Prevention for Young People

What Works

Encouraging Behavior Change
Increasing Access to Services

Today’s young people have never known a world without AIDS (Fransen-dos-Santos, 2009). “The world is generating the largest ever cohort of sexually active people in history, greatly expanding the numbers susceptible to HIV infections” (AIDS2031 Consortium, 2010: xii). Among those ages 15–24, five million were living with HIV as of December 2010, with young women accounting for 64% of those living with HIV (WHO et al., 2011b). Young people ages 15–24 account for an estimated one-third of new HIV infections (UNICEF, 2011c).

But there is cause for optimism. In an analysis of trends related to HIV and young people, HIV prevalence declined among young people aged 15–24 in at least 21 of 24 countries with national HIV prevalence of 1% or higher (UNAIDS, 2011b), particularly: Angola, Bahamas, Burkina Faso, Botswana, DRC, Chad, Ethiopia, Gabon, Ghana, Haiti, Kenya, Lesotho, Malawi, Mali, Mozambique, Nigeria, Namibia, South Africa, Swaziland, Togo, Uganda, United Republic of Tanzania, Zambia and Zimbabwe (UNAIDS, 2011b; Marsh et al., 2011). HIV incidence is rising, however, among young people in parts of Asia (UNAIDS, 2011e). The percentage of young women aged 15-19 who reported having sexual intercourse declined in eight countries and in many countries significant changes in safer sexual behavior were found, such as increased condom use and decreased number of partners (International Group on Analysis of Trends, 2010).

More HIV Programming and Evaluation is Needed for Young People

There is tremendous variation among young people globally and “what works” will necessarily be context-specific. Preventing HIV among young people requires a comprehensive, multi-sectoral response with consistent messages repeated numerous times from multiple sources. The interventions in this section should also be viewed in conjunction with other topics where young people are included such as Prevention for Women; Prevention Among Key Affected Populations; and Strengthening the Enabling Environment.

Even though “young people are critical to shaping the future of the world” (Fatusi and Hindin, 2010: 506), “few young people receive adequate preparation for their sexual lives... Being sexual is an important part of many people’s lives: it can be a source of pleasure and comfort and a way of expressing affection and love or starting a family” (UNESCO, 2009a: 1 and 4). Today, 1.2 billion adolescents, of whom 90% live in the developing world, are key to the future of our planet (Lake, 2011). Yet “there remains a stark mismatch between the HIV burden in youth and the number of attempts to design and test prevention interventions” (Michielsen et al., 2010: 1193) with only two of 28 studies in sub-Saharan Africa between 1990 and 2008 reporting biological outcomes of the interventions and many of the 28 studies had suboptimal study designs (Michielsen et al., 2010). In addition, more work is needed to disaggregate the data of studies by sex and by age: “what works” will be different for those age 10 to 14 compared to those in their late teen years or early twenties.

Young Women Are Often at Greater Risk for HIV Acquisition in Generalized Epidemics

Of the five million young people living with HIV in developing countries in 2009, 3.2 million were young women and 1.7 million were young men (WHO et al., 2011b). In the Caribbean, women account for approximately half of all infections (UNAIDS, 2009d: 54). However, among 15–25 year olds in Latin America, a slightly higher percentage of men (0.5 percent) than women (0.3 percent) are living with HIV (PAHO and NORAD, 2007).

In sub-Saharan African countries with high HIV prevalence, such as Kenya, Zambia, Malawi, and Lesotho, young women aged 15–24 are about two to four times more likely to be infected with HIV than young men (UNICEF, 2011a). On average, women acquire HIV infection at least five to seven years earlier than men in sub-Saharan Africa. “Age of sexual debut, viral load, stage of infection, route of transmission, anatomy, epithelial integrity and presence of curable sexually transmitted infections are some biological factors associated with excess risk of HIV infection in women… (While) there is a growing body of knowledge on HIV acquisition in the genital tract, it is insufficient to fully understand the biologic mechanism responsible for driving the vulnerability in women” (Abdool Karim et al., 2010a: S123).

Prevention Efforts for Young Women are Critically Needed

 “Our failure to curb the HIV pandemic is a reflection on our failure to reduce HIV in young women especially in sub-Saharan Africa” (Abdool Karim et al., 2010a: S127).“Gender disparities become more evident as children approach adolescence” (UNICEF, 2011a: 1). Young men are generally better informed about HIV and AIDS than young women, with accurate knowledge lowest among the poorest households in rural sub-Saharan Africa (UNICEF, 2011a). In 2009, only 34% of young people had comprehensive and correct knowledge of HIV. Young women tend to be less likely than young men to be aware of the prevention benefits of consistent condom use and globally, young men are more likely than young women to use condoms (UNICEF, 2011a). In many settings, girls equate sex with love and lack of condom use a sign of love and trust in a relationship (Machel, 2001; Vuttanont et al., 2006).

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. [See also Transforming Gender Norms and Addressing Violence Against Women] Globally, the median age of sexual debut is below the age of 20 for young women and men in many developing countries (DHS, 2009). Many young people, especially young women, have their first sexual experience before the age of 15. DHS data from 60 developing countries show that 25% of girls and boys had sexual intercourse before age 15 (DHS 2007 cited in IWHC, 2007).

Yet there is evidence that this is changing: according to a recent UNAIDS data, in 15 countries with HIV prevalence higher than 2%, the proportion of young men with an early age of sexual debut declined significantly in 7 countries and in 11 countries for young women (UNAIDS, 2011a).

A study in Tanzania found that among 2,019 women aged 20–44, those who had their first sexual intercourse before age 18 were more likely to be HIV-positive 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). Delayed sexual debut is also associated with girls’ education, which may play a crucial role in improving their self-esteem and options, enabling them to say no to unwanted sex. [See also Advancing Education]

Young women often 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). In Uganda, where 9 of the 24 interviewees first had sex at age 14 or younger, half described coercion during first sex. Many Ugandan girls believed that men are entitled to demand sex, especially in marriage. As a married 17-year-old Ugandan indicated, “sex is ‘an obligation because you are married’” (Geary et al., 2008: 22).

A study among out-of-school youth in Uganda aged 13–19 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 but 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 to plan to protect themselves—before their first sexual experience—is therefore vitally important.

“In countries in southern Africa, where HIV prevalence is extremely high, the probability that one’s sexual partner is HIV-positive is around one in four to six, making it risky to have unprotected sex with anyone whose HIV status is unknown” (UNAIDS, 2008).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). A study of 1,375 youth in Kenya ages 13 to 19 years of age found that only 48% fully comprehended abstinence as avoiding sex; 20% fully comprehended being faithful as having one sexual partner and only 7% comprehended consistent condom use as using a condom every time one has sex. Examples of lack of comprehension was a definition of being faithful “means that you should be obedient and do as told” or consistent condom use as washing condoms (Lillie et al., 2009: 283).

Traditional Gender Norms, Early Marriage Put Young Women at Risk

“Even if sexuality education programmes improve knowledge, skills and intentions to avoid sexual risk or to use clinical services, reducing their risk may be challenging to young people if social norms do not support risk reduction and/or clinical services are not available” (UNESCO, 2009a: 10). 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. [See also Transforming Gender Norms] A study in India among rural married women aged 15–24 and married rural men aged 15–29 found highly gender inequitable attitudes that influence HIV risk, such as multiple sex partners are acceptable for boys but not for girls: “Boys are like brass pot, it would shine back as it was like after cleaning. Girls are like clay pot, blackness remains forever once used,” as one young male stated (Pradhan and Ram, 2010:549). Others agreed “satisfying physically many partners proves the masculinity of a man” (Pradhan and Ram, 2010: 350). Increasing gender equity 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 equity in relationships with a male partner (Jama Shai et al., 2010). [See also Transforming Gender Norms]

Sixty seven million young women were first married or in union by age 18 in the developing world (UNICEF, 2011b). Research in 16 countries in sub-Saharan Africa (year(s) not specified) showed that on average, husbands of young girls aged 15–19 were, at a minimum, 10 years older than their young wives (UNICEF, 2001 cited in Mathur et al., 2003). Although emerging evidence from Western Kenya shows that 47% of adolescent girls were married to adolescent men, increasing the vulnerabilities of both adolescent boys and girls (Birungi, 2012). 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 collected in 2005 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 HIV-positive 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. The prevalence of child marriage has been declining, but progress has been slow: among women age 45 to 49, 21% were married before age 15 and 26% were married by age 18; among young women aged 20 to 24, 12% were married by age 15 and 23% were married by age 18 (UNICEF, 2011b). The poorest girls are the most disadvantaged, with the poorest girls three times as likely to get married by age 18 compared to the richest girls (UNICEF, 2011b). Legislation prohibiting child marriage is an important first step (Hervish and Feldman-Jacobs, 2011) but changing social and economic environments can also 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).

Intergenerational Relationships Put Girls at Risk

The tendency for unmarried sexually active adolescent girls to have much older sexual partners puts them at risk for HIV acquisition (Luke and Kurz, 2002). Young women with sexual partners ten or more years older than themselves are two to four times more likely to have acquired HIV than young women with partners of the same age or one year older (UNICEF, 2010a). 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).

In one area in Tanzania, “most girls over about 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: 7). Young women may choose intergenerational partnerships to “help provide for their families, gain social status or simply have what they believe is better sex” (Chandler, 2011: S349). Ways to incorporate demands for safer sex into negotiations for transactional sex are needed, as well as increased resources for girls.

“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 (Masvawure, 2010: 866) Power disparities also 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. Studies in South Africa and Zimbabwe have found high levels of rape and sexual abuse. [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.

While gender norms, legal rights, education, employment opportunities, addressing violence against women and stigma are critical to any HIV response, few studies have disaggregated the data by age and this is a large gap in the evidence base. In addition to those in Prevention for Women and Strengthening the Enabling Environment, interventions that work specifically for adolescents can be broken down into two main categories: encouraging behavior change and increasing access to services.