Methods: We conducted an explanatory multiple-case study using a risk environment framework. Based on social epidemiology and social ecological theory, a risk environment approach shifts the focus from individuals to social-structural conditions, and their reciprocal interactions. Focal dimensions emerged from a regional youth forum sponsored by UNICEF and the Asia-Pacific Interagency Task Team on Young Key Populations in mid-2019. Youth-led focus group discussions (FGDs) were conducted with diverse AYKP in each country. A researcher-youth co-developed topic guide explored experiences in education, families, communications, and mental health regarding HIV and SRHR. We conducted semi-structured key informant (KI) interviews with experts, program leaders, and policymakers exploring AYKP risk environments, resources, policies, and strategic initiatives. FGDs and KI interviews were transcribed, translated into English, reviewed within-country using thematic analysis, and synthesized and contrasted across countries. Emerging themes and draft reports were shared with stakeholders in a process of member checking, and their input integrated.
Results: From November 2018-October 2019, we conducted 16 FGDs (4/country) with 139 young people (16/18-24 years; 55 girls/women, 73 boys/men, 11 transgender persons) and 37 KI interviews (15 women, 18 men, 4 transgender persons) with multisectoral government, UN agency, NGO, and youth/AYKP experts (N=176). Risk environments manifested in widespread absence of comprehensive sexuality education (CSE): schools expected home-based CSE, parents expected school-based CSE; AYKP reported receiving information from neither, instead relying on social media/Internet. Some KIs recounted government policies mandating CSE; other KIs and AYKP revealed pervasive gaps in implementation. LGBT+ youth described school bullying, harassment, violence, and lack of teacher, healthcare provider and parental support; this exacerbated stigma and fears of disclosure that inhibited support and health-seeking behaviors. National lack of mental health professionals and credentialing amid religious fundamentalism presented barriers in access to competent care. Peer educators/ navigators, AYKP/youth networks, and social media were primary venues for HIV/SRHR education and social support amidst restrictive government policies that created pervasive barriers across the HIV prevention and treatment cascades.
Conclusions and Implications: Intersectoral, multilevel youth-engaged strategies are needed that build on existing strengths and foster transformation of HIV risk environments. Capacitating peer support networks, promoting CSE and HIV prevention and testing via social media, expanding access to youth-friendly healthcare and HIV services, and transforming restrictive government policies and laws that constrain access to condoms and HIV-testing for minors are fundamental to ending the epidemic among young people.