Contents
Chapters
- The Invisible Epidemic
- How Young People Become Infected
- Why So Vulnerable?
- Addressing the Epidemic
- Reaching Out
- Consequences of Inaction
- HIV/AIDS: What Young People Want to Know
- Profiles
- Youth at the Center
Highlights
- Why young women face more risk
- Culture can hurt
- Profile: Going public
- Education should start early
- Condoms for dual protection
- Orphans: A new challenge
- What can parents do?
- Reaching street children
- Putting youth at the center
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Published by the Population Information Program, Center for Communication Programs, The Johns Hopkins University Bloomberg School of Public Health, 111 Market Place, Suite 310, Baltimore, Maryland 21202, USA.
Volume XXIX, Number 3
Fall 2001
Series L, Number 12
Issues in World Health
The Burden on Youth
While not recognized at the onset, the HIV/AIDS epidemic is now clearly worst among youth.* Over a period of 20 years, more than 60 million people have been infected with HIV; half of them became infected between the ages of 15 and 24 (153, 432). An estimated 11.8 million people between the ages of 15 and 24 are living with HIV/AIDS (432). In some African countries more than one young woman in every five is living with HIV/AIDS (see Table 1).
*The terms "youth," "adolescents," and "young people" are defined variously. WHO refers to people between the ages of 10 and 19 as adolescents and the larger age group 10 to 24 as young people (409). The three terms often are used interchangeably, a practice that this issue of Population Reports follows.
Although young people suffer most from HIV/AIDS, the epidemic among youth remains largely invisible (216), both to young people themselves and to society as a whole. Young people often carry HIV for years without knowing that they are infected. As a consequence, the epidemic spreads beyond high-risk groups to the broader population of young people, making it even harder to control.
Already, AIDS has become generalized among youth in almost half of sub-Saharan Africa. In a generalized HIV epidemic 5% or more of the population are infected (7). In nearly 20 sub-Saharan countries an estimated 5% or more of young women ages 15 to 24 are infected with HIV (162). As each new generation of young people reaches reproductive age, another wave of infection becomes more likely (158).
As the AIDS epidemic spreads, younger and younger age groups are becoming exposed to the risk of HIV (126, 170, 308). Infection spreads to younger age groups as men choose increasingly younger sexual partners. Many men believe, probably correctly, that younger girls are less likely to be infected with HIV, while others hold the mistaken belief that having sex with a virgin can cure AIDS (299, 339, 367).
Reflecting these trends in sexual preferences, young women with HIV are infected on average ten years earlier than men, and, consequently, many will die of AIDS at younger ages than men. As a result of this situation, the US Census Bureau projects, by 2020 there will be more men of reproductive age than women, an imbalance that could lead men to seek even younger women, further increasing HIV infection among adolescent women (338).
Statistics from the Joint United Nations Program on HIV/AIDS (UNAIDS) indicate the scope of the catastrophe among youth:
- In 1998, the date of the most recent estimate of new infections, over 2.5 million young people ages 15 to 24 became infected with HIV (153)—half of all new HIV infections that year (169).
- Every day over 7,000 more young people become infected—about five per minute (153, 154, 165).
- Worldwide, people ages 15 to 24 account for about 30% of all people living with HIV/AIDS (432).
Such numbers underscore the urgency of addressing HIV/AIDS among youth. Youth comprise about one-fifth of the world's population (363). They comprise an even greater part of many developing countries' populations—nearly two-fifths where fertility rates are highest (295).
Young people are particularly vulnerable to HIV/AIDS because of the physical, psychological, social, and economic attributes of adolescence (70, 271, 284, 327, 422). Many adolescents are economically dependent and socially inexperienced, have not been taught or have not otherwise learned how to protect themselves from infection, and generally have less access to health care than adults (154, 158, 410).
Culture and society have powerful effects on behavior and often increase young people's vulnerability to HIV/AIDS (see side-bar How Culture Can Hurt). Adolescents often are not able fully to comprehend the extent of their exposure to risk and the potentially dangerous results.
Regional and national differences. The prevalence of HIV/AIDS among young people varies widely among regions and countries. Sub-Saharan Africa faces the worst prospects. Although just 10% of the world's youth live in sub-Saharan Africa, the region contained almost three-quarters of all youth living with HIV/AIDS in 2001—a total of 8.6 million (153, 432).
There are substantial differences in HIV prevalence among African countries. Botswana has the highest proportion of infected young people—at least one-third of women ages 15 to 24—while other countries of southern Africa are close behind (see Table 1). In contrast, HIV prevalence is low in West Africa.
Within Asia and the Pacific, Cambodia, Myanmar, and Thailand have the highest infection rates—the only countries in the region with HIV prevalence greater than 1% among youth. In Latin America and the Caribbean prevalence of HIV varies widely. The Caribbean has some of the most serious AIDS epidemics outside sub-Saharan Africa. In the Bahamas, Dominican Republic, Guyana, and Haiti, at least 2% of young women are infected with HIV.
In Eastern Europe and Central Asia, HIV prevalence is relatively low. Only in Ukraine are over 1% of young men ages 15 to 24 infected. The epidemic appears to be spreading rapidly among young people, especially from unsafe drug injecting. If HIV spreads from drug users into the general population, prevalence probably will rise rapidly (162). Similarly, in North Africa and the Near East, HIV infection among young people is rare (153). Nevertheless, injection drug use may soon cause a wave of infections in the region (171) and thus portend an increase in overall HIV infection rates among youth.
Only a few industrialized countries, including the US, have infection rates of 0.5% or higher. These countries had a combined total of about 240,000 youth living with HIV/AIDS in 2001, 2% of the world total (432).
Differences within countries. National statistics often conceal large differences in the HIV/AIDS epidemic within countries. Cities generally have higher HIV prevalence than rural areas (223). In Zambia, for example, women ages 15 to 19 in Lusaka, the capital city, are three times more likely to be infected than young women in rural areas (93). In time, however, movement of people between rural and urban areas could narrow such differences (223, 389).
HIV/AIDS statistics for the general population can also conceal dramatic difference among groups. For example, in the northeast parts of India, HIV appears confined to drug-injecting men and their sexual partners. In the southern and western states, however, it has moved beyond this group into the general population (153).
Gender differences. Gender differences in patterns of HIV infection among young people vary substantially around the world. Where heterosexual transmission of HIV dominates, often more young women are infected than young men (see Heterosexual Activity). In most of Africa infection rates among young women are at least twice the rates among young men (162) (see Table 1).
In certain regions adolescent women are as much as six times more likely than adolescent men to be infected (162). In some parts of Kenya and Zambia, for instance, teenage women have HIV prevalence rates of 25% compared with 4% among teenage men (171, 339). In Botswana about one-third of women ages 15 to 24 are estimated to be HIV-positive, twice the proportion among men the same age (162). A similar gender imbalance occurs in the US (373).
Where the HIV epidemic is widespread among injecting drug users, as in Australia, New Zealand, Europe, and Central Asia, most cases occur among young men, because young men are more likely than young women to use drugs (171). In China in the mid-1990s infected adolescent men between ages 16 and 19 outnumbered infected adolescent women nine to one (419).
Among young men in industrialized countries, sexual transmission of HIV is predominantly through men having sex with other men. For example, in the US in 1999 half of the AIDS cases in men ages 13 to 24 were among those who had sex with other men (373).
Economic and social differences. HIV spreads fastest and farthest in conditions of poverty, powerlessness, and lack of information (53, 223)—conditions in which many young people live. In fact, AIDS is now largely a disease of marginalized peoples (226, 395). Worldwide, the AIDS epidemic is most severe in the poorest countries (171). Within countries, the disadvantaged—people with few opportunities, services, and support systems—are at greatest risk (see Poverty and Deprivation). Among youth as well, HIV disproportionately affects the poor and the marginalized (283).
In sub-Saharan Africa AIDS first appeared to be a disease of wealthy men who could afford to travel, to have multiple sex partners, and to pay for sex. As the epidemic has spread, however, HIV has become far more widespread among the poor. The pattern is similar in Asia (395).
In the US HIV/AIDS was first reported among relatively wealthy white adult men who had sex with men. The epidemic has now migrated to less privileged groups, however. In fact, AIDS has become the leading cause of death among African Americans ages 25 to 44 (373).
