2,100 young people and adolescents are infected with HIV every day. In 2013, four million young people aged 15-24 were living with HIV, with 29% aged under 19.
The majority of young people living with HIV are in low- and middle-income countries, with 85% insub-Saharan Africa. Countries in this region already have youthful populations, and this trend is expected to increase until 2050. For example, 51% of the population of South Sudan are under the age of 18. For countries like South Sudan that already have a high burden of HIV infections, this will inevitably lead to more HIV transmissions among young people.
The number of AIDS-related deaths among adolescents rose by 50% between 2005 and 2012. This is in comparison to a 30% fall among people of all ages living with HIV.
Why are young people vulnerable to HIV?
Young people are vulnerable to HIV at two stages of their lives; the first decade of life when HIV can be transmitted from mother-to-child, and the second decade of life when adolescence brings new vulnerability to HIV.
There is a lack of data showing the proportion of young people infected at each stage, making it difficult to roll out HIV services specific to each group.
HIV transmission in the first decade of life
In 2013, an estimated 240,000 children were infected with HIV from their mother during pregnancy, childbirth or breastfeeding.Many of these children were linked to care as infants, and they need to be supported to adhere to their HIV treatment in adolescence and into adulthood.
This becomes difficult with pressures such as puberty, increased risky behaviours, changes to their HIV treatment needs and new responsibility for their own health. These explain why some young people stop adhering to antiretroviral treatment (ART) correctly during their adolescent years.
HIV transmission in the second decade of life
Unprotected sex is the most common cause of HIV among young people, with sharing infected needles second.Adolescence is often associated with experimentation of risky sexual and drug-related behaviours, increasing a young person's vulnerability to HIV.
For some, this is a result of not having the correct knowledge about HIV and how to prevent it, highlighting the need for HIV and sexual and reproductive health education. For others, it is the result of being forced to have unprotected sex, or to inject drugs.
Whilst programmes to prevent mother-to-child transmission of HIV (PMTCT) have been hugely successful in recent years, reducing new infections among adolescents is more difficult. There are many factors that put young people at an elevated risk of HIV.
Excluded from national plans
Young people are often forgotten in national HIV and AIDS plans which typically focus on adults and children. Consequently, there are a lack of youth-friendly health services.
Data issues
HIV-related data for young people is often divided between adolescents (aged 10-19) and young people (aged 15-24), with less data available for adolescents. However, these age groups are not well defined internationally and even vary within countries, making data collection and its reliability very complex.
Ethical and legal issues make it difficult to conduct studies and research on people under 18, limiting what data is available about how HIV affects young people.
Vulnerability via unprotected sex
Early sexual debut
The age of sexual debut is rising, showing a positive change in attitudes among young people with regards to sexual behaviour. However, it is still relatively low in many South and East African countries, and lower among adolescent girls than boys in low- and middle-income countries.
Not using condoms
Condom use among young people and adolescents is usually low, with only 34% of young women and 45% of young men in South and East Africa using them.
Multiple partners
The number of sexual partners young people have is falling, although it remains high in countries most affected by the HIV epidemic.More than a quarter of young men in Lesotho, Madagascar and Swaziland are thought to be in multiple relationships.
Older partners
Inter-generational sex (when young people have relationships with older people) is thought to be a driver of the HIV epidemic in sub-Saharan Africa.
Older partners are more likely to be living with HIV, therefore risking exposure to young people. Young women also find it harder to negotiate condom use with older partners who have greater power in the relationship and may use gifts or money to encourage girls to have unprotected sex.
Young people who are part of key populations
Young people may also belong to other key affected populations - such as sex workers, men who have sex with men, people who inject drugs or transgender people. In Asia, 95% of young people diagnosed with HIV fall under at least one of these groups
These young people are often subjected to strict laws and discrimination relating to their behaviours, preventing them from accessing specific HIV information and services. In some countries, being homosexual, injecting drugs or having sex under the age of consent is criminalised.
Young women
60% of new HIV infections among young people occur in young women, equating to 380,000 every year. In sub-Saharan Africa, women are likely to become HIV-positive five to seven years earlier than men.
A number of reasons for this are reported, including gender-based violence and a lack of access to education and healthcare services. In some places, up to 45% of women report that their first sexual experience was forced or against their will.
Young sex workers
40% of female sex workers (FSW) in North America, East and South Asia begin selling sex before the age of 18. In Bangladesh, many start before they reach 12 years old.
The low age of sex work initiation puts young women at an elevated risk of HIV, both biologically, and because of being powerless to negotiate condom use. In Papua New Guinea, 12.1% of young FSW and 14.6% of young male sex workers are living with HIV.
Young transgender people
Data for this demographic is very limited, but one survey in Indonesia reported that HIV prevalence was high among both adolescent transgender people aged 15-19 (5.4%) and young transgender people aged 20-24 (14.2%).
Due to social exclusion, homelessness and financial problems, many transgender people start selling sex at a young age to cope with these issues, which puts them at heightened risk of HIV.
Young men who have sex with men
Men who have sex with men are becoming HIV-positive at a younger age. 4.2% of young MSM under 25 are living with HIV, compared to 3.7% among all MSM.
In Bangkok, Thailand, HIV incidence among young MSM has risen dramatically, from 4.1% in 2003 to 25% in 2012.
Young people who inject drugs
HIV prevalence among young people who inject drugs worldwide is 5.2%. However, it is much higher in countries such as Pakistan, where 23% of young people aged 15-24 who inject drugs are living with HIV.
Many drug users who start injecting young are more likely to become HIV-positive because they are:
less likely to access harm reduction and treatment services
more likely to share needles and syringes
more likely to rely on older drug users for equipment
less likely to understand the risks of injecting
likely to require parental consent to access HIV testing, needles from pharmacies and harm reduction programmes.
There are often age restrictions on accessing harm reduction services, forcing young people away from services and being denied help to overcome their addiction.If someone starts injecting drugs in their youth, they should be prioritised for harm reduction services, not denied them.
HIV prevention programmes for young people
Age-appropriate services
Young people respond much better to HIV and sexual health services that are specific to their age group. This includes sexual and reproductive health education, contraception and condoms, mental health services, peer support, and support transferring from paediatric to adult health services.
Greater emphasis should be placed on counselling to encourage behaviour change among young people, rather than just handing out commodities such as condoms.
Voluntary medical male circumcision (VMMC)
The effect of male circumcision on reducing transmission of HIV from women to men via vaginal sex has shown to be most successful among men under the age of 25. This is likely due to the fact that it is easier to encourage safer sexual behaviour among younger people than older people who have already established behavioural norms.
Younger males also face less pressure from female partners when abstaining from sex during the healing process, due to greater cultural acceptance of circumcision among younger people.
Engaging schools in the response
Schools have the potential to provide detailed education on HIV and AIDS and other sexual health issues. More progress needs to be made to ensure there is equality in access to schools by both girls and boys, and to prevent them from dropping out.
Engaging young people in the response
Young people have the potential to be great peer educators, and to help in the design of HIV-related services and programmes. Technology and social media are consistently being proved as effective ways to engage young people in sharing HIV knowledge.
These peer educator and social media ideas have been combined by the Y+ Programme, a platform for young people living with HIV to talk, find a mentor, become a mentor and advocate for the needs of young people.
Cash transfers plus care
Small cash transfers to households on a very low income have been shown to have a positive effect on reducing risk-taking behaviour among adolescent girls in South Africa. The study also found that HIV incidence halved among both girls and boys who received cash, coupled with other forms of care, known as ‘cash plus care’.
HIV testing and counselling (HTC) for young people
It's thought that only 10% of young men and 15% of young women living in sub-Saharan Africa know their HIV status.
Increasing access to HIV testing is vital to prevent further transmission of HIV among young people. Mobile and community testing initiatives are a successful way of reaching young people who are less likely to voluntarily visit a static testing centre.
HTC has proved very successful as a form of HIV prevention in Eastern and Southern Africa.
A study in South Africa found that HIV testing and counselling (HTC) among 4,000 young people caused 41% fewer cases of HIV transmission in a four year period.
Barriers to HIV testing for young people
The World Health Organisation (WHO) 2013 guidelines for HIV testing and counselling for adolescents highlight the programmatic barriers currently preventing adolescents from accessing HIV testing, and what can be done to overcome them.
Age of consent to HIV testing
In many countries, the age of consent is high at around 18-21, leaving people younger than this having to obtain parental consent. This is much more likely to result in a young person not getting an HIV test when discussions with parents around sexual relations and HIV are necessary.
For many orphaned young people, parental consent is not an option and so they are denied access. Age of consent laws to HIV testing should be removed.
Age-appropriate HTC
Services must be open at appropriate times (after school/college), and be at appropriate venues where young people feel safe enough to go alone.
Legal protection
In the case of sexual violence, it is important that a young person is supported and referred to child protection services.
Linking to treatment and care
Young people need extra support to transfer to treatment if they test positive, as they may otherwise get lost in the treatment cascade.
Support around disclosure
Due to common low ages of sexual debut and age of first childbirth, it is important that young people are supported to protect the health of their partner(s) through disclosure.
Antiretroviral treatment for young people
Mother-to-child transmission (MTCT) rates are decreasing, but the fact that it still exists means that there will be an increase in adolescents needing antiretroviral treatment (ART) until it is eliminated. Access to ART for young people is unknown because data is disaggregated into children under 15 years and adults over 15 years.
For those who do access treatment, there are some common barriers to its effectiveness.
Adhering to antiretroviral treatment
Adherence to ART among young people has increased since 2005, thought to be due to more manageable antiretroviral drugs (ARV), less toxicity, and combined treatment. However, adherence support must be scaled up for young people to sustain treatment as a form of prevention, and stop onwards transmission to others.
Treatment adherence is greatest in Africa and Asia (84%), and lowest in North America (53%). One reason for this difference is the variation in ages of maturation. It is generally thought that young people mature earlier in Africa and Asia, where they start working and have relationships at a younger age. This bears great responsibilities, which may contribute to young people being more responsible for their own healthcare, and adhering to their treatment.
Transitioning from paediatric to adult care
In North America and Europe, there is a large jump at 18 years of age, when people living with HIV are moved from paediatric to adult services and allocated a new doctor.
This transition is complicated by the added pressure of suddenly becoming responsible for their own life-long treatment rather than with support from guardians. At this point, a lot of young people are lost to follow up and no longer retained in care.
Increased drug doses
Changing ARV regimens and doses during adolescence is another complex issue that results in young people not adhering to their treatment. As young people grow, their dosages must be increased to reflect increases in their weight and height.
Lost from the treatment system
One study that took place in clinics in Kenya, Mozambique, Tanzania and Rwanda found that young people were more likely to be lost from treatment services than older people. Clinics that offer condoms and youth support groups experienced greater retention in care, showing that youth-friendly services ensure young patients are retained in care.
Barriers to HIV prevention among young people
Low HIV and sexual health knowledge
In East and South African countries, only 40% of young people know how to prevent HIV because sex education in these countries is low.
Only 36% of young men and 28% of young women in sub-Saharan Africa have accurate HIV knowledge.This is unsurprising in a region where many children drop out of primary school and only 20% complete secondary school.
Opportunities to obtain knowledge about HIV, AIDS and sexual health are extremely limited for young people not in school.Youth clubs have the potential to provide HIV knowledge, but their small, localised reach means their impact is limited on a large scale.
Lack of access to HIV services
Many young people report that healthcare workers have negative attitudes towards young people seeking healthcare services, particularly those having sex under the national age of consent, engaging in homosexual relationships or using drugs. This deters them from seeking contraception, sexually transmitted infection (STI) check-ups and HIV testing.
Some young people are also fearful of stigma from their partners, families and communities, making them unwilling to come forward for HIV testing in case their families find out that they are sexually active or living with HIV.Other sexual and reproductive health services deny access to people who are not married.
Gender inequality and HIV vulnerability
Of all adolescents aged 15-19 who were diagnosed as HIV-positive during 2012, two-thirds were girls. Globally, young girls are more vulnerable to HIV for a number of reasons, but universally the level of HIV knowledge among girls is less than among boys because girls are less likely to attend and finish secondary school.
In order to address these gender differences, a systematic review of HIV programming for adolescents noted a number of interventions that are needed for programmes to be effective for girls:
an enabling environment, including keeping girls in school, promoting gender equity, strengthening protective legal norms, and reducing gender-based violence
Information and service needs, including provision of age-appropriate comprehensive sex education, increasing knowledge about and access to information and services, and expanding harm reduction programs for adolescent girls who inject drugs
social support, including promoting caring relationships with adults and providing support for adolescent female orphans and vulnerable children.
Young parenthood and HIV
15 million girls between 15 and 19 give birth every year.certain countries, the average age of parenthood is even lower - 41% of girls in Sierra Leone have their first pregnancy between 12 and 14 years of age.
As a result, young women are more likely to learn their HIV status before their partner does via antenatal clinic tests. This generates a culture of blame on the woman because she found out first, reducing her willingness to seek future healthcare services.
The future of HIV among young people
Among young people, the age of sexual debut is rising, the number of sexual partners is falling and the uptake of voluntary medical male circumcision is most popular among people younger than 25.
Still, young people are routinely forgotten in national strategic plans to tackle the HIV epidemic, especially those that also fall under other key affected populations. They are not targeted with age-appropriate HIV prevention programmes and data about their vulnerability is not collected.
As a result, young people are often forgotten and excluded from the international HIV response. Engaging young people is key to protecting their health and addressing the HIV epidemic as a whole.
A study in South Africa found that HIV testing and counselling (HTC) among 4,000 young people caused 41% fewer cases of HIV transmission in a four year period.
Barriers to HIV testing for young people
The World Health Organisation (WHO) 2013 guidelines for HIV testing and counselling for adolescents highlight the programmatic barriers currently preventing adolescents from accessing HIV testing, and what can be done to overcome them.
Age of consent to HIV testing
In many countries, the age of consent is high at around 18-21, leaving people younger than this having to obtain parental consent. This is much more likely to result in a young person not getting an HIV test when discussions with parents around sexual relations and HIV are necessary.
For many orphaned young people, parental consent is not an option and so they are denied access. Age of consent laws to HIV testing should be removed.
Age-appropriate HTC
Services must be open at appropriate times (after school/college), and be at appropriate venues where young people feel safe enough to go alone.
Legal protection
In the case of sexual violence, it is important that a young person is supported and referred to child protection services.
Linking to treatment and care
Young people need extra support to transfer to treatment if they test positive, as they may otherwise get lost in the treatment cascade.
Support around disclosure
Due to common low ages of sexual debut and age of first childbirth, it is important that young people are supported to protect the health of their partner(s) through disclosure.
Antiretroviral treatment for young people
Mother-to-child transmission (MTCT) rates are decreasing, but the fact that it still exists means that there will be an increase in adolescents needing antiretroviral treatment (ART) until it is eliminated. Access to ART for young people is unknown because data is disaggregated into children under 15 years and adults over 15 years.
For those who do access treatment, there are some common barriers to its effectiveness.
Adhering to antiretroviral treatment
Adherence to ART among young people has increased since 2005, thought to be due to more manageable antiretroviral drugs (ARV), less toxicity, and combined treatment. However, adherence support must be scaled up for young people to sustain treatment as a form of prevention, and stop onwards transmission to others.
Treatment adherence is greatest in Africa and Asia (84%), and lowest in North America (53%). One reason for this difference is the variation in ages of maturation. It is generally thought that young people mature earlier in Africa and Asia, where they start working and have relationships at a younger age. This bears great responsibilities, which may contribute to young people being more responsible for their own healthcare, and adhering to their treatment.
Transitioning from paediatric to adult care
In North America and Europe, there is a large jump at 18 years of age, when people living with HIV are moved from paediatric to adult services and allocated a new doctor.
This transition is complicated by the added pressure of suddenly becoming responsible for their own life-long treatment rather than with support from guardians. At this point, a lot of young people are lost to follow up and no longer retained in care.
Increased drug doses
Changing ARV regimens and doses during adolescence is another complex issue that results in young people not adhering to their treatment. As young people grow, their dosages must be increased to reflect increases in their weight and height.
Lost from the treatment system
One study that took place in clinics in Kenya, Mozambique, Tanzania and Rwanda found that young people were more likely to be lost from treatment services than older people. Clinics that offer condoms and youth support groups experienced greater retention in care, showing that youth-friendly services ensure young patients are retained in care.
Barriers to HIV prevention among young people
Low HIV and sexual health knowledge
In East and South African countries, only 40% of young people know how to prevent HIV because sex education in these countries is low.
Only 36% of young men and 28% of young women in sub-Saharan Africa have accurate HIV knowledge.This is unsurprising in a region where many children drop out of primary school and only 20% complete secondary school.
Opportunities to obtain knowledge about HIV, AIDS and sexual health are extremely limited for young people not in school.Youth clubs have the potential to provide HIV knowledge, but their small, localised reach means their impact is limited on a large scale.
Lack of access to HIV services
Many young people report that healthcare workers have negative attitudes towards young people seeking healthcare services, particularly those having sex under the national age of consent, engaging in homosexual relationships or using drugs. This deters them from seeking contraception, sexually transmitted infection (STI) check-ups and HIV testing.
Some young people are also fearful of stigma from their partners, families and communities, making them unwilling to come forward for HIV testing in case their families find out that they are sexually active or living with HIV.Other sexual and reproductive health services deny access to people who are not married.
Gender inequality and HIV vulnerability
Of all adolescents aged 15-19 who were diagnosed as HIV-positive during 2012, two-thirds were girls. Globally, young girls are more vulnerable to HIV for a number of reasons, but universally the level of HIV knowledge among girls is less than among boys because girls are less likely to attend and finish secondary school.
In order to address these gender differences, a systematic review of HIV programming for adolescents noted a number of interventions that are needed for programmes to be effective for girls:
an enabling environment, including keeping girls in school, promoting gender equity, strengthening protective legal norms, and reducing gender-based violence
Information and service needs, including provision of age-appropriate comprehensive sex education, increasing knowledge about and access to information and services, and expanding harm reduction programs for adolescent girls who inject drugs
social support, including promoting caring relationships with adults and providing support for adolescent female orphans and vulnerable children.
Young parenthood and HIV
15 million girls between 15 and 19 give birth every year.certain countries, the average age of parenthood is even lower - 41% of girls in Sierra Leone have their first pregnancy between 12 and 14 years of age.
As a result, young women are more likely to learn their HIV status before their partner does via antenatal clinic tests. This generates a culture of blame on the woman because she found out first, reducing her willingness to seek future healthcare services.
The future of HIV among young people
Among young people, the age of sexual debut is rising, the number of sexual partners is falling and the uptake of voluntary medical male circumcision is most popular among people younger than 25.
Still, young people are routinely forgotten in national strategic plans to tackle the HIV epidemic, especially those that also fall under other key affected populations. They are not targeted with age-appropriate HIV prevention programmes and data about their vulnerability is not collected.
As a result, young people are often forgotten and excluded from the international HIV response. Engaging young people is key to protecting their health and addressing the HIV epidemic as a whole.
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