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RHO archives : Topics : HIV/AIDS

Special Focus: Young People and HIV/AIDS

The United Nations Population Fund’s State of World Population 2003 reports that nearly half of the world’s six billion people are under the age of 25, including subsets of 1.2 billion adolescents (those aged 10 to 19) and one billion youth (those aged 15 to 24). The World Health Organization defines “young people” as those aged 10 to 24. This essay will generally refer to the subset of young people between the ages of 15 and 24. Today’s young people run the highest risk of HIV infection, and represent the greatest challenge for the prevention of new infections. Currently, half of all new HIV infections occur in people between the ages of 15 and 24, which translates to six young people becoming infected each minute, and a total of nearly 12 million young people living with HIV/AIDS. Many are likely to die of AIDS before they reach 35. In countries such as South Africa and Zimbabwe, where 20 to 25 percent of adults are infected with HIV, half of all 15 year olds are likely to die of AIDS. If young people are still the “hope of the future,” they clearly need to be major beneficiaries of efforts to prevent and respond to HIV/AIDS (JHU/PIP 2001; UNFPA 2002; UNFPA 2003).

Vulnerability

Young people’s particular vulnerability is an important reason for focusing HIV prevention and care efforts on those under the age of 25. Most people begin sexual activity during adolescence, with many having sex even before the age of 15. In studies recently conducted in Brazil, Hungary, and Kenya, for example, more than 25 percent of boys aged 15 to 19 reported having engaged in sexual activity before turning 15. A study carried out in Bangladesh revealed that 88 percent of unmarried boys and 35 percent of unmarried girls in urban areas had had sex before the age of 18. The risk for HIV transmission is linked not just to the fact that young people are having sex, but also to their lack of the knowledge and skills they might use to protect themselves, as well as their lack of access to condoms. Lack of experience also increases young people’s vulnerability to HIV infection: many young people believe themselves to be so removed from danger and risk that precautions are unnecessary, or even absurd. While they may admit that bad things can occur, they rarely believe that a catastrophe like HIV infection could happen to them. A study conducted in Nigeria revealed that 95 percent of girls between the ages of 15 and 19 “perceived their risk of getting AIDS to be minimal or non-existent,” while 93 percent of adolescents surveyed in Haiti considered themselves to be invulnerable (UNICEF 2002). In Thailand, 43 percent of young women participating in a study reported having had sexual intercourse, beginning on average at the age of 17. Many of the women reported having unprotected intercourse, undergoing coerced sex, low usage of contraceptives, and high usage of drugs and alcohol (Roth Allen et al. 2003). Despite clear evidence of sexual activity among young people, traditional biases commonly preclude them from discussing sex with their parents, relatives, friends, teachers, or counselors. For this reason, they often hold misconceptions about how to protect themselves against HIV infection and how the virus is transmitted (UNFPA 2003).

Many subgroups of young people are at particular risk for HIV infection. These include girls and young women; young people who are the target of coerced sex; those engaged in commercial sex work, often through coercion; young people living on the street; young men who have sex with men; young people living in areas or situations of conflict; and children whose parents have died of AIDS (UNICEF 2002). Drug use often begins during adolescence, and constitutes a further vulnerability to HIV infection. Half of Nepal’s injecting drug users are between 16 and 25 years of age. The incidence of HIV among injecting drug users in Nepal increased from 2 percent in 1995 to almost 50 percent in 1998. The Russian Federation and China also have high rates of HIV infection among those who inject drugs (UNFPA 2003).

Young people’s health continues to be at risk even after HIV infection has occurred. In a study carried out in the United States among 159 HIV-positive adolescents, researchers found that nearly 72 percent did not fully adhere to their antiretroviral regimes, with negative consequences for the strength of their immune systems. Study participants reported multiple reasons for missing doses of antiretroviral drugs, including feeling depressed or overwhelmed; having too many pills to take; confusion about when to take their drugs; not wanting others to know they had HIV; and simply forgetting (Murphy et al. 2003).

Girls and Young Women

The vulnerability of girls and young women to HIV infection deserves particular emphasis. Of the nearly 12 million young people living with HIV/AIDS, 62 percent are young women, and in 20 African countries 5 percent or more of females aged 15 to 24 are infected. Of newly infected young people aged 15 to 19 in sub-Saharan Africa, two-thirds are female. In western Kenya, one in four girls aged 15 to 19 is living with HIV/AIDS, whereas only one in 25 boys of the same age group is infected. Six times as many girls as boys are infected in rural Uganda; in Zambia the ratio is 16 girls to 1 boy (JHU/PIP 2001; UNFPA 2002; UNFPA 2003).

One reason for this vulnerability is biological: girls’ vaginal tracts are immature and tear easily during sexual intercourse. But cultural and economic factors are equally responsible: older, more sexually experienced men frequently seek out young girls for sex, often with the belief that younger partners are less likely to be infected with HIV. Some adolescents girls engage in sexual relations with older men in exchange for gifts; others offer sex in exchange for money to pay their school fees or to help support their families. Cultural norms dictate that girls in such relationships have little power to determine the way in which sex occurs, including the use of condoms (UNFPA 2003; UNICEF 2002).

Reproductive Health

In many places young people also lack access to reproductive health services in general. Young people tend to know very little about sexually transmitted infections (STIs), yet treating other STIs can help reduce sexual transmission of HIV, and more than 100 million new cases of STIs occur each year in those under 25. Although the occurrence of STIs exposes young people to chronic pain, infertility and other serious reproductive health repercussions, even those who think they may be infected are often reluctant to seek medical care. Young people feel embarrassed or guilty about their infections, fear a violation of their privacy, lack transportation or free time to access services, or are unable to access services due to provider bias. Even those young people who receive treatment for STIs are more likely than adults to become re-infected, for the reasons explained above (UNFPA 2003; UNICEF 2002).

Education

Since future generations of young people are continually joining the world population, efforts to educate adolescents about HIV infection are never complete and require constant renewal. Peer education focusing on decision-making and negotiation skills can help young people ward off undesirable sexual relationships, exploitation and violence, in addition to encouraging the use of condoms, when they choose to be sexually active (UNFPA 2002).

Effective education about HIV/AIDS depends on the existence or development of an enabling environment. In Indonesia, for example, several obstacles have impeded efforts to educate young people about HIV/AIDS. Cultural taboos exist that discourage communication about sex, particularly between men and women. A “culture of shame” inhibits addressing the sexual and reproductive health needs of young people in Indonesia. In addition, tabloid journalists have engaged in sensationalist reporting about HIV/AIDS, “in a manner that reinforces stereotypes, stigma and social condemnation of sexuality outside of marriage” (Bennett 2000). By contrast, government and community efforts in Uganda have opened a broad national forum of discussion about HIV/AIDS and sexuality. One school health education program in the Soroti district of Uganda improved access to information, peer interaction, and the performance quality of the existing school health education system. A cross section of students with an average age of 14 years reporting that they had been sexually active fell from approximately 43 percent to 11 percent after two years of programming (Shuey et al. 1999).

Case Study: South Africa

South Africa provides an important example of young people’s vulnerability in the face of widespread HIV infection. Forced to confront the challenges of political upheaval and a disunited national population, South Africa was slow to address the issue of HIV/AIDS. Lulled by low infection rates as late as the early 1990s, by 1994 antenatal HIV-prevalence rates among women aged 15 to 45 had reached 7.5 percent, and by 1998, the figure had jumped to nearly 23 percent, with 12-14 percent of the general adult population believed to be living with HIV/AIDS. HIV prevalence among antenatal clinic attendees aged 15 to 19 increased from 12.7 percent to 21 percent between 1997 and 1998, with the 1998 figure for 20-24 year olds topping 26 percent (Varga 2000).

Young people in South Africa have been especially prone to the risk of HIV infection. Social, political, and economic turmoil led to the radical revision or disappearance of the social institutions that traditionally ensured the transition to adulthood and sexual activity. Traditional peer education networks and extended family systems have eroded, household and marriage structures have undergone drastic changes, and communities are characterized by rapid urbanization and westernization. Young people now begin engaging in sexual intercourse at an early age, make little use of contraceptives, and have multiple sex partners and few sexual negotiation skills. Peer pressure and coercion (for girls) limit young people’s ability to abstain from sex. In addition, condom use in South Africa suffers from stigmatization, as many people associate condom use with HIV risk, infidelity, promiscuity, and prostitution (Varga 2000).

One HIV/AIDS peer education project initiated in South Africa, in which young people intended to educate their peers about preventing HIV transmission, faced such formidable social challenges that it failed. The project took place in Summertown, a township in the vicinity of Johannesburg. Residents of the township contend with high rates of crime, violence, unemployment and poverty, as well as under-funded schools, large class sizes, under-qualified teachers, and low rates of school completion. Interviews and focus groups conducted among 120 young people aged 13 to 25 revealed a general feeling of hopelessness about future advancement and work prospects. Informants also reported that their fathers—half of whom were absent—were “stern, authoritarian and unapproachable, displaying little interest in the daily activities of their children and wives.” The young people interviewed also made reference to frequent violence perpetrated by fathers or boyfriends against their mothers, resulting in a negative view of sexual relationships (Campbell and MacPhail 2002).

Despite these difficulties, researchers recruited 20 young volunteers from the community to become peer educators. These volunteers received training and information on HIV and other sexually transmitted infections. They also learned about participatory techniques such as role-plays, and they received an unlimited supply of condoms to distribute. When the peer educators took their knowledge to school and began to implement a program, they encountered considerable obstacles. The school was characterized by authoritarian rules, didactic teaching methods, and a critical attitude toward autonomy or critical thinking by pupils. The guidance teacher and principal retained strict control over the peer education program, including activities, schedules, message content, and access to resources. In addition, male pupils dominated what little activity and decisions took place within the program, marginalizing and bullying their female counterparts. After a few months, the guidance teacher summarily dissolved the peer education team (Campbell and MacPhail 2002).

This dramatic setback highlighted several lessons about HIV/AIDS peer education programs. First, efforts are needed to develop school contexts that are supportive and enabling of peer educators. Second, a unified governmental position on HIV/AIDS, characterized by strong leadership, is necessary to support peer education programs. Also necessary is work to raise community and parental awareness of the importance of open, candid communication about sex. All of those involved need to understand the philosophy of peer education: peer educators must think critically about the issues and messages they are conveying, and be involved in developing materials. Materials for peer education programs dealing with youth sexuality should be explicit, focused, and promote discussion of how gender affects sexual health (Campbell and MacPhail 2002).

Empowering Young People

Protecting young people from HIV/AIDS means giving them the power to protect themselves. This involves mobilizing general support for HIV/AIDS prevention, addressing cultural and social norms that put young people at risk, and promoting the use of condoms to prevent HIV and other sexually transmitted infections, as well as unwanted pregnancies. Protecting young people also means offering education and communication programs that impart knowledge and build skills to use this knowledge. Young people need to access health care services without fear of criticism or discrimination. They must also be substantively involved in HIV/AIDS prevention efforts, particularly those that focus on young people (JHU/PIP 2001).

UNICEF advocates a ten-step strategy that summarizes an effective approach to preventing HIV/AIDS in young people:

  • End the silence, stigma, and shame that surround HIV/AIDS.
  • Provide young people with knowledge and information.
  • Equip young people with life skills to put knowledge into practice.
  • Provide youth-friendly health services.
  • Promote voluntary and confidential HIV counseling and testing.
  • Promote the participation of young people in HIV/AIDS-prevention activities.
  • Engage young people who are living with HIV/AIDS.
  • Create safe and supportive environments.
  • Reach out to young people most at risk.
  • Strengthen partnerships and monitor progress (UNICEF 2002).

For additional information on young people, STIs, and HIV/AIDS, see RHO's Adolescent Reproductive Health section.

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Annotated bibliography

Please note that PDF files require Adobe Acrobat Reader software, which can be downloaded for free at www.adobe.com/products/acrobat/readstep.html.

Bennett, L. Sex talk, Indonesian youth and HIV/AIDS. Development Bulletin 52:54-57 (June 2000).
Linda Rae Bennett’s article focuses on the sociocultural obstacles that prevent young people in Indonesia from discussing sex and HIV/AIDS. She maintains that cultural taboos “inhibit communication about sex, deny and stigmatise ‘deviant’ sexual practices (particularly premarital sex for women), and are incorporated into sexual cultures characterized by silence, shame, and secrecy. The government has not actively promoted condom use due to fear that condoms encourage deviant sexual behavior. In addition, tabloid journalists have engaged in sensationalist reporting about HIV/AIDS, “in a manner that reinforces stereotypes, stigma and social condemnation of sexuality outside of marriage.” Bennett points to the need to “foster a social climate in which sexuality is discussed and debated more comprehensively, and narrow conceptions of sexual ideals, norms and values can be challenged openly.”

Cambell, C. and MacPhail, C. Peer education, gender and the development of critical consciousness: participatory HIV prevention by South African youth. Social Science & Medicine 55:331-345 (2002).
The authors of this article examine the reasons for failure of an HIV/AIDS peer education project conducted in Summertown, South Africa, and the need to develop critical consciousness among young people to prevent HIV transmission and reduce risk factors. Under the project, 120 young people aged 13 to 25 were the subject of interviews and focus groups centered on their perceptions of health, sexuality, and HIV. Researchers then recruited 20 young volunteers from the community to become peer educators. These volunteers received training and information on HIV and other sexually transmitted infections, learned about participatory techniques such as role-plays, and received an unlimited supply of condoms to distribute. When the peer educators began to implement the school-based program, they encountered authoritarian rules, didactic teaching methods, and a negative attitude toward autonomy or critical thinking by pupils. The guidance teacher and principal retained strict control over the peer education program, including activities, schedules, message content, and access to resources. In addition, male pupils dominated what little activity and decisions took place within the program, marginalizing and bullying their female counterparts. After a few months, the guidance teacher summarily dissolved the peer education team. The authors advocate for the need to develop supportive school environments; foment a unified governmental position on HIV/AIDS; raise community and parental awareness of the importance of open, candid communication about sex; better understanding of peer educators’ need to think critically about the issues and messages they are conveying; and the need for materials that are explicit, focused, and promote discussion of how gender impacts sexual health.

Johns Hopkins University School of Public Health, Population Information Program. Youth and HIV/AIDS. Population Reports, Series L, No. 9 (Fall 2001). Available at: www.infoforhealth.org/pr/l12edsum.shtml.
This issue of Population Reports covers several issues related to young people and HIV/AIDS. These include “the invisible epidemic,” “how young people become infected,” “why so vulnerable?” “addressing the epidemic,” “reaching out,” and “consequences of inaction.” In “addressing the epidemic,” the author recommends building support for AIDS prevention; offering education and communication; addressing cultural and social norms; promoting condoms for dual protection; making services youth-friendly; and reaching out to particularly vulnerable groups of young people.

Murphy, D. et al. Barriers to HAART adherence among human immunodeficiency virus-infected adolescents. Archives of Pediatric & Adolescent Medicine 157:249-255 (2003).
This article examines the findings of a study conducted among 159 adolescents, aged 12 to 19, living with HIV/AIDS in the United States and following highly active antiretroviral therapy (HAART). The study found that nearly 72 percent of the young people reported missing at least one dose of antiretroviral medications over the previous month. Most of those who missed doses were female and African American. Study participants mentioned many reasons for missing their medications, including feeling depressed or overwhelmed; having too many pills to take; confusion about when to take their drugs; not wanting others to know they had HIV; and simply forgetting. The authors recommend interventions at the level of patients and health care providers, in addition to modification of the health care system, to meet the challenges of helping HIV-infected adolescents adhere fully to their HAART regimens.

Roth Allen, D. et al. Sexual health risks among young Thai women: implications for HIV/STD prevention and contraception. AIDS and Behavior 7(1):9-21 (2003).
The authors of this article describe a cross-sectional, audio-computer-assisted self-interview conducted among 832 female vocational students in Chiang Rai Province, Thailand. Results of the interview revealed that 43 percent of those interviewed had had sexual intercourse, beginning on average at the age of 17. More than 20 percent reported coerced sexual relations, 27 percent had been pregnant, 80.5 percent reported use of alcohol over the previous three-month period, and 18 percent stated having used methamphetamines. The authors support the need for greater information on knowledge of risk among young Thai women as well as on factors that impede their ability to prevent HIV/STI transmission and unwanted pregnancies.

Shuey, D. et al. Increased sexual abstinence among in-school adolescents as a result of school health education in Soroti district, Uganda. Health Education Research 14(3):411-419 (1999).
The authors of this article provide an example of a successful school health education program carried out in Uganda from 1994 to 1996. The program aimed to improve access to information, peer interaction, and the performance quality of the existing school health education system, with regard to healthy sexual behavior decision-making. The study conducted focused on the results of the district-wide program through questionnaires administered to 400 pupils in 38 primary schools. A cross section of pupils with an average age of 14 years reporting that they had been sexually active fell from approximately 43 percent to 11 percent after two years of programming. Pupils also reported greater support for abstinence, greater discussion of sexual matters with teachers, and less sexual activity among their three closest male friends.

UNFPA. “HIV/AIDS and Adolescents.” In: State of World Population 2003. New York: UNFPA (2003). Available at: www.unfpa.org/swp/2003/english/ch3/index.htm.
This chapter of the United Nations Population Fund’s annual publication provides a comprehensive summary of young people and HIV/AIDS. The chapter discusses such risk factors as poverty, gender imbalance, marriage, lack of protection information and skills, feelings of invincibility, sexually transmitted infections, alcohol and drug use, and tuberculosis. The document also focuses on regional differences, the impact of AIDS on young people, social marketing of contraceptives, and services for HIV/AIDS prevention and care.

UNFPA. Preventing HIV/AIDS: young people and HIV/AIDS [fact sheet]. New York: UNFPA (2002). Available at: www.unfpa.org/issues/factsheets/aids_youth.htm.
This United Nations Population Fund fact sheet offers a succinct overview of the issue of young people and HIV/AIDS, and UNFPA activities that address the problem. Topics of particular focus include adolescent girls’ elevated risk for HIV infection, the role of education in preventing HIV/AIDS among young people, and why young people deserve special consideration in HIV/AIDS prevention efforts.

UNICEF. Young People and HIV/AIDS: Opportunity in Crisis. New York: UNICEF (2002). Available at: www.unicef.org/publications/index_4447.html.
UNICEF’s special report, produced in conjunction with UNAIDS and WHO, examines the need to focus on young people in HIV/AIDS prevention efforts. Reasons supporting this focus include the fact that young people do engage in sexual relations; young people lack information about HIV/AIDS and sexual health; girls are particularly vulnerable; some groups of young people are at particularly high risk of HIV infection; and young people have already demonstrated initiative in responding to HIV/AIDS. The document also outlines a ten-step strategy for preventing HIV transmission among young people and provides several pages of statistics on HIV/AIDS and young people in countries around the world.

Varga, C. Young people, HIV/AIDS, and intervention: barriers and gateways to behaviour change. Development Bulletin 52:67-69 (June 2000).
This article describes the social, political, and economic conditions in South Africa that jeopardize HIV/AIDS prevention among young people. Traditional peer education networks and extended family systems have eroded, household and marriage structures have undergone drastic changes, and communities are characterized by rapid urbanization and westernization. Young people now begin engaging in sexual intercourse at an early age, make little use of contraceptives, and have multiple sex partners and few sexual negotiation skills. Peer pressure and coercion (for girls) limit young people’s ability to abstain from sex. In addition, condom use in South Africa suffers from stigmatization, as many people associate condom use with HIV risk, infidelity, promiscuity, and prostitution. The author recommends confronting these difficulties through life-skills improvement, promoting acceptance of and destigmatizing condom use, advocating for consistent condom use, and depicting sex as a healthy, normal part of life, provided that it occurs in a responsible way.

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Links to resources

Advocates for Youth
www.advocatesforyouth.org
Advocates for Youth is a U.S.-based organization that champions efforts to help young people make informed and responsible decisions about their reproductive and sexual health. The organization’s website offers such rubrics as “News and Events;” “Facts and Figures;” “Recent Publications;” “Topics and Issues;” “For Parents;” “For Teens;” and additional useful websites. Under “Facts and Figures,” users can access a series of fact sheets (www.advocatesforyouth.org/publications/freepubs.htm#fs) about pertinent issues, including contraceptive use and sexual behavior; HIV/AIDS and STD prevention and treatment; adolescent sexual health in developing countries; access to sexual health services; youth in high risk situations; and youth leadership and peer education.

Sexwise
www.bbc.co.uk/worldservice/sci_tech/features/health/sexwise/index.shtml The Sexwise project is a joint project of the BBC World Service and the International Planned Parenthood Federation. The Sexwise online guide was conceived as a travel guide that provides information about young people’s sexual well-being, choices and rights. The guide offers explicit, interactive information on such issues as changes that affects boys and girls during puberty, circumcision, menstruation, and virginity. The Sexwise website also features “Global Views,” providing sexual news from around the world; “Audio,” allowing users to listen to real people’s experiences; “Contacts,” a listing of useful global addresses; “Radio Listings,” including dates, times, and frequencies; and “22 Languages,” through which users can download the guide in the most appropriate language for them.

YouthNet
www.fhi.org/en/Youth/YouthNet/index.htm
Family Health International is the sponsor of YouthNet, a global program to improve reproductive health and prevent the spread of HIV/AIDS among people 10 to 24 years old. The extensive website has links to program areas, research, YouthNet country programs, training materials, publications, frequently asked questions, news and events, and resources for young people. The "Resources for Young People” link (www.fhi.org/en/Youth/YouthNet/ResForYouth/index.htm) covers many of the world’s regions, and includes several options for direct access to online interactive advice for young people in each region.

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