• Editors' Summary
• Credits

1. The Invisible Epidemic
2. How Young People Become Infected
3. Why So Vulnerable?
• Adolescent Behavior Increases Vulnerability
• Lack of Information
• Norms and Expectations
• Poverty and Deprivation
• Social Intolerance and Discrimination
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.

Why So Vulnerable?

Young people are much more vulnerable to HIV/AIDS than older people are. Because their social, emotional and psychological development is incomplete, they tend to experiment with risky behavior, often with little awareness of the danger. In fact, risky sexual behavior often is part of a larger pattern of adolescent behavior, including alcohol and drug use, delinquency, and challenging authority (75).

At the same time, some researchers caution against a simplistic view of adolescents as "vulnerable" or "at risk." Such a perspective can cloud understanding of young people's situation, they argue, because young people are not a homogenous group and, moreover, can act for themselves (155).

Nevertheless, most young people have only limited knowledge about HIV/AIDS—largely because societies make it difficult for them to obtain information. Frequently, social policies reflect intolerance and discrimination against youth, as when they limit access to health information and care (127). Because adolescents are in a period of transition, in which they are no longer children but not yet adults, public health responses to their needs are often conflicting and confused (223). At the same time, social norms and expectations, along with peer opinion, powerfully affect young people's behavior, often in ways that increase their health risks.

Why does adolescence increase vulnerability to HIV/AIDS? Adolescence is a period of unpredictable behavior (70, 284, 354). Lacking the judgment that comes with experience, adolescents often cannot appreciate the adverse consequences of their actions.

The risks of HIV/AIDS may be particularly hard for young people to grasp. Because HIV has a long incubation period, a person's risky behavior does not have immediately apparent consequences. At the same time, the potential social costs to a young person of preventing HIV infection—including loss of the relationship, loss of trust, and loss of peer acceptance—can be too high a price for most adolescents to bear (393). Moreover, many young people are unaware of what constitutes risky sexual behavior (357, 392).

Even if they appreciate the risks for HIV/AIDS in general, many adolescents believe that they are invulnerable themselves. For example, in Tanzania only 26% of male students interviewed felt that they were at "high risk" for HIV/AIDS, even though 48% felt that their friends were at high risk (225).

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Many adolescents experiment with risky behavior such as smoking, often unaware of the potential adverse consequences.

Such findings reflect the distorted sense of invulnerability to HIV/AIDS that many young people have (127). This feeling leads many young people to ignore the risk of infection and thus to take no precautions (53, 283, 352). Of course, many adults also take risks and do not consider themselves to be vulnerable.

Cognitive maturity appears to be associated with safer sexual behavior. In Kenya and Zambia, for example, young women with high academic achievement are more likely to use contraceptives (186, 218). In Mozambique more schooling was associated with more use of condoms (162). In Uganda young women with secondary school education exhibited the most dramatic declines in HIV prevalence from 1991 to 1997 (181).

Even where the prevalence of HIV/AIDS is high, as in South Africa, some young people do not consider themselves to be at risk, while others have said in focus-group discussions that, if they became infected, other people would be responsible, not they themselves (217). Some youth even question the existence of AIDS (381). In Zimbabwe, where the national prevalence of HIV among young women is over 23%, more than half of young women interviewed said they were not at risk for HIV/AIDS (361).

Even when they know the risk, some young people may ignore it. Young women may engage intentionally in risky sexual behavior especially in cultures where marriage is highly valued and a woman's status depends on finding a husband and having children (43, 297). In some parts of Cameroon competition for eligible men is keen. Thus young women who face the threat of being displaced by other girlfriends may engage in unprotected sexual intercourse to bolster their chances of marriage (238). In parts of Asia young women may become sex workers because they receive higher pay than in many other occupations (56, 202).

Some young people even continue unsafe sexual behavior after being diagnosed with HIV (257). In the US, researchers found that adolescents who were infected with HIV were twice as likely as infected adults to engage in such high-risk behavior as having unsafe sex and sharing needles for intravenous drug use (64).

Other risk-taking behavior and HIV. For many adolescents, experimenting with tobacco, alcohol, sex, and drugs are rites of passage. The propensity to take risks applies to all sorts of risks. In Tanzania, for example, youth ages 16 to 24 who smoked and drank alcohol were four times more likely than others that age to have multiple sex partners (225). In Kenya the single most important predictor of sexual activity among adolescent women was using alcohol, drugs, or tobacco (189). Studies from Puerto Rico, the mainland US, and elsewhere report similar findings (251, 305). Risky behaviors are also directly linked. For example, among US college students, those who had sex under the influence of alcohol or drugs were 2.5 times more likely not to have used any protection (273).

Anxiety and embarrassment. Many young people are anxious and embarrassed about sex—in part because many societies themselves are anxious and embarrassed about it (18, 393). Even young people who know how to protect themselves from HIV/AIDS often lack the social skills to do so (20, 384). Anxiety and apprehension often prevent young people from using condoms because condom use requires their sex partner's awareness and cooperation.

Many people are afraid to ask their partner's sexual history for fear they might endanger the relationship (95). Thus they prefer to consider themselves "safe" rather than face the discomfort of taking steps to ensure their safety (381). At the same time, however, many say they would be relieved if the partner brought up the issue of protection (122, 214).

Some young people, especially women, are at risk for HIV/AIDS because they have a poor self-image (271) or are uncomfortable with their sexuality (32). Often, young people do not believe that they can control their sexual or contraceptive behavior. They deny that they need contraceptives or exaggerate the difficulty of obtaining them (344). Many avoid decisions about self-protection altogether (32). Denying risk is a common way that people cope with stress (34). Adolescents who deny their personal risk of HIV/AIDS can ignore AIDS-prevention messages, dismiss their relevance, or think that they do not bear responsibility for protection (20).

Peer opinion. Most young people are keenly sensitive to peer opinion. Especially among older adolescents, perceptions of what peers think often have a greater influence on sexual and other risk-taking behavior than the opinions of parents and other adults (94, 239, 261). Studies in the US and elsewhere have shown that the sexual behavior of friends influences young people's own sexual behavior (356, 386). When adolescents believe that their peers think that unprotected sex is not risky, then they are more likely to have unprotected sex themselves (32).

In Kenya adolescent men whose friends were sexually active were seven times more likely to be sexually active themselves (189). In Uganda young men report that peers pressure them to "prove that you are a man" (134). And one South African young man said, "It is not enough to get her to fall in love with you. You must be able to show your friends that you have slept with her" (381). Young women can also experience pressure. In South Africa adolescent females say that their peers will ridicule a person who fails to hold onto a relationship because she refused sex (297).