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Further interventions are needed to provide support (physical, psychological, technological, economic) to patients and caregivers. Studies showed that patients and caregivers have many physical, psychological, and economic unmet needs, with high rates of depression and poverty, and in some cases, rely on their young children or relatives to provide care with no outside support. Some studies show that caregivers suffer from stigma attached to caring for someone HIV-positive. [See also %{s:67}] Some studies showed that women have a lower quality of life than men. A study in a high HIV prevalence area showed that for women, lack of control in sexual decision-making was associated with depression, while for men, intergenerational sex was associated with depression.
Interventions, policies and budgets are needed to reduce sexual coercion and rape of both boys and girls, create awareness in communities that violence against children is unacceptable, strengthen child statutory protection systems, and conceptualize and implement appropriate child protection services in developing countries. Access to post-exposure prophylaxis in case of rape when the perpetrator is HIV-positive is also needed. [See also %{c:21}] In most countries of Eastern and Southern Africa, the age of consent for sex is 16. Despite these restrictions, more than 10% of girls have had sexual debut before age 15. A study found that in a sample of more than 1,000 males and more than 1,000 females, large numbers had experienced high rates of physical punishment, emotional abuse and touching of sexual organs when not wanted or sex due to force or coercion prior to age 18 and that incident HIV infections were more common in women who suffered emotional abuse, sexual abuse and physical punishment. Sexual abuse in men was associated with alcohol abuse and depression. Other studies found high rates of sexual coercion and high-risk behaviors among street children. “Few children disclose abuse, fewer still seek services and report to authorities, virtually no children actually receive services and perpetrators rarely suffer consequences” (Sommarin et al., 2014: S213). Most research does not provide adolescent-specific data on violence, instead listing results for ages 15 to 49. Reviews have not found evidence that preventive responses have had an impact on rates of sexual abuse. Effective programs in the US and Canada have not been assessed for adaptation in other countries.
Effective programs (as described here) must be expanded to reach many more young people, especially young people who are most neglected such as very young adolescents, out-of-school youth, young people living with HIV, homeless and rural youth, as well as lesbian, MSM and transgender adolescents and other key populations. [See also %{s:73}] Studies found adolescent girls did not know that anal sex increased the risk of HIV acquisition, did not use condoms, and did not know that oral sex carries a low risk of HIV acquisition. Out-of school-youth were at high risk of early sexual debut. A scan of sex education curricula found that information on key aspects of sex such as information on condoms in addition to negative, fear-based curriculum were prevalent and that less than half of out of school youth were reached. In some countries, pornography was the principal source of information about sex and pornography often depicts condom-free sex and gender inequality, with men in domineering roles (Day, 2014).
Interventions are needed to reduce barriers to treatment adherence and to understand how these differ by sex. Increased research is needed to understand the most effective strategies to increase adherence. Studies found that a number of barriers that impact treatment adherence, such as violence, stigma, transport costs, childcare, forced migration, the need for food, the need to hide their medication from their male partners and changes in body image. Screening and treatment for depression may improve adherence, although some studies have shown mixed results. A review found that adherence differs by sex, but with little disaggregation for which factors affect women. Data collection should be more nuanced and not assume that women fall into static groups. A study of people living with HIV who disengaged from ART found that harsh and disrespectful treatment by providers, as well as competing work and livelihood demands, lack of funds for transport, etc. made attendance at ART clinics challenging.
