HIV Prevention and Treatment for Adolescents: A Social Study of Africaid Whizzkids United's Comprehensive Model

This document describes a case study done on behalf of Oxfam in order to describe the "social aspects" of the work of Africaid Whizzkids United (WKU). Africaid is a non-governmental organisation (NGO) that provides HIV prevention, treatment, and care and support services to adolescents, particularly those living with HIV, in the Edendale Township, KwaZulu-Natal, South Africa, a high-prevalence, resource-constrained setting. "A key feature of Africaid's programs is that it uses football as a language and a medium to promote adolescents' health through life skills training, peer education, and a mixed-gender football league." According to the organisation, football is an appropriate language and medium for engaging adolescents on issues of sexual health. "It's Health Academy is central to its activities and to it's success in attracting young people to use sexual and reproductive health services and in improving their ARV [antiretroviral] adherence."

The research methods include a focus group which made use of age-specific structured play with members of an HIV support group for adolescents living with HIV, who attend the Health Academy. This included two interactive, creative activities: a poster making discussion session and a drama-based role playing session, which presented common HIV prevention related scenarios which have emerged from existing, relevant literature. Interviews were also used.

Strategies for involving young people include a systematised approach to using football to teach life skills to learners in schools using the WhizzKids United "On the Ball" curriculum, developed by Africaid's founding HIV specialist nurses during their time in Ghana, where they "gained critical insights into how playing sports with teenage clients could combat HIV-related stigma and be used as a forum to encourage them to come forward for HIV testing....The curriculum has the goal of cultivating qualities in its young participants such as self-efficacy, a love of learning, support and promotion of gender equality, and an appreciation for the positive dimensions of an active lifestyle." Africaid trained peer educators in schools to use this curriculum so that they could reinforce the messages it contained, as well as refer youth to appropriate places/services.

In addition to the life skills curriculum, Africaid had developed the Whizzkids United Health Academy by 2010 (known as the Health Academy), an adolescent-only health centre located at an area hospital, which provides a welcoming place for youth including a football pitch, access to food and beverages, a television, and social activities enjoyed by young people, all of which serve to draw the population in and provide them with access to HIV-related health services. The Health Academy was developed in conjunction with the Department of Health on their land, a strategically important collaboration for the future of this approach.

The Health Academy, which largely sees clients between the ages of 10 and 20 years old, works to overcome negative perceptions that young people have of public-sector health facilities, including: perceived judging by nurses for requesting contraception and lack of privacy from family and community when visiting a clinic. The academy uses psychosocial services such as support groups, couples counselling, peer counselling, and rape and trauma counselling. Clients (rather than patients - a specific language choice because "clients" receive education and recreation as well as health services and are consumers with rights) can participate in a 3-session adherence-training course to improve ARV follow through. There are homework clubs, life skills training, peer education, and psychosocial support for children who are heavily affected by or orphaned by AIDS, including home visits. Together with regular health services ranging from tuberculosis screening to family planning to nutritional analysis and support, the Health Academy has served as many as 2,000 clients in a year (2012) providing over 12,000 services.

Helping clients to overcome HIV-related stigma is a primary goal of the "On the Ball" curriculum because it is a "critical barrier to anti-retroviral initiation and adherence..." The report details the effects of stigma on disclosure, particularly among parents and children. To address this, the Health Academy encourages work with immediate and extended families on the importance of disclosure and overcoming stigma using the football analogy of "knowing your opponent.”"

In addition, to advance gender equality and emphasise that the Health Academy is a youth-friendly place, there was a piloted programme of a mixed gender football league (MGFL). During the period between October 2010 and March 2011, 62 players out of 64 underwent HIV counselling and testing (HCT), qualifying nearly half of them for social support services from the Department of Social Development.

Some tools that help present a warm and welcoming atmosphere to adolescent clients include:

• Rather than conventional nursing uniforms, Health Academy staff wears NGO-branded t-shirts.
• To address the fear of seeing neighbours and family at public-sector clinics, the Health Academy is an adolescent-only facility. Nurses and counsellors reassure their clients that "this is an adolescent clinic. You can’t even find your mother or your neighbours there if you come for family planning."
• Counsellors are trained to explain that their services are confidential.
• Outreach by Life Skills educators uses football analogies.
• Extra-curricular activities help to destigmatise HCT services because a young person could be watching music videos, seeing a physiotherapist for a football injury, or using the free Internet access. "The fact that there is a football pitch outside the front of the facility where teams made up of both young men and women play in a 'mixed gender league' is also designed to make the place into a 'cool hang-out' for adolescents."
• The name Health Academy rather than clinic is designed to reduce the stigma for young clients who are participating in being educated about HIV prevention and ARV adherence.
• Contraception is offered upon request without judgement and young people are attended to as soon they come, even if this is during school hours, and provided with a doctor’s note if need be. Attending to adolescents when they first appear means they are more likely to come back.

The NGO has a strong monitoring and evaluation programme (M&E) through which they document "the efficacy of, and changes to, their programmes." Through active M&E, Africaid has found that there was a "statistically significant improvement in 19 out of 30 behavioural predictors measured (such as physical activity level, knowledge about HIV transmission, and testing and self-efficacy to refuse unsafe sex) in participants in Africaid´s programmes." Another evaluation indicated that Africaid´s primary school "On the Ball" curriculum has also improved predictors of sexual risk behaviour among participants. The research notes that, among the initial adolescent clients with very low levels of ARV adherence, there was "a huge improvement in biological markers in terms of CD4 increase and viral load going down in about 90% of the youth...." after 8 months.