2004 Report on the global AIDS epidemic
FocusHIV and young people: |
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Today’s youth generation is the largest in history: nearly half of the global population is less than 25 years old (UNFPA, 2003). They have not known a world without AIDS.
Young people between the ages of 15 and 24 are both the most threatened—globally accounting for half of all new cases of HIV—and the greatest hope for turning the tide against AIDS. The future of the epidemic will be shaped by their actions. Experience proves this. The few countries that have successfully decreased national HIV prevalence have achieved these gains mostly by encouraging safer behaviour choices among young people.
Young people are exposed to HIV in different ways. In high-prevalence, sub-Saharan Africa, the main mode of transmission is heterosexual intercourse. This region contains almost two-thirds of all young people living with HIV—approximately 6.2 million people, 75% of whom are female (UNAIDS, 2003.) In Eastern Europe and Central Asia, HIV prevalence among young people is rising rapidly due to drug injecting with contaminated equipment and, to a lesser extent, unsafe sex (see Figure 30 and ‘Prevention’ chapter).
A variety of factors place young people at the centre of HIV vulnerability. These include lack of HIV information, education and services; the gambles many must take in order to survive; and the risks that accompany adolescent experimentation and curiosity.
Most young people become sexually active in their teens, and many before their 15th birthday. Factors such as increasing urbanization, poverty, exposure to conflicting ideas about sexual values and behaviour, and the breakdown of traditional sexuality and reproduction information channels are encouraging premarital sexual activity among adolescents.
Studies show that adolescents who begin sexual activity early are likely to have sex with more partners and with partners who have been at risk of HIV exposure. They are not likely to use condoms (WHO, 2000). In Kisumu, Kenya, 25% of sexually active young boys and 33% of young girls said they had not used a condom during their first and subsequent sexual encounters (Glynn et al., 2001). Erratic condom use with regular and non-regular sexual partners was also reported in studies in Argentina, Korea and Peru (WHO, 2000).
Barriers to prevention information in IndiaIn India, premarital sex and pregnancy are more common than generally acknowledged. The country’s capacity to provide sexual and reproductive health services to young people faces the twin constraints of cultural resistance to open discussion of sexuality and an overall lack of basic information about it. Although sex education is part of school AIDS education, some state officials dilute messages they disagree with, and teachers often avoid topics that make them uncomfortable. When they seek information or services, young people may be scolded or face judgemental health providers. Moreover, since sexual health services frequently offer little privacy or confidentiality, girls often seek substandard or illegal services (Greene et al., 2002). |
When the primary mode of HIV transmission is heterosexual, young women are the worst affected. The proportion of women living with HIV who are over 15 years old is 1.7 times higher in sub-Saharan Africa than in other regions (Population Reference Bureau, 2003). In Trinidad and Tobago, the number of women between 15 and 19 years old with HIV is five times higher than among adolescent males (Pisani,2003)(see‘Global Overview’ chapter).
The higher biological vulnerability of girls and women to HIV infection is one explanation for the growing numbers of young women infected with HIV. However, gender power imbalances, patterns of sexual networking, and age-mixing are important factors that tip the balance further against them. In sub-Saharan Africa, girls are having sex at an earlier age than boys (see Figure 31), and their sexual partners tend to be older.
Over 45 quantitative studies in sub-Saharan Africa on age differences between girls 15 to 19 years old and their sexual partners show that many male partners are six or more years older (see box on page 95). Typically, girls in cross-generational relationships have limited power to resist pressures to agree to unsafe sexual practices (Luke and Kurz, 2002). Abstinence before marriage may not be a successful strategy for these girls, because they marry early and their older husbands may already carry the virus.
Economics, sexuality and HIV in AfricaWhy do girls in sub-Saharan Africa often have much older sexual partners? The most common explanation is that poverty and hardship drive girls into transactional sex with older men. However, a regional survey found that economic necessity is one of several factors. Many girls also sought out older men because they were viewed as good marriage partners or providers of a better life who could help the girls with education or work opportunities. Many reported that gifts of clothes, jewellery and perfume enhanced their self-esteem and their status among their peers (Luke and Kurz, 2002). Whatever the reasons, the UN Secretary-General’s Task Force on Women, Girls and HIV/AIDS in Southern Africa has found that both transactional sex and intergenerational sex have become the norm in many countries. For example, a study in Zimbabwe found that nearly 25% of women in their 20s are in relationships with men at least 10 years older (United Nations, 2003). It is also clear that these relationships are a major factor in the ‘feminization’ of AIDS in Africa. African men are expected to have many sex partners, and on average, those living with HIV became infected in their mid-to-late 20s. In comparison, girls generally form long-term sexual relationships with one partner. Despite this relative fidelity, many living with HIV were infected soon after they started having sex. A Zambian study showed that 18% of women who said they became sexually active within the last year were HIV-positive. In South Africa, 20% of sexually active girls between the ages of 16 and 18 were infected (Pisani, 2003). Intergenerational sex appears to be a driving factor in the epidemic in Southern Africa. These relationships are based on equations of power and economics that leave girls vulnerable to abuse, exploitation, violence and HIV. |
From a very early age, many young women experience rape and forced sex. For example, 20% of all young girls interviewed in Kisumu, Kenya, and Ndola, Zambia, said their first sexual encounter involved physical force (Glynn et al., 2001). Similarly, around 25% of 15–24-year-old girls in KwaZulu-Natal, South Africa said they had been ‘tricked’ or ‘persuaded’ into their first sexual experience (Manzini, 2001). Violent or forced sex can increase the risk of transmitting HIV because forced vaginal penetration commonly causes abrasions and cuts that allow the virus to cross the vaginal wall more easily.
In Central Asia and Eastern Europe, there is evidence that the age of initiation of injecting drug use is falling (Rhodes et al., 2002). Furthermore, overall drug use appears to be increasing, due to rapid social and political change, sharp declines in living standards, and an increase in regional heroin availability (UNDP, 2003). Young injecting drug users are particularly at risk, since they may not have the knowledge or skills to protect themselves from infection via contaminated injecting equipment (UNAIDS, 2003).
Knowledge and information are the first lines of defence for young people. Some countries have taken bold steps to address the AIDS information needs of young people, but this education is still far from universal. For instance, in sub-Saharan Africa, only 8% of out-of-school youth and slightly more in-school youth have access to prevention education. The equivalent figures for Eastern Europe and Central Asia are 3% of out-of-school youth and 40% of in-school youth; and for the Caribbean and Latin America, 4% and 38% respectively (Global HIV Prevention Working Group, 2003). One global study showed that 44 out of 107 countries did not include AIDS in their school curricula (Lopez, 2002).
It is not surprising that data from 20 high-prevalence countries reveal that although most young people have heard of HIV and AIDS, they are mostly unable to recognize three misconceptions about HIV and to identify two prevention methods (see Figure 32). A recent survey in Egypt had similar findings. Most respondents had heard of AIDS and believed it to be a dangerous disease, but many had little additional knowledge.
Access to AIDS information alone is no guarantee of behaviour change, but education does have an impact. An analysis of 250 North American programmes found that among sexually active young people, AIDS education programmes were effective in decreasing the number of sexual partners and increasing condom use (Kirby, 2002). In Tanzania, the MEMA kwa Vijana (‘good things for young people’ in Swahili) AIDS education project targeted 15–19-year-olds in 20 rural communities (Obasi et al., 2003). The three-year effort substantially improved both knowledge and reported condom use among young people and will now be rolled out to 600 communities.
A vital lesson learned by the MEMA kwa Vijana project was that changing the norms and beliefs of adults in the community, particularly among men, increased the effectiveness of youth-targeted, behaviour-change interventions. Programme and policy directions in several countries have been hampered by adult beliefs of what young people should be permitted to know. Many adults, including political leaders, still find it difficult to acknowledge the sexuality of young people, and they fear that sexual education will lead to promiscuity.
However, various global studies have consistently found little evidence that sex education encourages sexual experimentation or increased sexual activity (Cowan, 2002). Successful young people’s AIDS and sexual health education initiatives have worked to allay the fears of adults by taking into account social norms, cultural practices, gender roles and expectations.
In Haiti, the Fondation pour la santé reproductive et l’education familiale (‘Foundation for reproductive health and family education’) has dramatically increased the use of AIDS reproductive health services for young people through a multifaceted approach that builds a support network among peers, parents and educators. Support from these ‘gatekeepers’ is a vital strategy that has also succeeded in breaking down social resistance in Cameroon, Madagascar and Rwanda.
Mass media, HIV prevention and youthMass media are increasingly important in most young people’s lives, and in many countries they represent excellent channels through which to reach youth with HIV prevention messages. Research has shown that media campaigns are most effective when combined with local education efforts. To encourage delays in sexual initiation, a mass media campaign in Jamaica uses a targeted, age-based approach to encourage young people. For 10–12-year-olds, abstinence messages are the focus. Children between 13 and 15 years of age are targeted with self-awareness and abstinence messages; older youth are targeted with information on protection from pregnancy, HIV and sexually transmitted infections. In South Africa, a survey found that the innovative media approaches and messages of ‘loveLife’, the national young people’s HIV prevention programme, have been helpful in breaking down social taboos regarding adolescent sexuality, promoting responsible sexual behaviour and increasing use of comprehensive health services. Working through 900 government-run clinics to promote youth-friendly health services, ‘loveLife’ has ‘Y-Centres’ or youth centres that provide HIV education and sexual health services in a recreational environment. MTV Networks International’s 2003 version of the Staying Alive campaign, conducted in partnership with UNAIDS, the World Bank and many others, reached 942 million households in some 171 countries. The television programmes and concerts promoted favourable HIV-prevention attitudes, knowledge and skills among young people. These programmes further formed the basis of in-depth campaigns launched in local areas across the globe. For example, Family Health International used the same television campaign to help build a national media campaign in Senegal (Family Health International, 2003). |
Young people are especially vulnerable to HIV, but they are also our greatest hope for changing the course of the AIDS epidemic. When young people are given appropriate tools and support, they can become powerful agents for change. Nothing short of a comprehensive HIV prevention strategy for young people is required. Early sexual debut, transgenerational sex and gender disparities highlight the fact that education alone will not protect the world’s youth from infection. Access to confidential health services and condoms, and protecting the rights of young girls, are also required to lower HIV prevalence among young people.
For example, in Uganda, political commitment and active community mobilization led to a dynamic youth movement concerned with AIDS. Between 1990 and 2000, HIV prevalence among pregnant teenagers (15–19 years) in Kampala fell from 22% to 7%. Delayed sexual debut, reducing the number of partners and increased condom use were all significant factors in this success (Cohen, 2003; UNICEF/UNAIDS/WHO, 2002).
In a world with AIDS, many young people’s life choices easily vanish. The AIDS agenda for young people needs to translate the 2001 UN Declaration of Commitment on HIV/AIDS into concrete actions. These include:
