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HIV Voluntary Counseling and Testing Among Youth Results from an exploratory study in Nairobi, Kenya, and Kampala and Masaka, Uganda Horizons Program Kenya Project Partners Uganda Project Partners HIV Voluntary Counseling and Testing Among Youth Ages 14 to 21 Results from an Exploratory Study in Nairobi, Kenya, and Kampala and Masaka, Uganda Horizons Program International Center for Research on Women Population Council Kenya Project Partners Adolescent Counseling Clinic in Kenyatta National Hospital (ACC) Kenya Association of Professional Counselors (KAPC) Kibera Community Self-Help Programme (KICOSHEP) Riruta City Council Clinic St.

John’s Community Center University of Nairobi Wazu Dance Troupe Uganda Project Partners AIDS Information Center (AIC) Buganda Kingdom Youth Project Center Kitovu Hospital Mobile Home Care Programme Makerere University Naguru Teenage Information and Health Center The AIDS Support Organization (TASO) Acknowledgments Many people and institutions have contributed their time and creativeness to this study and report. Julie Denison, Johns Hopkins University, and Sam Kalibala, Horizons Program/Population Council, guided the survey for the Horizons Project.

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Dr. Edward Kirumira of Makerere University, Dr. Charles Nzioka of the University of Nairobi, Jane Harriet Namwebya, Dr. Josephine Kalule, and Daniel Lukenge of the AIDS Information Center in Kampala, Edith Mukisa of the Naguru Teenage Information and Health Center in Kampala, Ann Owiti of the Kibera Community SelfHelp Program, and Dr. R. Koigi Kamau of the Adolescent Counseling Clinic in Nairobi all participated in part of the design or implementation of the survey research. Dr. Naomi Rutenberg, Horizons Program/Population Council, Dr.

Ann McCauley, Horizons Program/International Center for Research on Women (ICRW), and Scott Geibel, Horizons Program/Population Council assisted with the research component. Kerry MacQuarrie, ICRW, and Ann McCauley prepared this final report. Dr. Kirumira, Dr. Josephine Kalule, Julie Denison, and Horizons Program members Milka Juma, Karungari Kiragu, Laelia Gilborn, Naomi Rutenberg, Sam Kalibala, Ellen Weiss and Margaret Dadian reviewed the report before publication. This study was supported by the Horizons Program. Horizons is funded by the U. S. Agency for International Development, under the terms of HRN-A-00-97-00012-00.

The opinions expressed herein are those of the authors and do not necessarily reflect the views of the U. S. Agency for International Development. Published in October 2001. The Population Council is an international, nonprofit, nongovernmental institution that seeks to improve the wellbeing and reproductive health of current and future generations around the world and to help achieve a humane, equitable, and sustainable balance between people and resources. The Council conducts biomedical, social science, and public health research and helps build research capacities in developing countries.

Established in 1952, the Council is governed by an international board of trustees. Its New York headquarters supports a global network of regional and country offices. Copyright © 2001 The Population Council Inc. Table of Contents Executive Summary Methods Key findings Building on research Introduction Background Methods Study site and population Findings Youth testing experiences do not always match VCT model Most tested youth intend to practice safer sex Young people want to know their HIV status Youth appreciate counseling Several factors deter youth from seeking HIV tests 1 1 3 4 4 4 5 10 10 13 13 15 16 22 26 27 29 Peers play an important role for youth VCT study sites are not equipped to respond to youth issues Youth want confidential services and full disclosure of test results Building Interventions Based on Research References 31 HIV VCT Among Youth Executive Summary Voluntary counseling and testing (VCT) programs have increased the adoption of safe sexual behavior and the use of care and support services among adults (Coates et al. 1998). Are VCT programs appropriate for young people, who account for the majority of all new HIV infections in East and southern Africa?

To find out, researchers conducted exploratory research to identify opportunities for and barriers to providing VCT for youth. The first phase of the study, completed in May 2000, indicates that youth would like access to HIV testing and counseling services if the services are confidential and inexpensive and if the results are reported honestly. Methods In Nairobi, Kenya, and Kampala and Masaka, Uganda, researchers conducted focus group discussions and in-depth interviews with youth, parents, service providers, and community members and administered a survey among a convenience sample of young people ages 14–21.

In Uganda, the survey sample consisted of 135 youth who had taken an HIV test and 210 untested youth; in Kenya, researchers interviewed 105 tested and 122 untested youth. Although convenience samples cannot be used to generalize to larger populations, the respondents provided valuable comments and suggestions for improving services for young people. During a second phase, we will test different service delivery and promotional strategies identified in the exploratory phase to determine whether they increase the use of and satisfaction with VCT among young women and men. Key Findings

Most tested youth intend to practice safer sex. Among young people who had taken an HIV test, most said they would adopt safer behaviors, such as abstaining from sexual intercourse, practicing monogamy, using condoms, or reducing the number of sexual partners. Males and females reported similar intentions, except in Uganda, where the proportion of females who intend to practice monogamy is significantly greater than that of males. Counseling is a valued part of HIV testing. When asked to name the satisfactory aspects of their testing experience, clients mentioned the counseling more than any other component.

This happened even though the quality of counseling varied from service to service. One 21-year-old Kenyan woman commented positively on her experience: 1 “[The counselors who] gave me courage to go for the test were so friendly. They encouraged me that whatever the results I should not give up. I liked the fact that they told me to go back to them after the test. ” Yet some youth were disappointed with their testing experience, primarily because they did not receive counseling with the test. This occurred less often in Uganda than in Kenya, where fewer testing facilities provide truly voluntary services and good counseling.

Notably, one in four tested youth in the Nairobi group did not talk with a service provider before the HIV test. The same proportion of youth did not receive posttest counseling, and instead got their test results either as a written report or from a third person such as a parent. A 21-year-old Kenyan woman who found out she is HIV-positive expressed disappointment with the way she was dismissed after her test: “They should have sat me down and explained my status and counseled me on how I should take care of myself instead of treating me as if I were the first one to be diagnosed HIV-positive.

They made me feel as if I would die tomorrow. ” Most youth disclose their HIV test results. Only two young people in Uganda and ten in Kenya who got tested told no one about their serostatus. The most frequent response to the question “With whom did you share your test results? ” was partners/spouses and peers. Fewer than one-fourth told parents about their test results. Some said that they did not want their parents to know that they are sexually active. Others feared that their parents, especially their mothers, would worry if they knew about the testing.

The majority of untested youth would take an HIV test. Seventy-seven percent of untested respondents in Kenya and more than 90 percent in Uganda said they would like to be tested for HIV at some point in the future. Young people said they would be attracted to VCT if the services are confidential and inexpensive and if the results are reported to them honestly. Service providers are not equipped to respond to youth issues. Service providers interviewed in Kenya and Uganda reported that counseling young people requires special training and improved, youth-oriented referral services.

Because many youth do not easily open up when asked to explain their problems or answer sensitive questions, providers require training to develop the skills needed to work with these clients. However, some youth tell them so much about their personal lives that it is often difficult for counselors to respond. Counselors reported frustration when youth do not return for follow-up or ignore such advice as discontinuing unprotected sex. 2 HIV VCT Among Youth More support services are needed for counseled youth in Uganda.

Ugandan providers said they want to be able to refer youth who have been raped, threaten suicide, plan to leave home or school, or plan to harm their partners, but few youth-appropriate services or support groups exist. Providers in one clinic formed posttest clubs for youth to help them maintain safe behavior. Building on Research In Uganda, service delivery organizations have used the data from the formative research to design VCT programs that are youth-friendly and provide high-quality voluntary counseling and testing.

The program improvements include: • Increased training of service providers in counseling skills for youth about HIV. • Use of a separate room and alternative locations so that youth do not have to risk seeing familiar adults or family members when seeking VCT. • Reduced price of testing service. • Establishment of a referral system for young clients that providers can use at all locations. • Improved outreach to schools and youth groups. • Introduction of VCT at a youth reproductive health center. • A multimedia campaign to inform youth about VCT.

In Kenya, project partners are planning to develop and implement special services for youth, including: • Opening an adolescent counseling and recreational center where youth have access to free VCT, among other services. • Introducing youth-friendly VCT services at existing facilities, such as fast-tracking youth seeking VCT. 3 Introduction Background HIV voluntary counseling and testing (VCT) programs have demonstrated their ability to increase safe sexual behavior and use of care and support services among adults (Coates et al. 1998).

By helping clients learn their HIV serostatus and creating a personalized HIV risk reduction plan, VCT can provide the information and support necessary to change risky behaviors that could lead to HIV infection or transmission (CDC 1994). Counseling, both before and after the test, and a risk reduction plan are the key features that distinguish VCT from other HIV testing services. VCT has become a widely advocated HIV/AIDS prevention strategy among adults. Most clients of VCT services are in their mid- to late twenties (Coates et al. 998; Ladner et al. 1996; Allen et al. 1992). Sixty percent of all new HIV infections in sub-Saharan Africa, however, occur among young people between the ages of 10 to 24 (UNAIDS 1998). Will VCT work as well for youth? Because few young people use any health services, using VCT as a strategy to reduce risk behaviors among young people appears to be more challenging than it would be among adults. Findings from exploratory research at two sites in Uganda and one site in Kenya provide some answers to this question.

Specifically, researchers sought to understand young people’s experiences with HIV testing and the factors that inhibit or motivate youth to use testing services. Researchers, in partnership with service-providing organizations, used these findings to develop strategies to reach youth with VCT services. Methods Teams of researchers and service providers conducted the study in Nairobi, Kenya, and in Kampala and Masaka, Uganda (see Box 1). The research team conducted a survey, in-depth interviews, and focus group discussions among convenience samples of youth, parents and community leaders, and service providers.

Youth were categorized as “tested youth” if they had previously had an HIV test and as “untested youth” if they had never had an HIV test. The pre-coded survey was administered only to tested and untested youth. Researchers asked whether or not youth respondents had previously had an HIV test, but did Box 1 Kenya Project Partners Adolescent Counseling Clinic in Kenyatta National Hospital (ACC) Kenya Association of Professional Counselors (KAPC) Kibera Community Self-Help Programme (KICOSHEP) Riruta City Council Clinic St. John’s Community Center University of Nairobi Wazu Dance Troupe

Uganda Project Partners AIDS Information Center (AIC) Buganda Kingdom Youth Project Center Kitovu Hospital Mobile Home Care Programme Makerere University Naguru Teenage Information and Health Center The AIDS Support Organization (TASO) 4 HIV VCT Among Youth not ask survey respondents to disclose their HIV status. Given the focus of the study on services that youth had received, regardless of their HIV status, the research team felt that asking about a youth’s HIV status was invasive and not necessary to enhance our understanding of young people’s testing experiences.

However, several HIV-positive youth disclosed their status during in-depth interviews. Study Site and Population For the purposes of this study, youth is defined as being between the ages of 14 and 21 years. The survey sample sizes are, in Kenya, 105 tested youth and 122 untested youth and, in Uganda, 135 tested youth and 210 untested youth (see Table 1). All quantitative findings in this report are based on these convenience samples.

Although convenience samples cannot be used to generalize to larger populations, the findings do reveal important insights into youth experiences with HIV testing. Youth respondents also provided valuable suggestions for improving services for young people. Because the convenience sample did not include equal numbers of girls and boys at all sites and because sex-disaggregated sample sizes were subsequently small, we present data analyzed by sex only when there were interesting differences between males and females. 5 Table 1 Sociodemographic characteristics of youth samples

Tested youth Kampala (n = 86) % Sex Male Female Age group 14-17 18-21 Currently in school Yes No Marital status Single Married Cohabitating Separated/ divorced Ever had sex Yes No Site of HIV test Clinic Hospital School Youth center Blood bank Church Other No response 34 66 23 77 55 45 93 1 6 0 90 10 59 13 4 12 9 0 1 2 Masaka (n = 49) % 63 37 37 63 35 65 100 0 0 0 65 35 8 35 49 0 4 2 2 0 Nairobi (n = 105) % 23 77 15 85 21 79 91 5 2 2 90 10 39 34 8 2 0 0 14 3 Untested youth Kampala (n = 111) % 50 50 49 51 56 44 95 2 3 0 77 23 Masaka (n = 99) % 51 49 47 53 54 46 96 1 3 0 69 31 Nairobi (n = 122) % 48 52 48 52 49 51 92 7 1 1 66 34

Note: Percentages may not add up to 100% since percentages were rounded to the nearest whole. We also interviewed 16 service providers in Uganda and 30 service providers in Kenya. We conducted 12 focus group discussions with 120 parents in Uganda and seven focus group discussions with parents in Kenya. The parents in this study were not necessarily the parents of the youth surveyed in the study. 6 HIV VCT Among Youth Nairobi, Kenya Thirty-six organizations in Nairobi provide HIV counseling and testing services for all age groups, according to an inventory compiled by Family Health International and the Horizons program in 1998.

Another eight provide counseling and refer clients elsewhere for the HIV test. Many changes to health services have probably occurred since the 1998 inventory, including the closing of the only freestanding VCT center and a hospital service unit for adolescents because of lack of funding. In Nairobi, we recruited tested youth through each of the project partners that provided HIV testing services (see page 4). Some tested youth had their HIV tests through these providers, while other tested youth had their tests elsewhere, with clinics and hospitals being the most common provider.

Researchers were able to find and talk with more females than males and with more tested youth in the older age group (18 to 21) than the younger age group (14 to 17). We recruited service providers from these same services and from other health and community facilities around Nairobi. Untested youth, parents, and community leaders were recruited from Silanga Kibera, an area within one of Nairobi’s largest low-income areas. Some of the tested youth also came from this area. In general, fewer young people use health services than do adults.

As part of the study, the research team interviewed staff at seven of the inventoried sites that provide youth services as well as at six additional HIV testing facilities in Kibera that young people themselves identified. Most of these organizations provide general health services to fewer than ten young clients per month. Only four organizations serve more than 20 young people on average per month, although two services see an average of 500 female and 800 male clients of all ages per month for their general health care services.

Each testing service—including the project partners and the other services used by youth in the study—provides a slightly different configuration of HIV testing and counseling. For example, some services provide pretest counseling but refer youth elsewhere for the blood test and ask them to return with the result for posttest counseling. Other services provide testing but not counseling. HIV testing as part of antenatal care may not always be voluntary at all services. Some youth attended a VCT day organized at their school.

Many youth in the sample had taken an HIV test at a center separate from the location where they were recruited for this study. These variations reflect the realities of HIV testing services in Nairobi and should be kept in mind while interpreting the study results. Kampala and Masaka, Uganda Research partners again helped recruit young people for the study in Uganda. Tested youth in Kampala were recruited through the main branch of the AIDS Information Center (AIC), the Naguru Teenage Information and Health Center, and the Buganda Kingdom Youth Project Center.

In Kampala, researchers found it was relatively easy to identify tested youth without going through the providers’ networks. Most tested youth in Kampala had their test at a clinic, although hospitals, youth centers, and blood banks were also common places for testing. We recruited untested youth 7 from the Naguru Teenage Information and Health Center, the Nakawa marketplace, secondary schools, and elsewhere in the Naguru community. We recruited parents for focus groups and interviews from the Nakawa marketplace, parent-teacher associations, and two churches.

In Masaka, the research team depended more heavily on the providers’ networks to locate tested youth. We recruited tested youth in Masaka from the mobile clinic network and a farming school where the Kitovu Hospital Mobile Home Care Programme operates. Therefore, most tested youth reported they had their test at a school or hospital, and some reported having it at a clinic. We recruited untested youth from communities in the catchment areas of the Kitovu Hospital Mobile Home Care Programme. We recruited parents from parent-teacher associations and from those who brought their children for counseling at The AIDS Support Organization (TASO).

In both Masaka and Kampala, it was difficult to recruit younger participants, especially those between the ages of 14 and 15. For tested youth, it was easier to recruit tested males in Masaka because most farming school students are male. In Kampala the research team identified more tested females, and service providers in Uganda confirmed the tendency for higher numbers of females to request HIV testing in the city and more males to request HIV testing up-country. Separate HIV testing first became available in Uganda in 1990 in response to the growing number of people seeking to learn their HIV status through donating blood.

Various public facilities offer HIV testing, including the major district referral hospitals, the STD Clinic at Mulago Hospital, the Nakasero Blood Bank, Kampala City Council Health Centers (in Naguru, Kawempe, and Kiswa), and the Uganda Virus Research Institute. Testing in Kampala and Masaka is also available through private practitioners and nongovernmental organizations (NGOs), including the project partners. HIV testing is generally available to both adults and young people throughout Uganda. As in Kenya, however, these are not necessarily youth-focused services.

One existing directory, compiled by the Makerere Institute of Social Research and AIC, lists the major HIV-related service providers in Kampala, but no up-to-date record of the institutions offering such services specifically for young people is available. Youth in Kampala have more options than youth in Masaka for facilities that offer HIV testing, including AIC’s main branch, the Naguru Teenage Information and Health Center; other private facilities; and major hospitals. AIC youth-specific activities include free testing days in Kampala and educational outreach in schools and youth groups.

In Masaka, youth may seek an HIV test at TASO, Kitovu Hospital, or AIC’s indirect site at Masaka Hospital. In both cities, youth centers, which often provide HIV/AIDS counseling, also refer youth to AIC and hospitals for pretest and posttest counseling and the HIV test. The number of youth going to these services varies. The Naguru Teenage Information and Health Center, for instance, reports seeing an average of 350 youth per month for various health concerns; 60 percent of these youth are between the ages of 14 and 19.

However, service providers from Naguru report that youth often do not go to the same VCT service to which they were referred. Youth as young as 13 years old seek testing at AIC even though it does not target youth directly. In 8 HIV VCT Among Youth 1997 alone, 11 percent of all AIC clients were youth from age 13 to 19. Data from 1999 reveal that 4,675 youth from age 14 to 21 attended AIC, representing about 20 percent of the total clientele. 9 Findings Youth Testing Experiences Do Not Always Match VCT Model

The research team was interested in determining how closely the testing experiences of Kenyan and Ugandan youth match the VCT model (see Box 2). Since pretest and posttest counseling are distinguishing elements of VCT, researchers asked tested youth about the counseling components of their testing experience. Researchers also asked young people how they received their test results and whether follow-up care was offered. Researchers found that many young people’s testing experience did not closely match the VCT model. Box 2 What is the VCT model?

VCT is the process by which a person undergoes counseling enabling him or her to cope with stress and make informed choices about HIV testing. Confidentiality of counseling sessions, test results, and the voluntary choice to test are emphasized. Decision to seek testing Pretest counseling The test process The implications of testing Risk assessment & risk prevention Coping strategies Decision to test Preventive counseling No Yes Posttest counseling HIV-negative News given Risk reduction plan made Discussion about disclosure of HIV status HIV-positive News given Risk reduction plan made Discussion about disclosure

Follow-up counseling and support Medical care Emotional support Social support 10 HIV VCT Among Youth Nearly 20 percent of all tested youth did not talk to a health worker before taking the test. According to a 16-year-old female from Nairobi, “Nobody counseled me and I was afraid. ” As shown in Table 2, in Masaka, more young people had posttest counseling than pretest counseling , while in Kampala and Nairobi the reverse is true. In general, counseling appears to be more common among our sample in Uganda than in Kenya, with more Ugandan youth reporting pretest or posttest counseling than their Kenyan counterparts.

A few Kampala youth (3 percent) had group counseling instead of one-on-one counseling. Many Ugandan youth recall that Table 2 Youth exposure to counseling* pretest sessions with health care Kampala Masaka Nairobi Percent who: workers covered UNAIDS(n = 86) (n = 49) (n = 105) recommended counseling issues. % % % For instance, in Kampala at least 90 percent of youth from various Talked to a health worker 90 84 72 service locations reported before taking the test discussing how HIV is Received test results 84 98 58 transmitted, condoms, and the through counseling implications of an HIV-positive result (see Table 3).

More *This table is based on convenience samples of tested youth from Kenyan youth recalled selected sites. discussing topics related to a personal risk assessment or a risk reduction plan than did youth in the other sites. In Masaka, the majority of youth report discussing with a health care worker how the HIV test is performed. Fewer than half of Masaka youth, however, discussed other pretest counseling issues with a health care worker. Only 4 percent of Masaka youth and no Nairobi youth remembered discussing all the listed topics. Most youth received their test results through one-on-one counseling (see Table 2).

However, such posttest counseling was much more rare in Kenya (58 percent) than in the sites in Uganda (90 percent). In Kenya, 23 percent learned their test results only in writing, and 8 percent learned their results through their parents, suggesting that confidentiality was not maintained. More than twice as many young girls than boys received their results through counseling in Kenya. Tested youth in Masaka and Nairobi were almost never referred to follow-up or support services after the testing experience. About 90 and 93 percent, respectively, received no referrals.

Kampala youth fared somewhat better, however, with only 60 percent receiving no referral. Among the youth in Kampala who were referred, the largest number were referred for counseling services or for information about or access to family planning and condoms. 11 Table 3 Counseling topics* Client recall of issues discussed with counselor Survey sites Uganda Kampala Masaka (n = 77) (n = 41) % % 94 12 65 24 96 17 87 15 78 32 70 39 87 7 84 12 75 39 68 29 48 71 83 51 58 7 63 49 90 34 85 22 71 49 64 49 Kenya Nairobi (n = 76) % 95 93 96 97 91 92 86 71 71 61 64 66 86 75 71 72 74 63

HIV transmission Abstinence Condoms STIs infections Limiting number of sexual partners Monogamy Confidentiality of counseling session Second test Partner notification/discussion of VCT and HIV Bringing sexual partner for testing How the test is done Stages of HIV Returning for results Possibility of refusing the test Implications of being HIV-positive How to seek support if HIV-positive Who to tell HIV status to if HIV-positive How to tell someone you are HIV-positive * This table is based on convenience samples at selected sites.

These findings indicate that young people’s experiences with counseling are uneven. Young people may miss opportunities to develop personalized risk reduction plans. Although many youth received some form of counseling, such counseling is not universal and may not cover the range of topics recommended in VCT. Additionally, the lack of follow-up referrals is of particular concern. Without adequate referrals, young people may not have adequate access to health care and support services. 12 HIV VCT Among Youth Most Tested Youth Intend to Practice Safer Sex

Among the 235 young Figure 1 Behavioral intentions of tested youth people who have taken an HIV test, Since having an HIV test, do you intend to: 100% most intend to adopt safer sexual behaviors 80% after the HIV test. Kampala (n=84) 60% These include Masaka (n=46) abstaining from 40% Nairobi (n=105) sexual intercourse, 20% practicing monogamy, 0% using condoms, or reducing the number Decrease Abstain Use Practice number of condoms monogamy of partners with partners whom they have sexual intercourse. Both males and emales report similar intentions, except in Kampala, where the proportion of females who intend to practice monogamy is greater than that of males (84 and 72 percent, respectively). Researchers asked youth only about their intentions and not whether they actually adopted these behaviors. We therefore could not measure the impact of HIV testing on actual behaviors. During in-depth interviews in Kampala, several girls indicated that they would encourage their partners to also have an HIV test, and that they might break off the relationship if the partner refused. This decision is, perhaps, another risk-reducing behavior.

Below are some examples of what these females said about this topic: “I will talk to my boyfriend about the results. I will also request him to come for the HIV test. If he refuses we may have to separate. ” [18-year-old female, Kampala] “I didn’t tell my boyfriend [my results] because I had asked him to come with me and test, but he had persistently refused to listen to me. I am just going to leave him because he might infect me later. ” [20-year-old female, Kampala] It is interesting that some youth intend to practice safer sex even though they did not receive counseling.

Respondents Young People Want to Know Their HIV Status Survey results show that youth have a strong interest in knowing about their HIV status. More than 75 percent of untested youth in Kenya and about 90 percent in Uganda indicate they would like to be tested in the future. Furthermore, of those youth who have already had an HIV test, a similarly 13 large majority (74 percent in Kenya, 84 percent in Uganda) indicate they intend to repeat the test. Some have already proceeded with a second test. Untested youth are aware of existing testing services.

A majority of untested youth—more than eight out of ten—in all three samples can correctly name at least one facility that provides HIV testing services. However, they do not always name the nearest site or sites that provided youth-friendly services. Only 11 percent of untested youth in Nairobi named a service provider within their communities. Additionally, many untested youth who named hospitals as a source for testing services said that they assumed that such large facilities automatically provide HIV testing and counseling among their services. This assumption may or may not be the case.

Young people seek HIV tests while healthy. Young people usually seek an HIV test while they are healthy. Having HIV symptoms and feeling ill are seldom reasons that tested youth give for finding out their serostatus. Rather, the most commonly cited reason that tested youth give for getting an HIV test is to “know their HIV status in general. ” This reason is given by 84 percent of Ugandan youth. Reasons cited less frequently in Uganda include “distrust of partner” (30 percent), “being worried” (21 percent), and “exposure to HIV risk” (22 percent), and in Kenya, “pregnancy” (21 percent) and “service provider referral” (10 percent).

In Kenya, 7 percent of the sample report that the decision to have a test was not theirs but a parent’s or doctor’s, and several say they were not informed they had been tested for HIV. Few youth in any site mentioned “plans to marry” as a reason for the HIV test. Among tested youth, some 10 percent to 30 percent report that they have never had sexual intercourse (see Table 1). This finding suggests that young people may know little about how HIV is transmitted, or that they use VCT services to get accurate information about HIV.

Service providers’ perceptions of the reasons young people give for having an HIV test are somewhat different than those that youth reported. According to our in-depth interviews, service providers believe youth seek HIV tests because of exposure to HIV risk. This reason was given by two-thirds of the Kenyan service providers interviewed in the study. “To know one’s status” is the least common reason given by service providers in Uganda, perhaps because this answer encompasses more specific answers.

Other common reasons that providers gave include distrust of a partner and having HIV symptoms. About 77 percent to 93 percent of untested youth say they want to be tested in the future, and these youth also plan to get tested while healthy. “Knowing one’s status in general” again emerges from the survey as the most common reason for wanting an HIV test. This response is given by approximately 80 percent of all untested youth. Untested youth less frequently cite “plans to marry” in both countries and “distrust of partner” in Uganda as reasons they would like an HIV 4 HIV VCT Among Youth test. Even fewer young people count exposure to HIV risk, having STD symptoms, or having HIV/AIDS–like symptoms among the reasons they would like an HIV test. When asked why other youth probably go for an HIV test, Ugandan youth cited prevention. One male explained that the purpose of testing is “to know your status and plan accordingly depending on the results one gets. ” Another commented, “Some people who really care about their health, they deliberately go for medical check-up and even test for HIV. Having an HIV test while healthy usually opens up the possibility of using the testing experience as a preventive measure. A Ugandan youth stated simply how testing could be used as a tool for prevention, even if there has been prior exposure to risk: “You may just want to know your serostatus after messing up with so many women, then when you find that you do not have HIV, you may decide to abstain and wait for the time to marry and you go with your partner for the test. ” [male, 18 to 21 age group, Masaka] Youth Appreciate Counseling

When we asked young people what they liked about their testing experience, “advice” was the most common response (see Figure 2). In-depth interviews and focus group discussions give further insight into the importance of counseling. “These people, that is, the people who gave me courage to go for the test [the counselors], were so friendly. They encouraged me that whatever the results I should not give up. I liked the fact that they told me to go back to them after the test and tell them the results so that if there was something we needed to share, we would. [21-year-old female, Nairobi] “The counselor prepared us so that we could take the results well whether they were positive or negative. ” [19-year-old male, Nairobi] Yet some youth were disappointed with their testing experience, primarily because they did not receive counseling with the test. This occurred less often in Uganda than in Kenya, where fewer testing facilities provide counseling. A 21-year-old Kenyan woman who found out she is HIVpositive expressed disappointment in the way she was dismissed after her test: “They should have sat me down and explained my status and counseled me on how I hould take care of myself instead of treating me as if I were the first one to be diagnosed HIV-positive. They made me feel as if I would die tomorrow. ” 15 Even though some young people did not benefit from VCT-quality counseling, counseling proved to be the cornerstone of the testing experience. Providing full-scale VCT, or at least strengthening existing counseling efforts, would go far to increase youth satisfaction with and demand for HIV testing. Figure 2 What tested youth liked about the service 100% 80% Respondents 60% 40% 20% 0%

Warm reception Quick service Confidentiality Free Professionalism entertainment of health care workers Advice/ information given Kampala (n=85) Masaka (n=48) Nairobi (n=105) Several Factors Deter Youth from Seeking HIV Tests Different patterns in the process of deciding to take an HIV test emerged in Kenya and Uganda. Between 45 percent and 53 percent of Ugandan youth in our survey took a month or longer—quite some time—from the time they made the decision to seek an HIV test to actually go to a testing facility. Many untested youth (32 percent to 44 percent) also said they are still thinking about taking the test.

Many Kenyan youth (41 percent), however, took the test the same day—often within hours—that they made the decision to do so. Half of these youth reported that they had the test in response to the referral of a service provider or because of a pregnancy. For some of these youth, the decision to have an HIV test may not have been theirs alone. Promoting the benefits of VCT among Kenyan youth may increase the number who request HIV tests without prompting from service providers. 16 HIV VCT Among Youth Kenyan youth think testing is only for the ill. Although most Kenyan youth ho had an HIV test did so while healthy, focus group discussions with youth and adults reveal that the community perceives that young people seek tests only when ill. In actuality, only 7 percent of tested youth had the test because they felt ill. Similarly, only 4 percent of untested youth surveyed in Kenya said they wanted a test because of HIV-like symptoms. When explaining why they believe other youth in their community have an HIV test, however, untested Kenyan youth clearly associate seeking an HIV test with finding the cause of an existing illness.

The youth considered the HIV test to be a tool for doctors to use in diagnosing a problem and determining appropriate treatment. Only those who suspect they have HIV or other illnesses seek a test. “If you feel you are healthy, there is no point of having your blood drawn and you don’t have that disease,” according to one Kenyan female. The parents and community leaders interviewed in Kenya concurred that testing is only for those who are ill. One pastor in a focus group discussion noted that “residents of this community don’t go for HIV tests.

They only go for treatment of opportunistic diseases. ” It is through the process of diagnosing an illness that young people are tested for HIV, according to community members in the study. Having an HIV test to know one’s status generally or to prevent the spread of HIV was mentioned only rarely. There is, then, a difference between why young people actually want to go for an HIV test and why the community (including youth) thinks youth decide to have an HIV test. This perception (that testing is only for the ill) may discourage some healthy youth who want an HIV test from seeking it.

Furthermore, the linking of illness with HIV testing diminishes the role that VCT can have as a prevention tool for healthy persons. Youth do not feel at risk. At all sites, many youth have not had an HIV test yet because they do not feel at risk of HIV (see Table 4). This was the most commonly cited reason in both Nairobi and Masaka. However, the majority of the Nairobi youth who did not feel at risk also report sexual risk behaviors, such as infrequent condom use during sexual intercourse. 17 Table 4 Factors preventing untested youth from having an HIV test What are the reason(s) you have not gone for an HIV test? Cost Stigma Lack of youth-friendly services Fear of people finding out Fear of positive result Inconvenient hours of service Distance of service Beliefs Peer influence Provider attitudes Waiting period for test results Don’t want to have a test yet Still thinking about it Do not feel at risk Never had sex No response Other Kampala (n = 99) % 18 6 6 24 44 1 4 0 6 1 0 17 44 21 16 2 17 Masaka (n = 92) % 30 0 0 17 28 2 1 0 2 0 0 8 32 39 20 1 14 Nairobi (n = 122) % 13 0 1 3 4 1 0 1 2 0 1 3 9 44 11 0 38 This table is based on convenience samples at selected sites. The question was posed to all untested youth who said they would like to have an HIV test at some point in the future. Multiple responses were allowed. Youth fear a positive HIV test result. Forty-four percent of Kampala youth and 28 percent of Masaka youth who want a test in the future report that they have not done so because they fear a positive result. However, only 4 percent of Kenyan youth said that fear of a positive result was the reason they had not yet sought a test.

A young female described how her fears delayed her from seeking a test: “It took around five years to decide to come for the test. This is because I was always scared of being tested in case the results are positive. This is because I had a boyfriend I didn’t trust and yet I had been having sex with him. ” [20-year-old female, Kampala] 18 HIV VCT Among Youth Youth do not want others to know they have been tested. Twenty-one percent of Ugandan youth who have not been tested say that fear of others finding out had prevented them from seeking the test, compared to only 3 percent of Kenyan youth citing this reason.

However, when groups of untested and tested youth were surveyed about which factors they think prohibit other young people from seeking an HIV test, more than 85 percent in Kenya cited lack of confidentiality or fear of someone finding out. Two reasons for not wanting others to learn about the testing experience are that youth want to avoid the stigma that some HIV-infected people suffer or that they prefer not to disclose that they are sexually active. Approximately 80 percent to 90 percent of tested youth thought stigma may prevent other youth from seeking a test.

A Kenyan male explained, “If you have sex with someone who has AIDS and you were planning to go for a test, you will not because if people learn about it, they will isolate you. ” In all focus groups and key informant interviews, parents and community leaders associated seeking an HIV test as an indication that a young person is sexually active. This may be a deterrent to young people who would like to know their HIV status but are not prepared to disclose sexual activity, since that behavior may be socially unacceptable. As a parent, especially for the boy, I would start imagining he has started moving out with women and I would get very worried. ” [mother, Uganda] “There is nothing you can do, but it surprises you because you had never expected such a child to be playing sex. ” [parent, Uganda] “In that age group you’ve mentioned, there is fear. According to the African culture, a child in that age group cannot tell his father that he wants to go for an HIV test. You know this will mean that he is indulging in immoral behaviors and this is not acceptable. [male community member, Nairobi] In contrast, during focus groups, young people said parents who know their child wants an HIV test could be a source of support for him or her. However, these same youth acknowledged that it is a difficult subject to discuss and struggled with how to approach an adult. To request an HIV test requires acknowledging sexual activity, which many young people are not prepared to do. One boy could not imagine telling his father. “Father, even though I am in school, the devil entered me and I had sex with girls. [pause] I don’t know how I can tell him. No one suggested approaching parents directly. As a result of stigma and the association of testing with sex, youth are concerned about the confidentiality of services. Two 20-year-old females in Kampala described how important confidentiality was in their testing experiences. “[I] like it when they didn’t ask for my name,” one of them commented. The other said, 19 “What I liked best about the HIV testing service was the confidentiality. First of all, when you [go] for the test, you and your partner talk to a counselor alone; therefore you can tell him anything without fearing that others are listening.

And secondly, your results are given to you individually or with your partner if you wish. ” Twenty-one of 30 service providers interviewed in Kenya said they would ensure client confidentiality by not sharing a client’s medical records with anyone. Some, but not all, providers offered such protections as locked areas or restricted access to medical records. However, when given a hypothetical scenario of a friend’s child requesting an HIV test, five of the 30 service providers said they would inform the parent, and another five said they would determine whether the child planned to inform his or her parents.

Adults have conflicting attitudes about youth receiving confidential testing services. Parental and community attitudes in Uganda about young people testing for HIV are not generally supportive, perhaps because the test signals sexual activity. Young people reported disapproving responses and outright antagonism from their parents if they knew that their child had taken an HIV test. Parents were reluctant to support young people under the age of 18 to go for HIV testing without their consent. Kenyan parents had conflicting views about young people seeking HIV tests independently and keeping their results confidential.

Parents gave a variety of ages, ranging from 10 to 30 years, at which youth should be able to seek an HIV test without parental consent. One parent’s comment expressed a common attitude in the focus groups: “I feel at this age, they can make independent decisions about their life. If he/she wants to go for testing so be it. ” However, most parents feel that it is also the doctor’s responsibility to find the parents and inform them of their child’s positive or negative HIV status, even if they feel their child can make the decision to have an HIV test on their own.

Some parents seemed to believe that a service provider would inform the parents as a matter of course. “It is the doctor who will come to look for me. He will tell me about my child’s HIV status and I in turn will talk to my child about how he can protect himself, else he will infect so many. ” [mother, Nairobi] Service providers in Kenya echoed the sentiment that young people should tell their parents about having an HIV test, but 19 out of 30 also said they would not require parental consent before providing an HIV test to young clients aged 17 or younger.

Most service providers in Uganda felt that HIV tests should be provided with or without parental consent to any youth who is at an age when sexual activity is common. Service providers gave a variety of ages at which they thought youth may be sexually active. “The youth (14-21 [years old]) should have a right to services and information pertaining to their health, with or without consent in [the] case of minors. ” [female service provider, Kampala] 20 HIV VCT Among Youth Costs prohibit some youth from seeking an HIV test. Cost prevents a number of youth who want an HIV test from having one.

Thirty percent (28) of untested Ugandan youth and 13 percent of untested Kenyan youth cited cost as a reason they have not had an HIV test yet (see Table 4). Masaka youth (in a more rural area) were most likely to say cost prohibited them from seeking a test. Cost also emerged as a topic of concern during focus group discussions. The research team surveyed HIV testing facilities and found that the cost of an HIV test ranges from Ugandan shillings 500 to 9,0001 in Kampala and Masaka and from 410 to 1,600 Kenyan shillings2 in Nairobi.

These rates do not necessarily include counseling services, which may be an added expense. The major providers in Uganda, however, often have free testing days or provide exemptions in cases of financial need. For instance, AIC offers three free testing days a year in Kampala: one for youth, one for couples on Valentine’s Day, and one on World AIDS Day. The Kitovu Mobile Home Care team in Masaka also subsidizes the fee on a case-by-case basis. Most tested youth in both countries had their tests for free or at a subsidized rate (see Table 5).

Most who pay for the test do so with their own money. The next most common group to pay the fee for youth are partners or spouses in Uganda (for 16 youth) and mothers in Kenya (for 19 youth). One young person in Uganda explained how difficult it was to ask someone else for money: “Most youth have no money and the little they use they just ask [for] from parents, but how do youth start asking a parent that I want money to go for HIV testing? ” It is unknown how many tested youth would have been unable to have the HIV test if they had to pay the full rate.

Because most youth who pay for the test do so on their own, young people may be especially sensitive to the price of the service. Extending low-cost or free testing options to more youth may increase demand. Table 5 Testing fees paid by number of youth* Kenya (n = 95)** Free 100 KSH or less 9 2 Uganda (n = 135) 301 KSH or more 19 Free 1,000 USH1 or less 7 1,001– 3,000 USH 46 3,001 USH or more 10 101–300 KSH 11 56 72 * This table is based on convenience samples at selected sites. **Ten Kenyan youth did not know the amount they paid for their HIV tests. 2 1,740 Ugandan shillings = US $1. 00 at the time of the study. 70 Kenyan shillings = US $1. 00 at the time of the study. 21 Some Kenyan youth doubt service providers will inform them of their test result. During each focus group discussion in Nairobi, several untested youth expressed the belief that doctors do not share HIV test results with young clients. “If he [the client] has AIDS, the doctor won’t tell him that he has it,” a young woman stated. Some thought a doctor would conceal HIV test results to protect a young client from bad news.

Because of this belief, some young people think testing has little value, which might decrease demand for HIV testing among youth. “The best thing is not to be tested, because even these doctors will not tell you the truth about the results,” one youth said. The tested youth in our study did not indicate similar doubts about their service providers’ honesty. Some untested youth expressed frustration that medical staff are not believed to be forthcoming, while other medical staff thought it was necessary to hide a positive result from a young client who may be illprepared for it.

In the latter case, the counseling and referrals for follow-up support that come with VCT may better prepare young clients to receive their results. Peers Play an Important Role for Youth Young people talk to one another about HIV testing. Young people usually learn about HIV from their peers in both Kenya and Uganda. These findings corroborate other research indicating that peers are young people’s primary information source about a range of reproductive health issues. Most youth have discussed HIV/AIDS issues in general with peers, as reported by two-thirds to three-quarters of youth surveyed.

In Uganda, nearly onehalf of young people also report talking with a partner or spouse about HIV. About two-thirds of untested youth in Kampala and Masaka know someone who has had an HIV test, usually a sibling, cousin, or peer (that is, another young person). However, only one-quarter of untested youth in Nairobi know someone who has had an HIV test, usually a peer or a neighbor. 22 HIV VCT Among Youth Table 6 From what source did you learn where to get tested for HIV? Tested youth Kampala (n = 86) % Peer Partner/spouse Siblings/cousins Both parents Mother Father Other relatives Teacher Radio Newspaper Youth center Health clinic Other 57 31 31 1 10 3 19 3 80 24 12 9 14 Masaka (n = 49) % 69 6 10 0 12 4 16 4 47 6 0 6 53 Nairobi (n = 105) % 43 3 11 1 4 1 6 2 3 3 10 30 52 Untested youth Kampala (n = 111) % 51 11 14 5 6 4 5 3 68 26 14 9 17 Masaka (n = 97) % 62 11 18 1 3 1 14 2 42 14 0 13 16 Nairobi (n = 102) % 37 0 11 2 5 0 14 4 4 2 0 17 43 * This table is based on convenience samples at selected sites. Multiple esponses were allowed. Peers are also the primary information source for identifying HIV testing services, as cited by tested and untested youth in Masaka and Nairobi (see Table 6). Peers are the second most frequently cited source of information for Kampala youth. Youth in Kampala and Masaka also learn about services from the radio. In fact, radio is cited more frequently than peers in Kampala. Kenyan youth also learn about testing services from their relatives and from clinics and posters, although these sources are cited less frequently.

The fact that peers are a key source of information about HIV testing highlights the potential to use peer networks to promote youth VCT services. Table 7 Have you recommended an HIV test to any of your peers? (%) Kampala Tested Untested (n = 86) (n = 111) 62 87 Masaka Tested Untested (n = 49) (n = 97) 65 90 Nairobi Tested Untested (n = 105) (n = 102) 69 11 * This table is based on convenience samples at selected sites. 23 Young people also recommend HIV testing to one another (see Table 7). An interesting finding is that, in both Uganda sites, many untested youth as well as tested youth had recommended an HIV test to someone.

In fact, slightly more untested youth recommended an HIV test than did tested youth. The fact that so many youth recommend HIV tests to their peers—whether or not they have been tested themselves—reaffirms the importance of peer-to-peer communication about HIV issues. Young people involve their peers in the testing experience. Peers also play a role in the actual testing experience. More than two-thirds of young people (80 percent in Kampala) who had an HIV test told someone about their plans for the test before having it. Usually this person is a peer (see Figure 3).

Parents were told to a lesser degree than were peers in Kenya, but this proportion (one in three) suggests a possible role for parents. In Kampala, tested youth often spoke with their partners as well. Young F ig u re 3 W h o m y o u th te ll a b o u t s e e k in g people in Masaka or Kenya, a n H IV te s t however, rarely spoke with 40% partners. Similar patterns are found among untested youth K a m p a la (n = 8 6 ) who were asked to whom 30% M a s a k a (n = 4 9 ) N a iro b i (n = 1 0 5 ) they would like to talk if they decide to have an HIV test. Respondents . 20%

About one-third of tested youth in Nairobi and Masaka 10% and 20 percent in Kampala told no one before having an 0% HIV test. This may be partly P a rtn e r/ S ib lin g s / O th e r F a th e r explained in Kenya, however, spouse c o u s in s re la tiv e s by the common practice of having the HIV test immediately following the recommendation of a service provider. These youth may simply not have had the chance to discuss the test with anybody, which does not necessarily signify any reluctance to do so. It does point out, however, that these youth may miss the opportunity for peer or family support during what may be an emotional experience.

Two things are noteworthy about the data on who accompanies youth to the testing facility. The first is the high number of youth who had the HIV test alone: 36 percent in Kenya and more than 50 percent in Uganda. For too many young people, the testing experience may be a lonely one. They neither tell anyone about it nor go with anyone for the test. These young people, in particular, may find VCT, with its emphasis on counseling, to be more supportive than other HIV testing procedures. 24 HIV VCT Among Youth The second noteworthy aspect is who accompanied young people for their HIV test.

Youth in Masaka and Nairobi were most often accompanied by their peers, followed by siblings or cousins, and mothers. In Kampala, young people were also accompanied by peers or mothers, but even more youth were accompanied by a partner or spouse. Further analysis indicated that more females than males tended to be accompanied by a partner or spouse and that males more frequently went with peers. It is possible, though, that fewer males in our sample had partners. Table 8 summarizes the involvement of partners and spouses throughout the testing experience.

Table 8 Partner involvement in the testing experience* Respondents claimed that they: Survey sites Uganda Kampala Masaka (n = 86) (n = 49) % % 31 19 55 8 0 16 Kenya Nairobi (n = 105) % 11 4 35 Told partner/spouse they were going for HIV test Were accompanied by partner/spouse to test Shared results of HIV test with partner/spouse * This table is based on convenience samples at selected sites. Most youth share their test results with someone. A high percentage of tested youth, ranging from 87 percent in Kampala to 95 percent in Nairobi, shared their test results with someone (see Figure 4).

However, because the researchers did not ask tested youth about their HIV status, we do not know if HIV-positive and HIV-negative youth share their results to an equal degree. More than one-third of young people at each site shared their results with peers. Only in Kampala did more than one-half of respondents report sharing their test results with a partner or spouse. Some young women in Kampala who shared their results with their partners talked about ending the relationship if the partner did not also get tested. In Kampala, many young females also shared their test results with their mothers. 25

Nearly all tested Figure 4 With whom youth share test results youth reported that their confidants 60% responded in a Kampala (n=86) 50% positive way when Masaka (n=49) they learned of their 40% Nairobi (n=105) test results. Only one 30% person in Nairobi 20% reported that the 10% person they confided 0% in was angry. This Partner/ Peers Siblings/ Mother Other Both Father may not suggest that spouse cousins relatives parents everyone in young peoples’ networks is supportive, but rather that youth disclose only to people they are sure will be supportive. VCT Study Sites Are Not Equipped to Respond to Youth Issues

Service providers lack experience with youth. The research team interviewed 46 service providers in Kenya and Uganda during the course of the study. Although these service providers work at facilities that provide HIV testing and youth services, they have had very little preparation and experience in working with youth. Twenty-two of 30 Kenyan service providers, for instance, note they only see between one and five young males a week, and even fewer providers (17) see young females that regularly. Service providers recognize that youth of all ages may need HIV testing.

Service providers have been approached by clients as young as 12 years old seeking HIV tests and have provided HIV tests for clients as young as age 13. They also reported that counseling young people requires special training and improved, youthoriented referral services. Most service providers have had formal training in HIV/AIDS counseling (23 of 30 in Nairobi), but many lack similar training in counseling youth. Ugandan providers have had training in general counseling skills, but only one organization represented provided training in youth counseling skills.

Service providers note that it is difficult to work with youth because many of them do not easily open up when asked to explain their problems or answer sensitive questions. Some also said that youth are “promiscuous” and do not want to change their behaviors. They do not acknowledge risk factors or listen to advice such as discontinuing unprotected sex. Counselors reported frustration when youth don’t return for follow-up or ignore advice. Providers require training to develop the skills needed to work with these clients.

Specifically, Kenyan providers say they would like to acquire additional communication and listening skills related to their work with youth. Respondents 26 HIV VCT Among Youth Service providers request better support services. Ugandan and Kenyan providers also mentioned needing more support services for counseled youth. Ugandan counselors note that some youth tell them so much about their personal lives it is often difficult to respond. Providers want to be able to refer youth who have been raped, threaten suicide, plan to leave home or school, or plan to harm their partners, but few youth-appropriate services or support groups exist.

Kenyan service providers recommended training more youth outreach counselors, making services more youth-friendly, and providing more information, education, and communication efforts. Providers in one clinic formed posttest clubs for HIV-positive and -negative youth to help them maintain safe behavior. Youth Want Confidential Services and Full Disclosure of Test Results Youth want separate facilities that are convenient and comfortable. Young people are concerned about their privacy and are fearful that others may find out that they have sought an HIV test.

Therefore, young people prefer to have tests in facilities where they won’t run into parents or neighbors and where it is not clear to casual observers that they are there to have an HIV test. Table 9 Where would it be the most convenient for you to get an HIV test? * Tested youth Kampala (n = 86) % 6 19 38 0 0 23 14 Masaka (n = 49) % 0 67 2 12 2 4 12 Nairobi (n = 105) % 29 53 5 1 0 0 12 Kampala (n = 110) % 11 41 41 1 1 0 5 Untested youth Masaka (n = 97) % 8 73 14 2 0 1 1 Nairobi (n = 121) % 16 73 1 0 0 1 9 Clinic Hospital Youth center School Church VCT center Other This table is based on convenience samples at selected sites. Columns may not add up to 100% because percentages were rounded to the nearest whole. Young people want to have an HIV test in a convenient location where they feel comfortable and where staff is competent. Most youth in Kenya say they would prefer to have an HIV test at either 27 a hospital or a clinic, while most youth in Uganda prefer hospitals or youth centers. Most tested youth in Kampala prefer VCT centers (see Table 9). Young people who prefer youth centers do so because it is easier to seek testing with other youth.

Better-qualified staff who are kind to youth and understand youth issues is another consideration. A young person in Kenya suggested the following: “Have the testing services offered locally within the community. It should, however, not be a place known only for testing but a place where there are various other activities like school sports, [and] seminars going on so that when one walks in, nobody can tell for sure what reason that person has gone for at the center. ” Young people also prefer to receive their test results the same day (80 to 95 percent).

This would require improvements in the testing process, since some tested youth had to wait up to two weeks to receive their results. Young people seek qualified counselors. Young people look for counselors who are kind, knowledgeable about HIV, and good at communicating. Surveyed youth in Kenya said the most important characteristic they want in counselors is that they be qualified professionals. The second most important qualities they prefer are someone who is understanding and someone who can communicate well. Being a good communicator was mentioned more frequently by tested youth than untested youth.

Otherwise, there were no notable differences between the characteristics sought by untested and tested youth. In Uganda, tested and untested youth gave similar responses. Both tested and untested youth in Masaka emphasized having a knowledgeable and trained counselor, followed by a kind counselor. In Kampala, youth emphasized a counselor who is kind more than one who is qualified or a good communicator. In all locations, most youth (65 percent to 93 percent) said they would not mind talking with a health care worker of the opposite sex.

Tested youth in Masaka (65 percent) and untested youth in Nairobi (70 percent) were the least comfortable with this idea. More than eight out of ten young people would not mind discussing HIV testing as part of a group (for example, pretest counseling), although only 59 percent of untested youth in Masaka agreed that this would be okay. 28 HIV VCT Among Youth Building Interventions Based on Research In Kenya and Uganda, service delivery organizations have already used the data from the formative research to design VCT programs that are youth-friendly and provide high-quality voluntary counseling and testing.

The program improvements include: • Increasing training of service providers in counseling skills for youth about HIV. Training will combine acquiring skills for working with youth and knowledge of high-quality VCT counseling. A youth-specific VCT counseling curriculum will be developed. Using a separate room and alternative locations so that youth need not meet adult family members when seeking VCT. At one location, a teen center, VCT will be provided regularly during specific hours, and results will be available

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