HIV Prevention Across the Youth Spectrum

• Factors Contributing to Young People’s Risk of Contracting HIV
• The Vulnerability of Girls and Young Women
• USAID’s Strategy for HIV Prevention Among Youth
• A Look at USAID’s HIV Prevention Programs for Young People

	High-risk youth in Tashkent, Uzbekistan, attend an educational session addressing Break the Cycle issues. Source: Robert Gray

The global epidemic cannot be reversed without sustained success in reducing new infections among young people. The proportion of new HIV infections attributed to young people varies greatly across countries and by the type of epidemic. The UNAIDS 2008 Report on the Global AIDS Epidemic estimates that young people aged 15 to 24 accounted for 45 percent of all new HIV infections in adults in 2007. According to recent research from Africa, youth represent 38 percent of new infections in South Africa, 29 percent in Kenya, and 23 percent in Uganda. Studies in India and Myanmar indicate that HIV infection rates are often higher in younger members of at-risk populations compared with older age groups.

HIV infection rates among young people tend to be highest in the countries of sub-Saharan Africa (see graph below), where the epidemic has spread widely in the general population. In these “generalized” epidemics, all youth need to be reached with HIV prevention education, given the high overall risk of contracting HIV. In generalized epidemics, many more girls are infected than boys because girls face greater social vulnerability and may also be more biologically susceptible to infection. Other youth at increased risk in generalized epidemics include orphans and youth who lack social protection.

In Eastern Europe, Asia, and Latin America, where HIV transmission is primarily concentrated in populations engaging in high-risk behaviors, the majority of young people are generally at low risk of contracting HIV. Nevertheless, in many countries with concentrated epidemics, the populations that are at highest risk often have a youthful age profile. In concentrated epidemics, most young people who are HIV positive contracted the virus while engaging in the highest-risk behaviors, such as injecting drug use, sex work, and male-to-male sex. In Central Asia and Eastern Europe, the average age for initiating injecting drug use is between 16 and 19 years old. Studies conducted in Indonesia and Laos demonstrated that 41 to 76 percent of female sex workers were under 25 years of age. Younger members of highrisk groups may be less likely to protect themselves in risky situations. In Morocco, 28 percent of men who have sex with men (MSM) in the 15 to 24 year age group used condoms regularly compared with 57 percent of MSM over 25 years of age.

More research is needed on the special challenges relating to prevention programs for younger high-risk popluations compared with older high-risk popluations so that programs can address their distinct needs. Interventions need to be more widely implemented for these young people, who are at high risk of HIV across all settings.

Factors Contributing to Young People’s Risk of Contracting HIV

The social, cultural, family, and institutional environments in which young people live profoundly influence their behaviors. Close relationships with parents and other adults, regular school attendance, and supportive community norms are protective factors or conditions in the environment that are particularly associated with positive youth behaviors. Conversely, youth who experience family instability or who have negative peer role models are more likely to practice high-risk behaviors, including drug and/or alcohol use and early and/or unsafe sex. For AIDS-affected families, the impact of AIDS on family income forces many young people out of the protective environments of home and school, increasing their risk of exploitation and unsafe sexual behavior. For example, one study of orphans and vulnerable children (OVC) in Zimbabwe demonstrated that adolescent OVC have significantly higher HIV prevalence than other teens.

Across all countries and epidemic contexts, some young people are at very high risk of infection. In addition to the high-risk groups already mentioned, youth who lack family and social protection – street kids, refugees, domestic workers, and child soldiers – are at risk, as are youth in mobile occupations such as the trucking industry and the military.

HIV Prevalence Among 15- to 24-Year-Old Women and Men in Selected Countries in Sub-Saharan Africa, 2003–2007

Young people may also fail to recognize their own personal risk because of a lack of knowledge and understanding of HIV. In many countries, HIV knowledge, skills, and attitudes among youth remain inadequate to prevent further spread of the disease. Survey data from 64 countries indicate that only 40 percent of males and 38 percent of females aged 15 to 24 had accurate and comprehensive knowledge of three ways to avoid HIV transmission. More than 70 percent of young men know that condoms prevent HIV exposure; however, only 55 percent of young women cite condom use as an effective strategy for prevention. Young people often have difficulty accessing services that are not designed to meet their needs.

The Vulnerability of Girls and Young Women

In generalized epidemics, girls and young women are much more likely to become infected with HIV than their male peers. Girls are more socially vulnerable because they often have transactional sex with older men in exchange for financial or material support to pay for luxury items, school fees, or essentials such as food. Older men, who are more likely to be infected with HIV, may seek out younger girls assuming they are not infected and put the girls at risk. While girls often have limited power to insist on condom use within these relationships, they appear to play an active role in initiating and ending these partnerships, which may provide an opportunity for intervening to prevent HIV. Some studies also suggest that higher infection rates in girls may be due in part to biological vulnerabilities related to physiological and hormonal differences in young women.

Although all orphans and vulnerable children are at risk of engaging in high-risk activity, female OVC are particularly susceptible to early marriage and sexual debut, pregnancy, and sexual abuse and exploitation. According to a study of 1,523 adolescents in Zimbabwe, female OVC aged 15 to 18 were four times more likely to have initiated sexual activity, six times more likely to have had a teen pregnancy, and were more likely to be married than non-orphans. In Ethiopia, USAID reaches out to girls in urban domestic work, many of whom are orphans participating in the Bright Future program. The program is designed to prevent (and mitigate the effects of) early sexual debut, sexual abuse, and exploitation through literacy and HIV education, as well as ensure vital linkages to legal services, shelters, counseling, and medical services.

To address the special needs of girls in Botswana, Malawi, and Mozambique, USAID, in partnership with PEPFAR, is implementing an initiative to decrease girls’ vulnerability to HIV. Project activities include community consensus-building; engaging leadership and skills building; and linkages to social services (education, health, and income generation).

South Africa Health Communication Campaign Decreases Stigma and Increases HIV Prevention Behaviors Among Youth

Tsha Tsha Produced for SABC Education and JHU CCP by Curious Pictures   Tsha Tsha is a gritty Xhosa-language educational drama with English subtitles. Set in a fictional rural town in South Africa, the drama focuses on the lives of four 20-somethings living on the dusty streets of this impoverished town. The setting includes a ballroom dance club, which provides a background for exploring relationships and intimacy. As they transition to adulthood, the main characters deal with HIV/AIDS, relationships, sex, and poverty. The series aims to deliver lessons that enhance young people’s capacity to reflect on solutions and to see themselves as active agents who can shape their own lives. Tsha Tsha succeeds in reaching its primary audience of youth aged 18 to 24 due to its compelling and contemporary story lines. USAID has supported work on the research and development of all the episodes, providing input into the development of the characters, the unique lesson style of the series, the scripts, the production, as well as the design of the impact evaluation. The Tsha Tsha television drama maintains a weekly audience of more than 6 million people and is broadcast during prime time by the South African Broadcasting Corporation (SABC). Three 26-episode series were produced (a total of 78 half-hour weekly episodes). Each series was broadcast twice by SABC, beginning in 2003–2004 and continuing through the end of 2008 with the second broadcast of the final series. Tsha Tsha has won numerous awards, including one from the U.S. Film and Video Competition in the category of social drama. The main objectives of the campaign are to: • Encourage young people living with AIDS to seek HIV/AIDS-related services • Increase the rate of voluntary counseling and testing among youth • Increase condom use among youth engaged in high-risk sexual behavior • Decrease stigma associated with HIV/AIDS • Encourage secondary abstinence among unmarried youth • Increase self-efficacy of young people regarding positive decisionmaking and problem solving An evaluation of the first 26 episodes was conducted from 2003 to 2004 by means of a longitudinal sample survey of 960 youth aged 16 to 26 in three diverse provinces of South Africa: Gauteng, the Eastern Cape, and KwaZulu-Natal. Sixty-eight percent recalled seeing Tsha Tsha on television. Compared with nonviewers, exposure to Tsha Tsha was found to be significantly related to a positive attitude toward living with HIV/AIDS (reversed stigma), the prevention practices of sexual abstinence, faithfulness to one partner, condom use to prevent HIV, and condom use at last sex. Exposure was also positively related to obtaining an HIV test to determine one’s status. These findings were replicated in a national sample survey of 7,000 conducted in 2006 that included a sub-sample of 2,814 males and females aged 15 to 24 years. The survey demonstrated substantial exposure to the campaign and changes in behaviors among the Tsha Tsha viewers. Sixty-one percent of youth aged 15 to 24 surveyed had seen Tsha Tsha. Sexually active youth aged 15 to 24 were more likely to use a condom if they had seen Tsha Tsha than youth who were not exposed to the campaign.

USAID’s Strategy for HIV Prevention Among Youth

Since each country’s epidemic is unique, USAID responses under the Emergency Plan are tailored to the individual country situation. In generalized epidemics, USAID emphasizes a comprehensive approach that includes mutually reinforcing mass media, life skills education, and youth-friendly health services while also making condoms available for older married and sexually active youth. In concentrated epidemics, USAID works primarily with groups that are most at risk, such as sex workers and injecting drug users (IDUs), who, as previously noted, often include significant numbers of young people.

Behavior change is the cornerstone of HIV prevention. As a key PEPFAR partner, USAID endorses the “ABC” model, which stands for abstinence (including delayed sexual initiation among youth), being faithful, and correct and consistent condom use. The ABC approach can be adapted to a particular country context or target population. In order to empower youth to adopt healthy behaviors, USAID supports skills-based HIV education to provide young people with a basic understanding of HIV; help them personalize risk; and develop the self-esteem, communication, and decisionmaking skills they need to make healthy life choices. For younger teens, especially those aged 10 to 14, USAID puts primary emphasis on abstinence and delaying sexual debut to reduce transmission of HIV. For older youth, especially youth aged 15 to 24, USAID supports a comprehensive approach to reducing the risk of contracting HIV, including primary abstinence (delaying the age of sexual initiation) and secondary abstinence (abstinence after having experienced sexual initiation), mutual fidelity and avoidance of casual sexual partners, and correct and consistent condom use. In addition to supporting programs for young people themselves, USAID seeks to strengthen protective factors that help young people make healthy choices, for example, working to enhance parent communication with their adolescent children.

USAID programs also recognize the diversity of youth, for example, the need for programs to address the differences between boys and girls, in-school and out-of-school youth, younger and older adolescents, and young people who are married and unmarried. While prevention is paramount, USAID-supported youth programs include a special emphasis on linkages to HIV counseling and testing, as well as to the continuum of care and treatment. The Agency recognizes that HIV-positive young people need an array of services, such as psychosocial support, prevention of mother-tochild transmission, palliative care, and antiretroviral therapy (when medically appropriate). USAID also provides linkages to family planning services, including contraception for sexually active and married youth.

A Look at USAID’s HIV Prevention Programs for Young People

Skills-Based HIV Education is one of the key defenses against the spread and impact of HIV/AIDS. Well-implemented skillsbased HIV/AIDS education has been shown to help young people develop knowledge, attitudes, and life skills to protect themselves against HIV. In Uganda, USAID supports the Presidential Initiative on AIDS Strategy for Communication to Youth (PIASCY), a largescale life skills education program spearheaded by President Yoweri Museveni. USAID is currently working with the Ministry of Education and Sports (MOES) to expand PIASCY to include primary and secondary schools throughout the country.

Specifically, USAID is supporting the production and distribution of educational materials for the program, which are designed to increase risk perception about HIV and sexually transmitted infections, and also address the abuse of alcohol and other drugs as a co-factor in transmission of HIV. The program intervention is designed for age-appropriate beneficiaries within two sub-sectors of education. At the post-primary level, a total of 236,799 adolescent students and young adults are targeted to be reached through materials provision. A total of 1,830 teachers received training from 668 post-primary and vocational institutions. At the primary level, USAID will also assist the MOES in conducting refresher courses for 30,000 teachers from 16,000 government-aided and private schools to help them stimulate parent and community participation in the program. HIV readers have been developed and produced for use by 664,915 pupils. Training in use of the readers reached 9,774 teachers in 9,980 primary schools. In order to ensure capacity building at all levels and the involvement of government counterparts, training and implementation will be done in collaboration with the MOES, and local governments.

Mass Media Campaigns involve the creative use of theater, music videos, concerts, and radio and television programs that appeal to young people. The USAID-funded Tsha Tsha mass media campaign in South Africa recently won an Award for Excellence in HIV and AIDS Communication in Africa. This television series is designed to help its young viewers respond to the AIDS epidemic by reflecting on their own problems, engaging in developing solutions, and becoming active agents in shaping their futures. To better understand how mass media campaigns are utilized in the fight against AIDS, please see the detailed text box on the Tsha Tsha television series.

Break the Cycle (BTC) is an example of a USAID-supported program targeting the concentrated epidemics among young IDUs in Central Asia, where 70 percent of HIV infections are related to injecting drug use. In a 2004 qualitative assessment of youth perspectives on drug use, curiosity was the biggest reported driver of young people initiating drug use. Moreover, in a 2006 study among IDUs in Uzbekistan and Kyrgyzstan, 86 percent surveyed said that siblings, cousins, and friends had helped them initiate injecting drug use. BTC reduces the exposure of young non-IDUs to injecting drug use and reduces the enabling of injecting drug use by others. BTC encourages and supports IDUs not to help others initiate injection drug use, inject in the presence of non- IDUs, or talk about the benefits of injecting drugs. An initial evaluation of the program demonstrated that IDUs who participated were less likely to help someone initiate drug use or talk about the benefits of injecting drug use with a non user. BTC offers a promising model for evidence-based drug demand reduction among young people worldwide.

USAID also supports knowledge management through support for the Interagency Youth Working Group (IYWG) activity, which seeks to provide global technical leadership to advance the reproductive health and HIV/AIDS outcomes of young people aged 10 to 24 in developing countries. IYWG publications and the Web site, www.youthwg.org, share research and programmatic results and lessons learned on youth reproductive health and HIV/AIDS, and promote strategies that move promising research findings into programs and policies. For example, YouthLens is a series of research briefs that summarizes the latest information on key issues regarding reproductive health and HIV prevention among youth aged 10 to 24. Recent YouthLens topics included school-based HIV programs, youth peer education, and community involvement in youth HIV prevention. Youth InfoNet is a fully electronic source for new publications and information on youth reproductive health and HIV prevention.

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February 2009

The U.S. Agency for International Development works in partnership with the U.S. President's Emergency Plan for AIDS Relief.