Prevention and Services for Adolescents and Young People

What Works

Mitigating Risk
Increasing Access to Services

 The interventions in this section should also be viewed in conjunction with other topics where young women are included. Studies with adolescent-specific data are also included in the following sections: Prevention for Women; Prevention for Key Affected Populations; HIV Testing and Counseling for Women; Treatment; Safe Motherhood and Prevention of Vertical Transmission ; Strengthening the Enabling Environment; and Care and Support.

HIV among adolescents is a growing concern.  UNAIDS notes that adolescent girls and young women are a key population in danger of being left behind in the AIDS response. Worldwide, there are approximately four million young people aged 14 to 24 living with HIV and 29% of those are adolescents aged 15 to 19 (WHO, 2014 cited in Bekker et al., 2015).  Every week, more than 5,000 adolescent girls and young women acquire HIV (UNAIDS, 2015e).  In Sub-Saharan Africa, 7 in 10 new infections in 15 to 19 year olds are among girls. Further, AIDS is now the leading cause of death among 10 to 19 year olds in Africa and the second leading cause of death among adolescents globally (UNAIDS, 2015e). Estimates for July 2015 show that 82% of all adolescents ages 10 to 19 living with HIV are in Sub-Saharan Africa (UNICEF, 2015c). At a time when HIV incidence overall is on the decline, adolescents and young people – particularly girls and young women – remain vulnerable. 

The needs of very young adolescents (10–14 years old) differ greatly from those of older adolescents (15–18 years old) and young adults (19–24 years old), therefore the following interventions and their components must be implemented in age-appropriate ways. However, adolescent sexual behavior does not follow age restrictions: some adolescents may experience early sexual debut, others may remain abstinent until they are older. In these sections, the terms “adolescents” and “young people” are used to refer to those aged 10 to 19 and 20 to 24, respectively. 

But there is cause for optimism. HIV incidence among young people has been reduced 37% between 2005 and 2015. In eastern and southern Africa, where vulnerability to HIV is high among young people, the percentage of girls who were sexually active before age 15 declined from 16.6% to 14.3%; among boys that percentage also declined from 14.5% to 10.9% between 2005 and 2015 (UNAIDS, 2015a). Over that same time period, condom use increased from 21.1% to 22% among boys and from 21.6% to 32.5% among girls (UNAIDS, 2015a). These trends show encouraging declines in behavior that may put young people at risk, but young women and girls continue to face difficulty navigating these risks due to the power imbalances that result from being young and female.  While WHO has not issued HIV-specific guidance, some technical briefs have been issued to address the needs of young people and key populations (WHO et al., 2015).

Gender and Age Contribute to Power Imbalances that Increase Young Women and Girls’ Vulnerability

Young women are particularly vulnerable to the multiple risks that result from the power imbalance of inequitable gender norms, including early sexual initiation, coerced sex, and early marriage. “The disproportionate HIV incidence in young – often poor – women underscores how social and economic inequalities shape the HIV epidemic” (Richardson et al., 2014: para 2), with high gender inequality a significant predictor of a heterosexual HIV epidemic (Richardson et al., 2014). A recent study in Uganda found that HIV incidence was four times greater among adolescent women, ages 15 to 19, compared to adolescent men of the same age, suggesting that “HIV risk is high as soon as young women initiate sexual intercourse” (Santelli et al., 2013: 398). Countries with severe gender inequality are more than 15 times more likely to have a heterosexually driven epidemic compared to countries with near gender parity (Richardson et al., 2014). 

Gender norms typically dictate that boys are expected to be sexually aware, while girls are expected to be sexually submissive, placing both boys and girls at risk of HIV acquisition. Parents promote gender inequitable sexual relationships through citing proverbs such as, “a man is an axe so he can be borrowed,” with boys noting that this means “that as a boy I am not confined to one girl” (Boy cited in Malinga-Musamba and Ntshwarang, 2014: 236). Others in India agreed that having “many partners proves the masculinity of a man” (Pradhan and Ram, 2010: 350). Increasing gender equality can have a direct impact on HIV risk; a study in South Africa found that among 1,204 young women, ages 15 to 24, consistent condom use was associated with higher gender equality in relationships with a male partner (Jama Shai et al., 2010). A study of in-depth interviews with 18 to 24 year old young women in South Africa found that the majority expected financial independence, freedom to make decisions, including over sexuality; however, they were in relationships marked by intimate partner violence, infidelity or lack of condom use, demonstrating the tension between current gender norms and legal changes that have emphasized gender equality. Those young women who did not believe in their autonomy were at higher risk for relationships of violence, infidelity and no condom use (Pettifor et al., 2012b). [See also Transforming Gender Norms and Addressing Violence Against Women]

Young women frequently have limited power in sexual relations, and many young women experience sexual coercion, often from older partners. For example, a 2008 study interviewed pregnant and never-pregnant women under the age of 17—twenty-four in rural Rakai District, Uganda and thirty-two in urban Jamaica—about their sexual experiences and found that many young women were pressured to have sex at an early age, did not make a conscious decision to do so, and later regretted it. In Jamaica, all of the interviewed young women indicated that they “should have been older the first time they had sex” (Geary et al., 2008: 18). 

A study among out-of-school youth in Uganda aged 13 to 19 found that young people, themselves, felt that they started to have sex “too early” (Nobelius et al., 2010b: 666). In addition, girls reported that from the time their breasts began to develop, boys repeatedly requested sex. Boys also reported being pressured to engage in sex before they really wanted sex or felt ready for sex in order to prove their masculinity and because they were unsure if it was physically safe for them to delay sex (Nobelius et al., 2010b).  In Nigeria, another study found similar misconceptions about the dangers of delaying sex, with boys worried that delaying sex meant they would never be able to have sex and girls worried that delaying sex would close their vagina (Oladepo and Fayemi, 2011). Ensuring that young people have the appropriate information and available services to protect themselves—before their first sexual experience—is therefore vitally important.

Age-Disparate Relationships and Early Sexual Debut Put Young Women at Risk

Large age differences (5-10 years or more) between younger women and older men result in unfavorable power imbalances for women that put them at risk for HIV acquisition. A study of adolescents in South Africa found that those with partners more than five years older were 4.5 times more likely to have acquired HIV (Kharsany et al., 2014). A study in Tanzania found that among 2,019 women aged 20 to 44, those who had their first sexual intercourse before age 18 were more likely to be living with HIV than women who had their first intercourse between 18 and 19 years of age (Ghebremichael et al., 2009b). Another study in Mali found that girls who became sexually active before the age of 15 had older partners, frequent coercive relationships and poorer communication skills; all associated with increased risk for acquiring HIV (Boileau et al., 2009).  In a study of 1,675 sexually experienced girls aged 15 to 24, initiating sex after age 15, as compared to before age 15, was associated with having used a condom at first sex (Mmari et al., 2013). 

“You have to weigh it up if a blouse is worth giving him sex. Obviously it is not. So if a guy wants sex just because he bought me a blouse I will tell him to take it back!” Young woman, aged 19 in Zimbabwe (cited in Masvawure, 2010: 866)

Age-disparate relationships are sometimes transactional in nature so that girls and young women can meet their basic needs. For example, in an area in Tanzania, “most girls over about age 14 considered that they needed a sexual partner who could give them money for peanuts or sugarcane to calm their hunger…Many schoolgirls reported that they spent the money they received for sex on school requirements, such as books, pens, shoes, uniforms and food at school” (Wamoyi et al., 2010: paragraph 35). In Zimbabwe, a study of 2,593 young women aged 18 to 22 found that food insufficiency was associated with HIV prevalence (Pascoe et al., 2015).

Focus group discussions and interviews with young women in Uganda found that, despite knowing the risks of acquiring HIV, they reported that their parents expected them to engage in transactional sex with older men to gain cash to reduce the financial burdens on the family (Nicholas, 2010; Wamoyi et al., 2011). At the same time, in some societies, men are expected to give material goods or money as a sign of love and a serious relationship in exchange for sex; women and girls who get no material gain from sex are viewed with contempt (Wamoyi et al., 2011; Nobelius et al., 2010a). With an absence of explicit negotiation, plus a sense of male entitlement, men perceive that gifts of cash result in a women or girl accepting sex on his terms. In addition, provision of basic necessities or pocket money is higher for brothers than for sisters, forcing young women to engage in transactional sex to gain access to goods (Jewkes et al., 2012). Cash transfers to prevent HIV acquisition, particularly among adolescent girls in Sub-Saharan Africa can help reduce the need for these transactional relationships and are currently a subject of active research and debate. For example a randomized controlled trial has been completed in South Africa to assess whether cash transfers for school attendance is associated with reduced HIV acquisition, but results have yet to be reported (HTPN065, cited in Pettifor et al., 2012). Though questions remain, “there is now sufficient evidence to include social protection programming as a key strategy…to contribute to HIV prevention among adolescents” (Cluver et al., 2015: para 1).  

Girls’ education is associated with delayed sexual debut, which may play a crucial role in improving their self-esteem and options, enabling them to say no to unwanted sex (Todesco and Gay, forthcoming 2016). Many girls, however, are not in school.  In 2012, 31 million females of primary school age and 32 million girls aged 12 to 15 were out of school (UNICEF, 2015d). Data from Uganda from 1993 to 2013 found that school enrollment rose steadily during these years and increasing school enrollment was associated with declining risk for acquiring HIV among both boys and girls 15 to 19 years of age, with young men in school reporting fewer recent sexual partners and lower rates of sexual concurrency (Santelli et al., 2015a). Nine surveys from 1999 to 2011 with 18,244 sexually experienced adolescents in Uganda found an estimated 71% of the decline in HIV incidence among adolescent women due to increased school enrollment. Increased school enrollment coincided with the new Ugandan national policy of universal primary education and the abolishment of school fees (Santelli et al., 2015b).Additional data from Uganda found that secondary school completion rates delayed sexual debut and lowered their lifetime risk of HIV acquisition (Alsan and Cutler, 2013). Another recent study that used 2010-2011 DHS data from Malawi and Uganda found that a one year increase in schooling decreases the probability of an adult woman testing positive for HIV by 6% in Malawi and by 3% in Uganda (Behrman, 2015). [See also Advancing Education]

Violence and Sexual Coercion of Young Women and Girls Must be Eliminated

Delay of sexual debut is a key intervention to enable young women to complete school and increase their economic opportunities; enable more informed decision-making about when to have sex, with who and how; and acquire the skills to communicate their desires about preventing HIV infection, unintended pregnancies, and other issues to protect their rights  (Abdool Karim et al., 2010a: S123). However, a study in Nigeria found that forced sex was a main reason for sexual debut among adolescent girls and forced sex was associated with self-reporting of living with HIV (Folayan et al., 2014b).Intimate partner violence is widespread among adolescents; in 6 countries where data were available on intimate partner violence, more than 1 in 3 adolescent girls has experienced such violence in the past 12 months (Cameroon, Haiti, India, Malawi, Namibia and Zimbabwe) (All in to End Adolescent AIDS, 2015d).

“I have the right to say no to sex.” (South African woman aged 24 cited in Pettifor et al., 2012: 482). 

Power disparities put young women at greater risk of sexual coercion and rape. Anecdotal evidence suggests that men who are aware of AIDS are targeting younger girls and, assuming they are ‘risk free,’ are less likely to use condoms with young partners. Recent studies of young girls who have had transactional sex and acquired HIV found that they had inequitable relationships and were more likely to have experienced violence (Jewkes et al., 2012). Studies in South Africa and Zimbabwe have found high levels of rape and sexual abuse and recent WHO estimates on lifetime prevalence of intimate partner violence among ever-partnered women aged 15 to 19 was 29.4% globally (WHO et al., 2013). SASA, a community based gender norms and prevention of violence randomized trial (Abramsky et al., 2014), also showed that children who lived in these communities were less likely to be exposed to acts of intimate partner violence (Raising Voices et al., 2015), which may reduce the intergenerational impacts of violence. [See also Addressing Violence Against Women] In many countries, few men who have sex with young girls, with or without coercion, are prosecuted. Interventions that encourage adolescents to adopt protective behavior and those that address the power disparities between young girls and older male partners are of the utmost importance in further efforts to protect adolescents from acquiring HIV. 

Efforts are Needed to End Early Marriage/Child Marriage 

One-third of women in the developing world are married before the age of 18 and one in nine are married before the age of 15, with the largest number of child brides in South Asia (ICRW, 2016). Women with little education are more likely to have married as children, even in countries where the prevalence of child marriage is low (UNICEF, 2011b). And women who marry as children are more likely to think that a husband is justified in beating his wife (UNICEF, 2011b). In addition, cross-sectional analysis performed on data from a nationally representative household study of 124,385 Indian women aged 15 to 49 found that women married as minors were significantly more likely than those married as adults to report experiencing marital violence (Raj et al., 2010). [See Addressing Violence Against Women] 

Girls in child marriages are financially dependent on their husbands and typically cannot leave because they cannot repay their dowry, thus they have extremely limited power to refuse sex, negotiate condom use or access HIV testing and services (Nour, 2006). Increased sexual experience is often associated with increased age and therefore young girls married to older men are at an increased risk of HIV transmission. Data collected in Zambia and Kenya (year(s) not specified) showed that “young married girls are more likely to be [living with HIV] than their unmarried peers because they have sex more often, use condoms less often, are unable to refuse sex, and have partners who are more likely to be HIV-positive” (Clark, 2003; Luke and Kurz, 2002 cited in Mathur et al., 2003: 9). Girls and their families and communities need to know that early marriage does not necessarily offer protection against HIV transmission. 

Parliament in Malawi, a country where 1 in 2 girls are married by the age of 18, recently raised the legal age of marriage to 18.  However, it remains legal for 15 to 18 year olds to marry with parental permission and marriage of those under 15 is not expressly illegal, merely discouraged (Girls Not Brides, 2016). It is, however, an important first step. It is also important to change social and economic environments, which can be significant in changing practices. “The practice of child marriage practically disappeared from many East Asian countries within two to three decades, largely due to the process of social, economic and policy changes” (Malhotra et al., 2011: 25). 

Reducing child marriage can reduce HIV risk for young women and girls.  A review of 23 child marriage prevention programs found that successful approaches that empowered girls and offered incentives to parents and girls to prevent child marriage reduced the incidence (Lee-Rife et al., 2012).  

More HIV Programming is Needed for Adolescents and Young People Who Are Also Part of Other Key Populations

Young key populations experience more unprotected sex, unintended pregnancy and violence compared to older populations (Delany-Moretlwe et al., 2015).  In addition, a recent comprehensive literature review from 1999 to 2014 of adherence and retention in care found that outside the US and other resource-rich countries, there were no studies reporting on adolescents or young people who identified as sex workers, were transgender, used drugs or had been in prison (Lall et al., 2015).

A UNESCO review found that data of key populations, especially those of adolescents who inject drugs, is lacking (UNESCO, 2012c; UNICEF, 2010d). Where there is data, it is alarming. In Myanmar, HIV prevalence was 7% among 15 to 19 year olds who injected drugs (UNICEF, 2013a). UNICEF has issued guidance on the need for strategic information for young key populations (UNICEF et al., 2013b). 

Adolescence is a critical time during which many young people initiate their first romantic and sexual relationships (UNESCO, 2013) and develop awareness of sexual orientation (Delany-Moretlwe et al., 2015). Gender norms not only affect adolescent girls, but also young adolescent boys (Gibbs et al., 2012), as well as transgender adolescents. Sexual orientation and gender identity is a wide and fluid spectrum, not a lifestyle choice, and sexuality education programs in resource-rich and resource-poor areas have neglected to cover this topic (Plan, 2015).  While there has been some success with livelihood interventions such as the IMAGE study (Kim et al., 2009c), little research is available as well on the intersection of masculinities and livelihoods and how this informs HIV risk and how livelihood interventions could be gender transformative for men and boys (Gibbs et al., 2012). At a consultation in Thailand in 2012, some young transgendered people reported that they had unprotected sex to validate their gender identity and signify trust and love (Schunter et al., 2014; Delany-Moretlwe et al., 2015).  Yet little or no support exists for these adolescents (Plan, 2015). WHO recommends that health care workers should receive appropriate recurrent training “to ensure that they have the skills and understanding to provide services to adult and adolescent transgender people based on all persons’ right to health, confidentiality, and non-discrimination” (WHO, 2015b: 10).”

The GFTAM has noted that in a 2015 review of 46 country concept notes and 15 regional concept notes that “access to services for key populations under the age of 18 was rarely addressed” (GFTAM, 2015: 14; McClure et al., 2015). Adolescents may also belong to multiple groups (for example, adolescent girls who sell sex). WHO 2013 guidance on adolescents notes that sex work by definition only involves adults and that sex work among those under age 18 is considered sexual exploitation (WHO, 2013:13). Little research is conducted among adolescent sex workers as they “are considered victims of sexual exploitation and trafficking by international conventions, thus conferring obligations to refer them to the relevant authorities for social protection (Goldenberg et al., 2011 cited in Busza et al., 2014: 86). Yet behavioral surveillance indicates that in India 17% of female sex workers initiate selling sex before the age of 15 years (Baggaley et al., 2015). In some cases, adolescents enter into sex work to pay school fees (Busza et al., 2014). 

Further Programming is Needed for Adolescents and Young People Living with HIV

“HIV prevention and decreasing HIV-related deaths depend critically on reaching adolescents” (Bekker et al., 2015: para 3).

As treatment access has improved, a number of children born with HIV have reached adolescence and young adulthood and they have unique needs for information and services that also must be addressed. Treatment statistics for HIV typically segregate data into ages 10 to 14 and 15 years and older, obscuring the needs of adolescents ages 10 to 19 (Wood et al., 2015). Some experts recommend data disaggregation between ages 10 to 14; 15 to 17; and 18 to 19 (Kurth et al., 2015).A recent review of evidence on interventions commonly accepted as best practices found that significant numbers of adolescents are not adequately reached; ineffective interventions continue to be implemented; and effective interventions are delivered ineffectively or with inadequate scale or resources to have an impact (Chandra-Mouli et al., 2015b). In 2015, UNAIDS and WHO released global standards for quality health care services for adolescents, but they were not HIV-specific (WHO and UNAIDS, 2015). “The epidemic in adolescent girls reflects the strong combined impact of gender and income inequality, early sexual debut, age disparate sexual relationships, and heightened biological vulnerability…” (Kasedde et al., 2013: 160). Yet adolescents have received insufficient attention in HIV prevention, treatment and care (Kasedde et al., 2014).Few national AIDS strategies have explicit programming for adolescents (Kasedde et al., 2013) and only 32 countries have measurable targets in their policies related to adolescents (Dick and Ferguson, 2015). 

There is Renewed Global Attention to Adolescents and Young People 

Encouragingly, there is renewed global attention to adolescents among bi- and multi-lateral organizations as well as private foundations to address the growing HIV and sexual and reproductive health needs of adolescents and young people. Two major intiatives are All In and DREAMS. UNICEF has begun the All In campaign to end the AIDS epidemic among adolescents ages 10 to 19 by 2030.  The campaign proposes to end AIDS-related deaths among adolescents by 65%; reduce new infections among adolescent girls and reduce stigma (All In to End Adolescent AIDS, 2015b).  PEPFAR, in partnership with the Bill & Melinda Gates Foundation, Girl Effect, Johnson & Johnson, Gilead Sciences and ViiV Healthcare and others, have launched the DREAMS Initiative to reduce new HIV infections in adolescent girls and young women in 10 countries in eastern and southern AfricaKenya, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Uganda, Tanzania, Zambia and Zimbabwe – where nearly half of all new HIV infections among adolescent girls and young women occurred in 2014. In addition, in March 2016, the US released the Global Strategy to Empower Adolescent Girls.

There is tremendous variation among young people globally and “what works” will necessarily be context-specific. Given the multiple influences on the lives of adolescents, from family to community to society, it is important to look beyond the health sector for interventions to reach adolescent girls. Evidence for programming for adolescent girls falls under a range of interventions in at least three areas: (1) strengthening the enabling environment, including education attainment, promoting gender-equitable norms, reducing violence; (2) providing information and services, including comprehensive sex education and non-stigmatizing service provision; and (3) ensuring social support, including caring relationships with adults and psychological and other support for orphans and vulnerable children (Hardee et al., 2014). Further guidance and technical briefs to address the needs of young people and key populations have been published by WHO (WHO, 2015h; WHO, 2015i; WHO, 2015j; WHO, 2015k)

Successful and promising interventions that work specifically for adolescents, in addition to those found in other sections as noted above, are further broken down here into two main categories: 

A: Mitigating Risk

B: Increasing Access to Services