF 2012:7).In Uganda, comprehensive knowledge about AIDS is generally lowest at 36% among those age 15–19 (UBOS 2011:191).There is an urgent need to address the knowledge gap about HIV. Therefore, there is a need to equip young people with the knowledge and skills which would empower them to make responsible choices on their lives.

All the above factors contribute to late diagnosis of HIV infection resulting in delayed initiation of antiretroviral therapy (ART) and poor adherence to therapy for both perinatally and horizontally infected adolescents (WHO 2013b:ix).

Policy and programmatic efforts to develop effective HIV prevention and treatment programs targeted towards youth living in resource-poor urban settings require

empirical evidence on the drivers of HIV-related behaviour including HIV testing and counselling. This section has demonstrated that HIV is still a growing public health problem in Uganda and the younger age-group (adolescents) is at more risk because of communication gaps and inadequate information on effective preventive measures in this age group. Therefore there is a need to explore the implementation of school-based sexuality education in rural primary schools in Uganda.