Preventing HIV infection among adolescents and young people
In Eastern and Southern Africa, some 2.7 million people aged 15 to 24 years live with HIV, more than half of all HIV-positive young people globally. In the hyper-endemic countries Botswana, Lesotho and Swaziland, more than 1 in 10 young people are infected.
The risk of becoming infected is disproportionately higher for girls and young women. The regional HIV prevalence among young women aged 15 to 24 years is 4.8 percent, which is two and a half times higher than among men of the same age. In Swaziland, for example, 15.6 percent of young women are HIV-positive, compared to 6.5 percent of young men.
The feminization of the HIV epidemic starts at an early age. Among adolescent girls aged 15 to17 years in Swaziland and Lesotho, for example, the HIV prevalence is more than four times higher than among their male peers (6.2 percent/1.4 percent and 6.1/1.6, respectively). Further analysis reveals that many of these girls have been infected by young men, who are at least five years older, a result of the fact that age-disparate relationships are very common in the region.
Once girls and young women enter into a stable relationship, it often becomes difficult for them to insist on condom use. As a result, HIV infection rates among married women are significantly higher than among single women. In Zimbabwe, for example, among females aged 15–24, HIV prevalence ranges from 6.2 percent among women who had never married, up to 14.2 percent among those currently married or in union and up to 26 percent among those divorced or widowed.
The highest increase in prevalence occurs when young women start engaging in regular sexual relationships. Population-based survey data show an HIV prevalence of around 6 percent among adolescent girls aged 15 to 17 in Lesotho and Swaziland. The rate jumps to nearly 30 percent in Lesotho and over 40 percent in Swaziland among young women aged 23 to 24.
Adequate information can change attitudes and behaviours related to HIV markedly. Evidence shows that adolescents and young people are less likely to be vulnerable to HIV when they are offered relevant gender-sensitive prevention information, skills and services in an enabling and protective environment. The much lower infection rate among adolescent girls is a promising sign for prevention efforts. This age group provides a ‘window of opportunity’ for halting the spread of HIV infection if younger girls are empowered with life skills and provided with a protective family and community environment.
The proportion of young people aged 15 to 24 years with comprehensive knowledge of HIV prevention, however, is still low in ESA. Comprehensive knowledge is a combination of 5 indicators: knowledge of 2 modes of transmission and 3 misconceptions. The regional average of such knowledge now stands at 41 percent for men and 33 percent for women. Across the countries, enormous variations occur, ranging from 4 percent of young women with comprehensive knowledge of HIV prevention in Somalia to 65 percent in Namibia.
Overall, young women and youth of both sexes living in rural areas are less likely to have such knowledge than young men and those living in urban areas. However, the knowledge on HIV prevention is increasing among the youth in the region. In Rwanda, for example, the proportion of young women with comprehensive knowledge of HIV prevention rose from 23 percent in 2000 to 51 percent in 2009. These levels are still far below the 2010 target of 95 percent comprehensive knowledge set at the United Nations General Assembly Special Session on HIV/AIDS in 2001.
There is compelling evidence of the cost-effectiveness of prevention. A recent study projected that expanding prevention programmes could more than halve the number of HIV infections by 2015 and save U$24 billion globally in treatment costs. However, there is still insufficient attention given to preventing new infections among young people. The specific needs of adolescents and young people are often overlooked during the development of national HIV strategies, policies and budget allocations. As a result, young people living with HIV/AIDS often have inadequate access to health and social support services, and face considerable stigma and discrimination.
UNICEF in action
The evolving face of the HIV epidemic has dramatically altered and refocused UNICEF’s approaches to prevention among adolescents and young people. The increased awareness of the differences between a generalized epidemic and one centred around particularly vulnerable populations, and the ever pressing need for analyzing current trends and data, and staying in touch with new technologies, have all contributed to more focused and more relevant prevention programming.
By far the most widespread type of prevention intervention supported by UNICEF in the region is life skills education, where the focus is on the reduction of adolescents’ risk and vulnerability to HIV by increasing their access to gender-sensitive knowledge, skills and services. Focusing on the particular vulnerability of girls and young women, UNICEF aims to reduce multiple concurrent partnerships, gender-based violence as well as age disparate and transactional sex. The strong increase in prevalence between the adolescent age group and young women calls for a much greater attention to the 15 to 17 year olds, as well as to their older male sexual partners.
UNICEF’s regional goal in ESA is to ensure by 2013 that 80 percent of adolescent girls 15 to 19 years old, in 11 countries, practice behaviours that reduce their risk of HIV infection. To achieve that, UNICEF’s work with national partners over the next years will be focused on increasing comprehensive HIV knowledge among adolescent girls, increasing their use of HIV testing and counselling services, as well as the use of condoms, and reducing the percentage of sexually active girls reporting a recent partner who is more than five years older.
Results for children
By 2008, six countries in Eastern and Southern Africa showed a statistically significant decline of 25 percent or more in HIV prevalence among young women attending antenatal clinics in rural or urban areas or in both: Botswana, Ethiopia, Kenya, Malawi, Namibia and Zimbabwe. An additional three countries showed a significant decline in HIV prevalence among young women (Zambia) or men (South Africa and Tanzania) in national surveys.
In 2009 and 2010, specific attention has been paid to the gender dynamics of HIV transmission through initiatives that more explicitly include gender in UNICEF’s HIV programming, especially through life skills and peer education programmes.
In the context of its targeted focus on adolescent girls, UNICEF developed a programme called Sister2Sister (S2S), which is being rolled out in Malawi, Tanzania, Lesotho and Namibia. It includes intensive 3-day risk reduction education organized in schools, but outside of the normal curriculum. The programme is facilitated by young women for their peers, and is based on a set of core modules and aims at behavioural outcomes around multiple concurrent partnerships and age-disparate sex.
Another programme is called Brothers for Life, targeting men’s behaviour and gender values. The programme was developed by Johns Hopkins University together with UNICEF and USAID. A number of well-known football players from Manchester United, FC Barcelona and the South Africa national team have recorded short video messages around the risks of alcohol and the promotion of correct and consistent condom use. They also mobilize men to participate in counselling and testing programmes together with their partners. The messages are also distributed through outdoor billboards and radio spots. The campaign was launched prior to the FIFA World Cup 2010. Its original focus has been on South Africa, but it has also been implemented in other countries.
In Botswana, UNICEF is supporting specifically targeted life skills and psychosocial programmes for adolescents living with HIV/AIDS, before they start having sex. It is estimated that by 2011 there will be some 3,000 HIV-positive adolescents living in Botswana. In Ethiopia, more than 65,000 adolescents and young people were reached in 2009 through life skills, youth dialogue, peer education and youth leadership.
In South Africa, 2,000 adolescents are members of Girls and Boys Education Movement clubs in schools, where they are provided with life skills and information to prevent and address HIV/AIDS, gender-based violence, teenage pregnancy and other issues.
In Kenya, a life skills curriculum for use in primary and secondary schools has been finalised and is now being rolled out. In partnership with MTV International - Staying Alive, MTV Africa, and other partners, UNICEF supported the development of a multimedia package focused on the behaviours of a group of young people living in Nairobi. The package includes a TV drama called Shuga, an internet site and community mobilisation tools. Set in Nairobi, Shuga is about the lives, loves and aspirations of a group of university-age friends, and has had a large audience and a strong impact since it was aired. Sixty percent of Nairobi youth surveyed had seen the programme, and 90 percent of the viewers reported that it had affected their thinking around HIV testing, concurrent relationships and stigma. The show was also broadcast in Zambia.
More on HIV prevention among youth
Watch Shuga, a Kenyan TV drama on AIDS awareness among youth, produced by UNICEF and partners together with MTV
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