• Editors' Summary
• Credits

1. The Invisible Epidemic
2. How Young People Become Infected
3. Why So Vulnerable?
4. Addressing the Epidemic
• Towards an Enabling Environment
• AIDS Education
• Mass Media Communication
• Condom Use
• Voluntary Counseling, Testing, and Referral
• HIV Treatment and Care
• Youth Livelihood Approaches
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.

The impact of the AIDS epidemic could have been reduced substantially had political leaders taken it seriously and responded at once. As the United Nations General Assembly Special Session on HIV/AIDS noted in 2001, "strong leadership at all levels of society is essential for an effective response to the epidemic" (166).

In countries with effective approaches, national policies provide a supportive and enabling environment in which projects and programs can operate and be sustained (156, 233). In some countries leaders have responded decisively and have made a difference. Uganda's success against HIV/AIDS, for example, is often attributed in part to President Yoweri Museveni's bold leadership in acknowledging the epidemic early and encouraging widespread prevention efforts (150). In India the prime minister has urged members of parliament to recognize the epidemic as the most serious public health problem in the country (247).

In Thailand, after surveillance reports in 1989 showed that the country was in the early stages of an AIDS epidemic, the government responded with a comprehensive approach. This approach included a widespread public information campaign, efforts to discourage visits to sex workers, and a program to promote universal and consistent condom use in commercial sex (the 100% Condom Use Program) (149, 408, 414).

One of the most dramatic changes in individual behavior that resulted from the Thai government's efforts was a sharp decline in young men visiting sex workers for their first sexual experience (48). Condom use with brothel-based sex workers is now nearly universal. Condom use with casual partners remains less common, however (155, 408). Nevertheless, Thailand's aggressive action has reduced adult HIV/AIDS prevalence to less than 2%, compared with an estimated 10-15% without such prevention efforts (247).

In Cambodia, after surveillance reports in 1998 showed 40% HIV prevalence among sex workers, the government adapted Thailand's 100% Condom Use strategy. As a result, condom use in brothels rose substantially. In 1997 about 40% of brothel-based sex workers were using condoms with their clients; by 1999 the figure had doubled to 80% (162).

Similarly, upon the first indications of HIV/AIDS in 1986, the government of Senegal moved to confront the epidemic, galvanizing community groups, working with religious leaders, and introducing AIDS prevention in the school curriculum in primary and secondary schools. Communication campaigns also reached people by radio, in mosques, and at the markets. Parents and other adults were encouraged to speak to their children about HIV/AIDS. As a result, HIV prevalence among pregnant women has remained under 2%, with no upward trend (288). In addition, condom use has risen among young men. Today, only about 10% say they do not use condoms with casual partners.

In contrast, some governments may have set back AIDS prevention with statements and positions that perpetuate misunderstanding and divisiveness about HIV/AIDS and its victims. For instance, in 2000 South Africa's President Thabo Mbeki speculated publicly that HIV does not cause AIDS—even though South Africa has more HIV-infected persons than any other country (162). In Argentina a project to improve reproductive health among young people, including HIV prevention, came to a halt when the project became a divisive issue during an election campaign (241).

Until more leaders speak out and break the wall of silence, shame, and blame that surrounds AIDS, there is little hope of mounting a vigorous broad-based effort against the epidemic (162). Government leadership is particularly important on behalf of young people, who are rarely in positions of authority and cannot often speak for themselves.

Population Services International (PSI)

In India reproductive health educators use a puppet show to tell commercial sex workers how to avoid HIV/AIDS and to protect against pregnancy. Some programs advocating condoms—the only contraceptive that also prevents HIV transmission—have reduced prevalence of HIV among sex workers.

Advocacy. Advocacy can stimulate effective action on behalf of reproductive health, including prevention of HIV/AIDS (136, 378). International agencies, including the UN and its various agencies, can do much to advocate addressing AIDS as a global development issue and to increase and sustain international support. Advocacy efforts are particularly needed for a sharper focus on youth.

Some countries have launched advocacy efforts that are likely to benefit youth. In the Philippines, for example, advocacy by a coalition of NGOs led to legislation that bans compulsory HIV testing, guarantees the right to privacy, and outlaws discrimination against persons living with HIV/AIDS (136). The advocacy also led to passing of the 1998 Philippines AIDS Law, which provides a legal mandate for enforcement of statutes at the local level (247). Advocates are working in Botswana to establish HIV/AIDS education in schools, and in Cambodia, AIDS education for young beer-hall waitresses (113). In Nepal groups are advocating the rights of girls who have been trafficked into prostitution (56).

The Central American HIV/AIDS-Prevention Project (PASCA) works to strengthen collaboration among parliamentarians in the region by exchanging information on AIDS issues. The project motivated leaders from Honduras, Nicaragua, Panama, and El Salvador to sign the San Salvador Declaration, which focuses on youth (113).

Some young people living with HIV/AIDS have become advocates themselves (397). In South Africa Nkosi Johnson, a 12-year-old boy who was infected at birth, became a compelling voice for children living with HIV/AIDS. After a school refused to admit him because of his infection, he brought his case to then-President Nelson Mandela. As a result, the parliament passed a statute allowing HIV-infected children, including Nkosi, to attend school (63). Nkosi died of AIDS in June 2001.

Funding. Funding for HIV/AIDS prevention is inadequate (403). While more and more policy-makers acknowledge HIV/AIDS, rarely do governments provide enough funding for effective action against the epidemic (162). In fact, between 1988 and 1997, as HIV spread, the amount of donor assistance per HIV-positive person fell by more than half (16).

Moreover, funding for AIDS is not going where it is needed most. While 95% of people with HIV infection live in developing countries, 95% of all AIDS-prevention money is spent in industrialized countries (265). According to UNAIDS, a total of US$7 billion to $10 billion is needed annually for AIDS prevention and care in low- and middle-income countries, most in Africa. This amount is five times that currently spent (163, 167).