• Editors' Summary
• Credits

1. The Invisible Epidemic
2. How Young People Become Infected
3. Why So Vulnerable?
4. Addressing the Epidemic
5. Reaching Out
• Involving Parents and Families
• Involving Men
• Reaching Youth at Special Risk
• Building Partnerships with Youth
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.

Some groups of youth are at far greater than average risk for HIV/AIDS (310). For some, HIV/AIDS is an ever-present threat because their poverty forces them to endure situations that place them at risk. Adolescent sex workers and street youth are the most visible disadvantaged youth. For example, in Vijayawada, a city in Andhra Pradesh, India, nearly half of the 25,000 street children had an STI, and 30% were infected with HIV (13). In Jakarta, Indonesia, one in every seven street children had a history of STIs (247).

Less visible are youth who are disabled, refugees, in institutions, or working in conditions in which they are easily exploited, such as domestic work. In Brazil 10% of young women in a state institution for homeless and offender youth were infected with HIV (425) compared with less than 0.5% of the general population of young women (162).

Military men, who are predominantly young, face above-average risk for STIs, including HIV/AIDS (33, 322). Estimates are that prevalence of STIs is two to five times higher in the military than in the general population in peacetime and as much as 50 times higher during conflicts (148). In the military forces of some African countries, HIV prevalence ranges from 10% to 60%, according to an estimate by the US National Intelligence Council (268).

A number of programs seek to reach high-risk youth. For example, in Brazil a project in 10 communities works to prevent abuse of girls and to reduce the number who become sex workers. None of the 850 adolescents who have participated in the program has returned to street gangs or become a sex worker (156). Another program in Brazil, Movimento Saude No Verde (Green Light Health Movement) has recruited health care professionals to provide treatment for street youth (82).

HIV/AIDS outreach programs can find youth where they spend most of their time (37). Most programs to reach street youth approach young people on their own terms, using peer education and already trusted adults (387). Some also involve family, but this does not always work. In the US, for example, an effort to send street youth back to their parents or guardians failed. Many of the young people ran away, or their parents or guardians rejected them (387).

In Nepal programs have tried reuniting girls who have been trafficked into prostitution with their families. Sometimes the families do not accept the girls back, however, fearing social censure or ostracism due to the stigma associated with HIV/AIDS. In addition, some parents fear retribution from the broker, particularly when parents had consented to send the young woman into sex work (56).

In Guatemala, Casa Alianza, an NGO, organizes outreach teams that offer street youth emergency medical care, HIV information, informal education, and counseling (326). In Thailand a program reaches high-risk youth by working with the management of discos, bars, and other nightspots where young people gather (85). In Nepal some NGOs provide legal support to young trafficked women seeking to prosecute their abductors—often a long and complicated process, as court cases can take two years or more to resolve (56).

Reaching disadvantaged youth is a challenge. For some young people the immediate conditions of daily life are so adverse that they outweigh concerns about contracting HIV/AIDS. Still others are unable to protect themselves against infection. Many do not have any adult protectors and lack resources of their own (27).

Still, programs can address HIV/AIDS among the disadvantaged by reaching them with information and services while at the same time addressing the root causes that put them at risk (15, 104, 342). Programs are more successful when they are comprehensive, providing not only information and counseling about HIV/AIDS but also housing, medical care, mental health services, drug abuse treatment, education, job training, and legal services (15, 310, 407). For example, when a project in Brazil helped young street dwellers deal with their day-to-day survival concerns, rather than providing them only with health education materials, more youth visited the participating health facilities (145).

Africa Alive! Kenya Chapter

This AIDS-prevention project in Kenya used giant costumes to appeal to young people at special risk. The project reached nearly 10,000 people in a low-income settlement near Nairobi, where many young people are out of school and where sex work is widespread.

In general, programs for youth work better when young people help plan and run them (194, 347, 375). Involvement gives young people a sense of ownership of the program and helps develop skills such as management, organization, and decision-making (129, 179, 347, 411). It also helps assure that services and messages meet young people's needs.

Involving youth can be difficult. Turnover rates among youthful staff members can be high (347). Legal issues may arise, such as labor laws restricting employment of minors. Youth participation also can require organizational change, since the organization and the young people involved must share a vision and agree on objectives. Also, teaching and mentoring a young person can be time-consuming (375).

Youth involvement is more likely to thrive when program leaders are committed to it. Also, the staff may need training to work with youth effectively—to learn to "let go," to mentor, to understand youth culture, and to discuss sensitive issues comfortably. The US CDC Preventive Marketing Initiative has used such training techniques as role-reversal skits to help adults see their behavior as youth see it (375).

Programs can involve youth in a variety of ways. One program in Latin America listed various activities in which young people could participate and gave them the option to choose those they felt most comfortable doing (231). The activities in which youth are involved should be selected carefully, however. For example, while youth can serve as receptionists at a clinic to make other young people feel welcome, they might be denied access to medical records to protect patient confidentiality (421).

The value of involving clients in the planning and management of programs that serve them is well established. Although systematic engagement of youth remains the exception rather than the rule among HIV/AIDS programs, a growing number of programs are involving youth (328, 411). These efforts offer promise for the future.