• Editors' Summary
• Credits

1. The Invisible Epidemic
2. How Young People Become Infected
• Heterosexual Activity
• Same-Sex Relationships
• Drug Injecting
• Other Means of HIV Transmission
• HIV and Other STIs
3. Why So Vulnerable?
4. Addressing the Epidemic
5. Reaching Out
6. Consequences of Inaction
7. HIV/AIDS: What Young People Want to Know
8. Profiles
9. Youth at the Center

• Figures
• Tables
• Side-bars
• Bibliography

• 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.

How Young People Become Infected

Young people, like adults, contract HIV primarily in three ways—through men and women having sex, through men having sex with men, and through intravenous drug injecting (158). Having other sexually transmitted infections can increase the odds of contracting HIV/AIDS during sex with an infected person from two- to eightfold (96, 126, 148, 173).

HIV can also be transmitted from a woman to her baby, during pregnancy, birth, or through breastfeeding (see HIV Transmission from Mother to Child). While the first generation of babies infected by mother-to-child transmission would now be adolescents, the proportion of such infants still living is probably small (274).

Other means of transmission account for only a small proportion of infections. These include transfusion with infected blood and activities that can break the skin with unsterilized equipment (359).

HIV/AIDS has brought a new examination of what "having sex" means, especially among young people. How young people define "having sex" is important because it helps determine whether they consider themselves to be at risk, how they respond to HIV-prevention efforts, and how they report sexual experience in surveys.

Surveys generally have considered people as sexually active only if they are having vaginal intercourse. Sexual behaviors such as anal intercourse, however, are not linked to pregnancy but do pose a risk of HIV/AIDS and other STIs. In fact, heterosexual anal intercourse is common (110). The few studies that have examined what young people themselves think have found considerable differences in what is considered to constitute sex (30, 44, 128, 195, 301, 303, 317, 325).

Nevertheless, many young people report sexual activity (see Table 2). Young men surveyed are more likely than women to report sexual experience. Many young women are not sexually active; in fact, in only four countries surveyed—Canada, Côte d'Ivoire, Togo, and the United States—do more than one-half of 15-to-19 year old women report any sexual experience. Also, in countries where data are available, young men are more likely than women to have multiple sex partners (see Figure 1).

In some places sexual activity among unmarried young people has decreased in recent years. In Lusaka, Zambia, for example, 35% of unmarried women in 1996 reported that they were sexually active compared with 52% in 1990 (162). In Tamil Nadu, India, the proportion of young men who reported sex with casual partners declined from nearly 50% in 1996 to 30% in 1998 (162). In Uganda the average age at first sex among adolescents in urban areas has risen by two years—a change perhaps responsible for the 33% decline in HIV prevalence among pregnant women ages 15 to 19 (14).

Young women face substantial risk. The risk of becoming infected with HIV during unprotected sex is two to four times greater for a woman than for a man (7, 171, 312). Male-to-female transmission is more likely because during vaginal intercourse a woman has a larger surface area of her genital tract exposed to her partner's sexual secretions than does a man. Also, HIV concentration is generally higher in a man's semen than in a woman's sexual secretions (203, 388).

Adolescent women are at even greater risk than adult women. The vagina and cervix of young women are less mature and are less resistant to HIV and other STIs, such as chlamydia and gonorrhea. Changes in the reproductive tract during puberty make the tissue more susceptible to penetration by HIV. Also, hormonal changes associated with the menstrual cycle often are accompanied by a thinning of the mucus plug, the protective sealant covering the cervix. Such thinning can allow HIV to pass more easily. Young women produce only scant vaginal secretions, providing little barrier to HIV transmission (22, 140, 141, 250, 289). As more studies of HIV infection include women as well as men, they are finding that, for unknown reasons, women get sicker at a lower viral load than men (79, 377).

In the industrialized world an estimated 70% of HIV transmission occurs among men who have sex with men. UNAIDS estimates that 5% to 10% of all HIV cases worldwide are due to transmission of the infection between men (157).

Adolescence can be an especially difficult period for young men and women who are exploring their sexuality by experimenting with same-sex relationships as well as heterosexual ones (382). Many young people have heterosexual relationships during their early teenage years before later identifying themselves as lesbian or homosexual (314). Young men who have sex with other men are often forced into clandestine arrangements to keep their sexual orientation secret (60).

In many countries openly homosexual, or "gay," communities are rare or even nonexistent. In nearly every country, however, men have sex with other men (including penile-anal and penile-oral sex) even if they do not consider themselves to be homosexual or gay or if others do not consider them so (155, 157, 162, 247). The phrase "men who have sex with men," as opposed to "homosexual men," has been coined and used widely to reflect this fact.

While research findings are scarce on same-sex partnerships among adolescents in developing countries, especially where HIV prevalence is highest, data from the US suggest that young men in same-sex relationships are at substantial risk. According to the US Centers for Disease Control and Prevention (US CDC), 50% of all AIDS cases reported in the US in 1999 among males 13 to 24 years of age involved men who have sex with men (373). Although in the US rates of HIV infection appear to have declined among adult men who have sex with men, infection rates appear to have risen among young men who have sex with men, especially among minorities (374). Because many young men who have sex with men also have sex with women, they can introduce HIV to the larger population (10, 24, 55, 157, 160).

While the biological risk of HIV transmission through female-to-female sex is thought to be low, the US CDC advises women who have sex with women to take precautions such as the use of latex gloves and dental dams to reduce contact with a partner's bodily fluids (316, 371). Because HIV can be found in genital secretions, menstrual blood, and breastmilk, exposure to these fluids during female-to-female sex could lead to infection. Moreover, on average, women who have sex with women have more sex partners than women in the general population and engage in injected drug use more (81, 343).