JHU/CCP

Contents

• Editors' Summary
• Credits

1. The Invisible Epidemic
2. How Young People Become Infected
3. Why So Vulnerable?
4. Addressing the Epidemic
5. Reaching Out
6. Consequences of Inaction

To print the following sections, please click on the respective link.

• HIV/AIDS: What Young People Want to Know
• Profiles
• 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.

Youth and HIV/AIDS

Can We Avoid
           Catastrophe?

Today's young people are the AIDS generation. They have never known a world without HIV. Millions already have died. Yet the HIV/AIDS epidemic among youth remains largely invisible to adults and to young people themselves. Stopping HIV/AIDS requires comprehensive strategies that focus on youth.

Of the over 60 million people who have been infected with HIV in the past 20 years, about half became infected between the ages of 15 and 24. Today, nearly 12 million young people are living with HIV/AIDS. Young women are several times more likely than young men to be infected with HIV. In nearly 20 African countries 5% or more of women ages 15 to 24 are infected. Such statistics underscore the urgent need to address HIV/AIDS among youth.

Physical, psychological, and social attributes of adolescence make young people particularly vulnerable to HIV and other sexually transmitted infections (STIs). Adolescents often are not able to comprehend fully the extent of their exposure to risk. Societies often compound young people's risk by making it difficult for them to learn about HIV/AIDS and reproductive health. Moreover, many youth are socially inexperienced and dependent on others. Peer pressures easily influence them-often in ways that can increase their risk.

Recent declines in incidence of HIV/AIDS in a few countries, accompanied by signs that young people are changing their risk-taking behavior, give hope. AIDS today is widely seen as a social crisis as well as a problem of individual behavior. The AIDS epidemic is complex, and thus only a combination of approaches can succeed. It is increasingly clear, however, that youth must be at the center of strategies to control HIV/AIDS.

Building support for AIDS prevention. Until more leaders speak out about the AIDS crisis among youth and give it top priority for funding and action, there is little hope of a solution.

Offering education and communication. Young people need help to become aware of risks for HIV/AIDS and how to avoid them. Education and communication programs must go beyond merely offering information to fostering risk-avoidance skills as well, such as delay of sexual debut, abstinence, and negotiation with sex partners. HIV/AIDS education should begin early, even before children become sexually active.

Addressing cultural and social norms. Many traditions and cultural practices increase risks for young people more than adults and for young women even more than young men. Efforts to involve communities and to change social norms are as crucial as efforts to reduce individual risk-taking.

Promoting condoms for dual protection. Condoms-the only contraceptive method that can protect against HIV as well as against pregnancy-are vital to controlling HIV/AIDS among youth. Condoms should be widely accessible, and their use promoted among sexually active people of all ages.

Making services youth-friendly. To serve young people better, health care providers must do more to make young people feel welcome and comfortable. Services, including treatment of STIs and voluntary HIV counseling, testing, and referral, should be provided confidentially and sensitively.

Reaching out. Programs need to reach out to street children, sex workers, and other vulnerable youth, including the millions of young people orphaned by AIDS. Most programs for youth work better when young people help plan and run them. Programs must also find more effective ways to reach parents and other adults who can influence young people's lives.

All countries can and must develop strategies to address HIV/AIDS. The health sector alone cannot overcome this epidemic. Now is the time to act. It is already too late for many youth. Even if HIV risk were cut in half by 2015, in some countries 20% to 80% of today's 15-year-old boys still would die of AIDS. In some places the prospects for youth who survive are declining as teachers and other leaders die of AIDS and as productivity slows. Only acting decisively now to control HIV can ensure that today's young people will have a future as adults.

Credits

This report was prepared by Karungari (Karusa) Kiragu, Ph.D. Research assistance by Ketan Joshi, M.H.S., and Ruwaida Salem, M.P.H. Bryant Robey, Editor. Stephen M. Goldstein, Managing Editor. Design by Linda D. Sadler. Production by John Fiege, Peter Hammerer, Mónica Jiménez, and Deborah Maenner.

The assistance of the following reviewers is appreciated: Jane Bertrand, Susan Taylor-Brown, David Celentano, Shanti Conly, Katherine Crawford, Jennifer Delaney, Simel Esim, Geeta Rao Gupta, Bernard Guyer, Mihira Karra, Douglas Kirby, Cheryl Lettenmaier, Laurie Liskin, Robert Magnani, Ann McCauley, Neil McKee, Leo Morris, Nike O'Esiet, Phyllis Tilson Piotrow, Malcolm Potts, Elizabeth Serlimitsos, J. Joseph Speidel, Karen Stanecki, Lindsay Stewart, Francisco Sy, Nancy Williamson, Anne Wilson, Basia Zaba, and Laurie Zabin.

Suggested citation: Kiragu, K. Youth and HIV/AIDS: Can We Avoid Catastrophe? Population Reports, Series L, No. 12. Baltimore, The Johns Hopkins University Bloomberg School of Public Health, Population Information Program, Fall 2001.

Phyllis Tilson Piotrow, Ph.D., Director, Center for Communication Programs, and Principal Investigator, Population Information Program (PIP)

Ward Rinehart, Project Director, PIP

Anne W. Compton, Deputy Director, PIP, and Chief, POPLINE Digital Services

Hugh M. Rigby, Associate Director, PIP, and Chief, Media/Materials Clearinghouse

Jose G. Rimon II, Deputy Director, Center for Communication Programs; Project Director, Population Communication Services developing family planning communication strategies, projects, training, and materials.

Population Reports (USPS 063-150) is published four times a year (Spring, Summer, Fall, and Winter) at 111 Market Place, Suite 310, Baltimore, Maryland 21202-4012, USA, by the Population Information Program of the Johns Hopkins University Bloomberg School of Public Health. Periodicals postage paid at Baltimore, Maryland and other locations. Postmaster to send address changes to Population Reports, Population Information Program, Johns Hopkins University Bloomberg School of Public Health, 111 Market Place, Suite 310, Baltimore, Maryland 21202-4012, USA.

Population Reports is designed to provide an accurate and authoritative overview of developments in the population field. The opinions expressed herein are those of the authors and do not necessarily reflect the views of the US Agency for International Development or Johns Hopkins University.

Published with support from the United States Agency for International Development, Global, G/PHN/POP/CMT, under the terms of Grant No. HRN-A-00-97-00009-00.

The Invisible Epidemic

AIDS-acquired immunodeficiency syndrome-was recognized as a global crisis by the mid-1980s (213). In 1986 the World Health Organization (WHO) estimated that there were 100,000 AIDS cases worldwide and from 5 to 10 million cases of infection with HIV-the human immunodeficiency virus that causes AIDS. Researchers projected that the annual number of deaths due to AIDS would peak in 2006 at 1.7 million (268). Instead, 3 million AIDS deaths were reported for 2001 alone (432).

An estimated total of over 22 million people have already died of AIDS (172). Worse yet, more than 40 million people are living with HIV (432). Thus the number of people now living who will die of AIDS exceeds the number who have already died. The crisis has become a catastrophe.

HIV/AIDS is the fourth largest cause of death globally and the leading cause of death in Africa (413). Despite its widespread reach, the epidemic is still in its early stages. Public health officials estimate that the illnesses and deaths to date represent only 10% of the eventual impact (287, 406). Researchers project that by 2010 HIV/AIDS will reduce average life expectancy in some southern African countries to around 30 years (338).

WORLD AIDS CAMPAIGN 2001
"Stop, listen and learn all you can about HIV/AIDS. Prevention and life-it's your choice!" Joey DiPaolo, AIDS educator living with HIV			"We must involve young people living with HIV/AIDS in the struggle against the epidemic. They, after all, know best what it means to live with AIDS." Kofi Annan, Secretary-General of the United Nations

Estimated Numbers of Women and Men Age 15-24 Living With HIV/AIDS as of December 2001
Region	Young Women	Young Men	Young People
Africa, sub-Saharan	5,700,000	2,800,000	8,600,000
East Asia & Pacific	87,000	200,000	2800,000
South & South-East Asia	930,000	590,000	1,500,000
Latin America	170,000	260,000	420,000
Caribbean	72,000	59,000	130,000
North Afrida & Near East	110,000	41,000	150,000
Eastern Europe & Central Asia	85,000	340,000	420,000
North America	47,000	100,000	150,000
Western Europe	33,000	55,000	89,000
TOTAL	7,300,000	4,500,000	11,800,000
Note: Figures are rounded Source: Joint United Nations Programme on HIV/AIDS (UNAIDS), 2001 (432)

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 box 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, Chapter 2.1). 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, Chapter 3.3). 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).

No one strategy against AIDS can apply everywhere; the approach in each country should reflect the epidemiological patterns of the infection (7). Nevertheless, because most HIV infections occur during adolescence, focusing on young people appears to be a crucial strategy.

Based on simulation models, in a hypothetical African country with HIV prevalence of 10% in the general population, focusing on preventing HIV among adolescents would be more effective than focusing on high-risk populations-defined in this case as people having sex with more than one partner in the past six months. A combined focus on young people and on high-risk groups would be most effective, the models suggest-at only 20% of the cost of a full-scale national campaign against AIDS (345).

Another reason to focus prevention efforts on youth is that HIV-positive youth, because they were recently infected, are highly infectious. HIV is most infectious when viral loads in the blood are high, resulting in HIV shedding in many body fluids. Normally, there are two such periods: The first period, the primary infection, occurs immediately after HIV infection and lasts only a few months. The second period is at the end, when HIV infection progresses to AIDS (11, 46, 312). Because adolescents are likely to have been recently infected, many are at the primary, most infectious stage, where behavior change could be especially effective at reducing further HIV transmission (46, 312).

Preventing HIV infection among youth also would help reduce the mounting cost of treatment, providing resources that could help meet other needs of young people. For instance, in India the cost of treating one AIDS patient for one year, even without expensive therapies, equals the annual cost of providing primary school education for 10 students (266).

Early action against HIV/AIDS is far more effective than delayed action. One estimate is that an AIDS-prevention program begun 10 years ago would have had 60% more impact on HIV prevalence than the same program begun today (345). In particular, addressing HIV/AIDS among youth earlier rather than later could do much to stem the spread of the epidemic.

Delegates at the 2001 United Nations General Assembly Special Session on HIV/AIDS resolved to "reduce by 2005 HIV prevalence among young men and women aged 15 to 24 in the most affected countries by 25% and by 25% globally by 2010" (166). Reaching this ambitious goal will require much greater efforts.

The health sector alone cannot hope to contain the HIV/AIDS epidemic, nor can individual AIDS-prevention programs, working alone-although any and all efforts help. Only a large-scale, coordinated strategic approach, involving national governments, local communities, and the private sector, with international support, holds real hope.

Reproductive Health Association of Cambodia (RHAC)

Young people excitedly crowd the stage following an entertaining educational event organized by the Cambodian Reproductive Health Association. While no single strategy against HIV/AIDS can apply everywhere, focusing on youth is crucial, especially if efforts begin right away, because most HIV infections occur during adolescence.

HIV Transmission from Mother to Child Nearly 5 million children have died from AIDS before reaching age 15 since the onset of the epidemic, and an estimated 2.7 million children are living with HIV. Another 800,000 were infected in 2001 alone-about 90% in sub-Saharan Africa (432). The overwhelming majority of children with HIV were infected from their mothers, during pregnancy, childbirth, or breastfeeding. Prevention of mother-to-child transmission of HIV is now a high priority of HIV/AIDS programs. Without treatment, rates of transmission from mother to infant are between 15% and 20%, according to European and US studies. Breastfeeding can lead to an additional 10% to 20% risk of HIV transmission, based on studies in Africa (415). Breastfeeding? Debate continues about whether and when to recommend breastfeeding versus bottle feeding, especially in countries where poor sanitation makes bottle feeding risky. UN agencies now recommend that bottle feeding starting at birth may be a safer choice than breastfeeding for a mother who is infected with HIV-but only if it is nutritionally adequate and safely prepared and given, and if an uninterrupted supply of alternative foods is available (415). Recent studies, however, suggest that infants who are exclusively breastfed up to three months might have less risk of getting HIV from their mothers than those who receive other fluids and foods in addition to breast milk (428, 438). One explanation is that the immune factors of breast milk protect infants from HIV but that contaminants in other fluids and foods counteract this benefit by damaging the infant's stomach (428). If confirmed by further research, these studies suggest that exclusive breastfeeding up to three months could present an alternative to HIV-positive mothers who want to breastfeed their infants. Many prefer to avoid bottle feeding because of the stigma associated with it-an admission in some communities that one has HIV-and because the price of formula feeding may be too costly. CONASIDA "Don't allow your child to be born with the AIDS virus...Get tested," says this poster from Mexico. Mother-to-child HIV transmission is a growing problem. What Can Be Done? WHO recommends a three-sided strategy to prevent transmitting HIV from mother to child. The first is to prevent the mother's infection, especially among young women. The second is to prevent unintended pregnancies among HIV-positive women, and the third is to expand access to antiretroviral therapies. Education programs can reduce transmission from mother to child by helping young people understand and avoid the risks of HIV infection and pregnancy. These programs can reach youth in schools, preferably before onset of sexual activity. Family planning programs can do more to help women with HIV avoid unintended pregnancy. Young women who are contemplating pregnancy should consider being tested for HIV. For young pregnant women who are infected with HIV, a health care provider should discuss feasible feeding options. Where available, the antiretroviral drug Nevirapine, which has been shown to reduce the risk of transmission by nearly 50% (416), should be made available. The use of such antiretroviral drugs to prevent transmission of HIV between mother and child has been intensely studied. In developed countries the combined use of antiretroviral drugs, elective cesarean sections, and bottle feeding from birth has reduced the risk of HIV transmission from infected mother to child to less than 2% (415).

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 box). 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).

Injection of drugs using needles contaminated with HIV plays a key role in spreading AIDS among young people, especially young men. Drug injection transmits HIV readily because it introduces the virus directly into the blood stream. In some countries-including Argentina, Bahrain, Georgia, Iran, Italy, Kazakhstan, Portugal, and Spain-over half of all AIDS cases involve drug use. Also, in Canada, China, Latvia, Malaysia, Moldova, Russia, Ukraine, and Vietnam, more than half of all new infections in 1998-1999 were among intravenous drug users (162). In Asia drug injection is leading to explosive growth of HIV infection in several countries. For example, in Kathmandu, Nepal, over half the injection drug users have HIV, up from less than 1% in the early 1990s (247).

Many injection drug users are young. The average age for starting drug use has dropped as the supply of illicit drugs has grown (412). For example, in the US the highest rate of illicit drug use is among people ages 18 to 20 (368). A person's first drug injection can be particularly risky, since the new drug user is likely to lack equipment and to need help with injection-often sharing contaminated equipment (354).

A Russian-language poster graphically warns that injection drug use carries the risk of death by transmitting HIV/AIDS.

People receiving blood transfusions can become infected with HIV when the blood is contaminated. In fact, biologically, blood transfusion with contaminated blood is the most efficient way of transmitting HIV since large quantities of the virus are directly infused into a person's body (312). In the early years of the epidemic in the US, people with hemophilia and coagulation disorders made up the largest number of adolescents with HIV, which was acquired primarily by receiving contaminated blood products. Now that blood can be tested, the proportion of young people infected this way is minimal (100).

In most high-income and middle-income countries, routine screening of donated blood for HIV antibodies has greatly reduced the risk of infection from blood transfusions or blood products. In low-income countries, however, where donated blood is not always tested for HIV, blood transfusions continue to transmit HIV (7, 78). Where blood is not routinely tested for HIV, young women may be particularly at risk of infection if they receive transfusions during childbirth (78).

The presence of STIs makes transmission of HIV more likely (42, 52, 73). Sexually active youth are at substantial risk not only for HIV but also for other STIs because they tend to have multiple sex partners, to engage in unprotected sex, and-among young women-to have older men as sex partners (232, 312, 372). In many countries young people have the highest rates of STIs of any age group (282, 372).

Having another STI both makes HIV-positive persons more infectious and makes HIV-negative persons more susceptible to infection. Some STIs increase the replication of HIV (141, 300, 351). In addition, the lesions and ulcers caused by STIs provide openings through which HIV can pass from person to person (8, 52, 126). The presence of STIs also increases the presence of CD4 lymphocyte cells in the genital tract. These lymphocytes carry HIV (208).

STIs can increase by more than 100-fold the amount of HIV shed into genital secretions (418), thereby raising the probability that the secretions will contain enough HIV to cause infection (204, 312). Thus, while the risk of HIV transmission is normally higher from men to women, in the presence of STIs in either partner the likelihood of transmission is just as likely from women to men as from men to women (126).

Treating STIs could help to curb the HIV epidemic in some places (96, 126, 227, 280). As with HIV/AIDS prevention, the earlier STI prevention begins, the better. For example, in Mwanza, Tanzania, treating STIs reduced the incidence of HIV infection by 40% over two years (106). But in Rakai, Uganda, which had a similar STI treatment program, treating STIs had much less effect on HIV incidence (390). The primary explanation of this difference is timing. In Mwanza treatment took place early in the epidemic, when HIV prevalence was 4%, whereas in Rakai HIV prevalence already had reached 16% (105, 278). Because adolescents are, in effect, in the early stages of the epidemic, like the Mwanza population, treating STIs among them could substantially reduce HIV transmission (126, 227).

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).

JHU/CCP

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).

Many adolescents are at risk because no one-including parents, educators, counselors, health care workers, or the media-has taught them about HIV/AIDS or about how to protect themselves and others. Despite over 15 years of international recognition of the need for education and communication to prevent HIV/AIDS, young people today still have only limited opportunities to learn about the virus and the disease.

Some adults still think that sex education encourages sexual experimentation. Consequently, programs and campaigns often are limited in what they can discuss. For example, educators at the University of Cairo in Egypt had to alter their program "so as not to be accused of immoral propaganda" (72).

Despite such worries, reviews of program evaluations find that HIV/AIDS education programs do not hasten the start of sexual activity, do not increase the frequency of sex, and do not increase the number of sex partners among adolescents. In fact, some programs that included discussion of contraception delayed the onset of sexual activity and increased the likelihood of condom use (107, 108, 191).

While the importance of education about HIV/AIDS is widely recognized, 44 of 107 countries studied recently did not include AIDS education in their school curricula (295). In interviews with 277 secondary school principals in South Africa, 60% acknowledged that their students were at moderate or high risk of HIV/AIDS, but only 18% of the schools offered a full sex education curriculum (292).

Uganda Ministry of Health

This poster from Uganda urges young women to help friends avoid relationships with older men-"sugar daddies"-who might infect them.

At the same time, traditional ways of educating the young about sex have diminished or disappeared altogether. For example, in many sub-Saharan countries Christian missionaries discouraged initiation rites that defined the passage from youth to adulthood (205). As a result, opportunities for telling young people about sex, traditionally a part of those rites, were lost (186). The social bonds and traditions that used to shape young people's behavior and help them make the transition to adulthood have weakened in the face of urbanization, new attitudes toward sexuality, and the breakdown of the extended family.

As a result, more young people are sexually active but without adequate information to protect themselves. In Cameroon, Côte d'Ivoire, Kenya, Tanzania, and Zambia-countries where HIV/AIDS is now epidemic among adolescent women-the Demographic and Health Surveys (DHS) in the mid-1990s found that 20% to 50% of young women did not know any way to protect themselves (see Figure 2). In Mozambique, where an estimated 15% of young women have HIV (162), 74% of young women and 62% of young men could not name a single way of protecting themselves.

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Young women are far less knowledgeable about HIV than are young men (see Figure 2). For instance, in five countries surveyed the percentage of young women who know a way to protect themselves against HIV is only half that of young men (361). Moreover, young women often hesitate to challenge misinformation from their partners lest they appear too knowledgeable about sex (393).

When young people do know something about HIV/AIDS, their knowledge is often shallow. For example, when students in Papua New Guinea were asked how to protect against HIV, 27% said that it was enough to get to know a partner first or to make sure that their partner had not had sex in the previous six months (92). Similarly, many young people do not know that a healthy-looking person can have HIV. In some countries where AIDS is widespread, such as Lesotho and South Africa, 50% to 75% of women ages 15 to 19 do not know that a person with HIV may look healthy (45, 361).

Many adolescents incorrectly think that HIV/AIDS can be transmitted in ways unrelated to known risks. In Papua New Guinea, for example, one-third of tenth grade students thought incorrectly that a person could get HIV from a mosquito bite, and 15% thought sharing a drinking glass could cause HIV infection (92). In Trinidad 16% of secondary students thought incorrectly that a person could get HIV from toilet seats (244).

Misinformation about HIV transmission contributes to negative attitudes about people living with HIV/AIDS. In Russia 40% of male high school students and 30% of female students said they "would not like to be in the same class as a person with AIDS" (215). In Scotland nearly 34% of adolescent men and 22% of women would feel uncomfortable if their teacher had HIV/AIDS (353).

At the outset of the crisis in the early 1980s, AIDS was defined as a problem of individual behavior. Today, however, as the epidemic reaches catastrophic proportions, it is widely recognized as an enormous social crisis as well. Social norms and expectations and community attitudes and policies toward the roles and behavior of young men and women contribute to their risk for HIV/AIDS and make it more difficult to address the epidemic. Some traditional cultural practices add to the risk (see box How Culture Can Hurt).

Often, a double standard prevails about sexual behavior (39, 125, 221, 426). Virginity is the traditional norm for unmarried girls, while young men are expected to seek sexual adventure. Fearing that they will be admitting to sexual activity, many young women cannot ask for information about sex or protect themselves (299). In Brazil and some other countries, married men's infidelity is considered normal and acceptable (98). Among the Zulu of South Africa, the term for a man with many sexual partners, isoka, is the ultimate compliment. In a recent study, news that one of the respondents had fathered a third illegitimate child was greeted with relief by his family as evidence that he had demonstrated beyond doubt his isoka status (381).

In some societies young women as well as young men are expected to be sexually experienced. In some West African communities virginity is considered to be unmodern, anti-social, and unhealthy, and virgins are considered to be "frigid" (321). In Cameroon norms of sexual activity among adolescent girls are so strong that virgin girls tend to be scorned both by men and women. People feel that, so long as a young woman is not promiscuous, premarital sexual experience enhances her prospects for marriage (238).

AIDS is now largely a disease of deprivation (403, 410). A World Bank analysis of 72 countries shows that at the national level both low per capita income and unequal distribution of income are associated with high rates of HIV infection. Among urban adults in the typical developing country, a US$2,000 increase in per capita income is associated with an HIV infection rate 4 percentage points lower (7).

In a climate of deprivation young people, and especially young women, are at particular risk. In Kenya, for example, adolescent women from poor and unstable family environments were more likely than women from better family environments to have had sexual experience (189). In Ecuador sexual risk-taking by adolescents was more common among families with only one income earner than in those with two or more (109).

In many countries young women, lacking opportunities, seek support from men, trading sex-and thus the risk of contracting HIV infection-for security. The risks are greater when the men are older. In Tanzania, for example, where growing poverty has made traditional marriages more difficult to arrange, young women compete for the attention of older men, who are better established than young men and thus more attractive as potential husbands (205). Often, this practice is driven by parental expectation of financial support from their children (434). Similarly, in Nicaragua economic upheavals have caused many young women to prefer older men who can take better care of them (426).

Although the motivations for this are complex (434), young women sometimes enter into relationships with older men-called "sugar daddies" in sub-Saharan Africa-who pay their school fees, buy them gifts, and offer other inducements (205, 238, 255, 315, 434). Other young women establish similar relationships with young men (134, 205, 255, 267). In South Africa many young women have sexual relationships in exchange for favors, gifts, and cash (217). A few studies report similar arrangements between young men and older women, as in Cameroon and South Africa, where some young men have "sugar mummies" (238, 322).

Economic hardship and civil unrest have pushed more and more young men and women away from home and into towns and cities to look for work. Many enter multiple sexual relationships that carry risk for HIV and thus transmit the virus from one place to another (111, 247). Female migrant workers-many of them unmarried girls in domestic or seasonal work-are often sexually exploited (277). Poverty and lack of alternatives also are major reasons that many children become sex workers (31, 37, 137, 176, 219). In some Asian countries young women enter the sex trade with the sanction of parents, in order to send money home (56, 202).

When societies do not recognize that young people share the same human rights as adults, they make young people more vulnerable to intolerance and discrimination. Policies toward youth often reflect adult views of what young people should and should not be doing, not what young people really need. For example, discriminatory policies do not respect young people's need for medical confidentiality and may restrict access to information (127, 361). Many young people who have been tested positive for HIV have learned of their status not from health care providers but from their parents, who have been informed without the young person's consent (130).

Prejudice based on sexual orientation and discrimination due to HIV status further fuel the AIDS epidemic (162). Many societies contribute to the spread of HIV/AIDS by stigmatizing, and often outlawing, homosexual behavior (55). Until recently, the Catholic Church in Ireland did not recognize the existence of homosexuality, and thus health officials did not respond to cases of AIDS among gay men (336). In the US the initial labeling of HIV/AIDS as a "gay disease" distanced the rest of society from the epidemic and made it difficult to obtain government funding for prevention programs in the early 1980s (97). Such attitudes particularly affect youth experimenting with or coming to terms with being bisexual or gay-leading to sex in a climate of secrecy or shame (283).

Addressing the Epidemic

In several developing countries recent declines in the prevalence of HIV/AIDS among young people, accompanied by clear signs of individual behavior change, give hope of eventually curbing the epidemic:

• In Thailand HIV incidence among young army recruits declined by 90% between 1991 and 1995 after the government adopted its comprehensive AIDS-prevention campaign (151).
• In Lusaka, Zambia, HIV prevalence among 15-to-19 year old women dropped from 28% in 1993 to 15% in 1998, and similar declines occurred in some rural areas (93, 424).
• In Uganda several studies have documented declines in HIV prevalence among young men and women in the 1990s (14, 181, 254).
• Tanzania, too, has seen recent declines in HIV prevalence among young people (199).

While few countries have made a determined effort to deal with the HIV/AIDS epidemic, 20 years' experience has demonstrated that national strategic approaches, not just more projects, are essential to contain the epidemic effectively (162). In Australia, Brazil, Senegal, Thailand, and Uganda, AIDS-prevention programs owe their relative success in part to collaboration among government, the private sector, and nongovernmental organizations (NGOs) (150, 151, 243, 288, 406). An AIDS strategy is likely to be more sustained when included in national government budgets and development goals (62).

Within an AIDS-prevention strategy, a combination of approaches is essential, including:

• Advocacy. Advocacy efforts inform and motivate policy-makers and communities-at international, regional, national, and local levels.
• Education and communication. Education and communication alert young people to the risks of HIV/AIDS and promote healthier behavior-through, for example, curriculum-based programs in schools, mass-media campaigns, peer education, and community outreach.
• Access to condoms. Condoms are the only contraceptive method that also prevents transmission of HIV. Making condoms widely accessible to young people can and does help control the spread of HIV/AIDS.
• Voluntary counseling, testing, and referral. Knowing one's HIV status can lead to healthy behavior. Also, as treatments become more widely available, early voluntary counseling and testing can lead to timely care (156).
• Improving young people's lives. AIDS-prevention efforts that focus on protecting young people's health will have more impact if they are joined by other efforts to improve young people's economic and social conditions (7).
• As program efforts to change people's behavior continue, other efforts to influence social norms and empower communities to address the epidemic are becoming more important. Researchers and policy-makers now recognize that individual behavior is more likely to change in the context of a supportive community (7, 155, 156, 184, 223, 264, 329).

Patrick Coleman for JHU/CCP	South Africa Department of Health
A South African school drama troupe performs a play about HIV/AIDS for young people. Some wear t-shirts with the poster from the "Action for AIDS-Youth: A Force for Change" campaign (see inset). Addressing the AIDS epidemic requires a variety of approaches, including advocacy, sex education, and communication.

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).

In June 2001 member states at the United Nations General Assembly Special Session on AIDS agreed to "ensure that by 2005, at least 90% of young men and women aged 15 to 24 have access to the information and education necessary to develop the life skills required to reduce their vulnerability to HIV infection" (366). One way to achieve this goal, at least in theory, is through a country's education system-especially if programs reach students at an early age, before some begin to drop out of school (65). At the International AIDS Conference in Durban in 2000, the "Prevention Works" Symposium recommended that HIV/AIDS education begin early, focusing on children as young as five years old (180).

Nevertheless, there is considerable disagreement over HIV/AIDS education-including what to teach, at what age, in what setting, by whom, and to what end. Political pressures often keep sex education-and thus HIV/AIDS education-out of the classroom. Sensitivities about sexuality and young people's behavior often obstruct AIDS education even where there is a strong national commitment to address the AIDS crisis (329) (see Lack of Information, Chapter 3.2). In spite of such obstacles, some school programs appear to have made gains, although evidence from program evaluation is sparse (327).

Comprehensive evaluations have examined the impact of HIV education programs worldwide. In Canada and the US researchers found that one-third of the 28 programs they reviewed delayed the age at sexual initiation among students participating (191). A more recent analysis that reviewed school-based education programs in Namibia, Nigeria, South Africa, and Zimbabwe found that some of the programs helped delay sexual initiation, decreased number of partners, and increased contraceptive use (430). For example, in Namibia a curriculum that emphasized abstinence and safer sex practices helped some female students delay the start of sexual activity but did not increase abstinence or condom use overall (437). In Brazil students participating in a school-based AIDS education program reported having fewer sex partners than students in schools without the AIDS program (58).

Important components of AIDS education programs for youth include addressing peer pressure and norms that encourage risky behavior (53, 190). Changing young people's risk-taking behavior requires going beyond providing information to helping young people acquire the ability to refuse sex and to negotiate with sex partners.

In Thailand a comprehensive education program for young people included problem-solving exercises, role playing, and analysis of "triggers" for unsafe sexual behavior (such as alcohol use). This program helped to achieve a 50% decline in new HIV cases, and the incidence of STIs among young men in the program was one-seventh of that among a control group without AIDS education (49).

Researchers have identified key elements of HIV/AIDS education programs, largely from US-based studies (190, 191). Programs are more likely to be successful by:

• Focusing on reducing specific risky, sexual behaviors;
• Using theoretical approaches to behavior change that have proved successful as a basis for program development;
• Having a clear message about sexual activity and condom use and continuously reinforcing this message;
• Providing accurate basic information about the risks of adolescent sexual activity and about methods of avoiding intercourse or using condoms against HIV infection;
• Dealing with peer pressure and other social pressures on young people to be sexually active;
• Providing modeling and practice of communication, negotiation, and refusal skills;
• Using a variety of teaching methods that involve the participants and help personalize information;
• Using teaching methods and materials appropriate to students' age, sexual experience, and culture;
• Selecting as teachers people who believe in the program and then training them to be effective.

More evaluation is needed of developing-country AIDS education for youth in school and out of school (436).

HIV/AIDS education programs should be age-appropriate-that is, programs for younger adolescents should focus on avoiding or delaying sex, while those for older adolescents should include discussion of condoms and other contraceptives in addition to urging abstinence (7, 53, 193). Of course, education cannot help young people who cannot avoid or delay sex, even if they want to-for example, young women trafficked into prostitution or raped in refugee camps.

DONNER L'EDUCATION SEXUELLE AUX ADOLESCENTS C'EST PREVENIR LES MATERNITES PRECOCES, LES GROSSESSES NON DESIREES, LES MST ET LE SIDA

Association for the Care of Children's Health (ACCH)

"To give sex education to adolescents is to prevent early births, unwanted pregnancies, STIs, and AIDS," says this poster from Cameroon. "If only I'd had good information!" this young woman reflects, while her classmates laugh at her on their way to school.

Peer education. Many strategies for youth now make peer education a key approach (80). Perhaps the most important goal of peer education is to establish standards for acceptable behavior. When youth play a role in developing social and group norms that protect against HIV infection, they serve as positive role models for behavior change (272).

Most young people find trained peer educators credible because they communicate well with other youth and set believable examples of behavior. Peers also can help other young people acquire such skills as sexual negotiation and assertiveness (65, 77, 80, 179).

For peer education programs to be effective, training of the peer educators is essential-including follow-up sessions that reinforce knowledge, beliefs, and skills (129, 194, 347).

Training not only should ensure that peer educators know how to teach about HIV/AIDS but also that they are able to see things from the perspective of the young people they are trying to reach (129).

A wide variety of peer AIDS-education programs in developing countries reach young people, including in Indonesia (139), Kenya (156), Peru (431), Thailand (49, 85), and Zambia (285, 331). While evidence from evaluation is slight, peer education programs have been found to reduce the incidence of STIs including HIV, change risky behavior, and improve health (129, 179), including among the peer educators themselves (269). In a US peer education program among youth, for example, condom use increased from 45% to 55% among participants surveyed (272). In Peru, in the absence of the Es Salud peer project, youth condom use in the project area would have been 39% less (431).

Peer education is sometimes assumed to be inexpensive, since it relies on volunteers. Costs can run high, however, to train, support, equip, and supervise peer educators (129). High turnover among peer educators requires continuous recruitment and training of replacements. Also, peer programs usually need professionals to provide guidance and support. While a growing consensus holds that peer educators should be compensated in some way, experience cautions against overcompensation to avoid distancing peer educators from their audience (82, 129, 347).

The mass media-especially television and radio-reach large numbers of young people around the world and have enormous influence. In a 23-country study among 12-year-old school children whose homes had electricity, over 90% watched an average of three hours of television per day (365). In virtually all developing countries most women ages 15 to 19 have regular access to television and radio (45). While young people obtain a great deal of information about reproductive health from entertainment programs in the mass media, many of these programs have the effect of promoting unsafe attitudes and behavior and portraying sex in ways that encourage risk-taking (23, 346).

Increasingly, reproductive health groups are working with the mass media and entertainment industries to develop accurate and healthy presentations of sexual topics and to raise media literacy among young people (263). A 1999 review in Europe found that the mass media promoted open and frank discussion about responsible sexuality. Messages encouraged healthful sexuality and did not stress fear or shame (23). In the US the Media Project honors members of the entertainment industry who incorporate accurate and honest portrayals of sexuality into their programs (234). In South Africa a program by Soul City helps young people understand that television and radio programs do not always reflect reality and that viewers should think critically about what they see and hear (246).

JHU/CCP

In rural Thailand a student peer educator prepares a presentation on HIV/AIDS for youth. Peer educators are credible among young people; they communicate well and are believable role models.

Because mass media entertainment is so popular, it can reach many young people with positive health information. In Uganda, for instance, The Safer Sex or AIDS Campaign, which encouraged young people to make responsible decisions about HIV/AIDS, reached 92% of its intended audience (210). In Zimbabwe a similar communication campaign reached 97% of youth surveyed (182). In Botswana Tsa Banana, a mass media campaign to improve adolescent reproductive health, reached about 70% of adolescents (114).

Mass media can be an efficient way to reach and influence young people. For example, in Kenya a call-in radio program for youth cost just three US cents per young person reached. The cost of getting one young person to take action to improve reproductive health-for example, visiting a health clinic-was 12 cents (188).

AIDS-prevention programs can use a variety of media, including dance, drama, folk theater, and sports events as well as television, radio, and print media. Programs such as Africa Alive! work with popular entertainers and sports heroes to reach young people with messages about HIV/AIDS (146, 152, 159, 206). Different communication channels reach different audiences, and messages are most effective when reinforced by various communication channels (182, 210).

Mass media communication can lead to positive health behavior. In Zimbabwe, for example, young people reached by a communication campaign to encourage "saying no" to sex were 2.5 times more likely than those whom the campaign did not reach to change their sexual behavior for the better (182). In Zambia adolescents exposed to a TV campaign promoting abstinence and condom use were 87% more likely to use condoms. In addition, viewers were 46% more likely to be abstinent or to have resumed abstinence (439). In Uganda self-reported condom use among sexually active young men rose from 33% to 70% following The Safer Sex or AIDS Campaign, and from 58% to 73% among young women (210). In South Africa 38% of young people who watched the TV program Soul City reported always using condoms compared with 26% of those who did not watch (323).

Mass media programs are not able to address all aspects of HIV prevention (114, 210). Experience shows that the most effective communication programs involve both mass media and face-to-face communication, such as peer education in small groups (296).

Increasing condom use is crucial to controlling the spread of HIV/AIDS. Condoms are the only contraceptive method that offers dual protection-that protects against infection as well as pregnancy (see box, Dual Protection: Avoiding Pregnancy and HIV/AIDS). Despite increasing needs, worldwide donor support for condom purchases declined from about US$68 million in 1996 to $38 million in 1999 (291).

Most unmarried young people who have sex do not use condoms. For example, in surveyed countries of sub-Saharan Africa, the percentage of unmarried sexually active women ages 15 to 19 who reported using condoms in their most recent sexual encounter ranged from 2% to 18% (see Figure 3). In Colombia, Peru, and Kazakhstan from one-fifth to about one-third used condoms. Condom use among unmarried sexually active young men was slightly higher.

Better access to condoms can increase their use (66, 71). Condom social marketing-the promotion of healthy reproductive behavior and sale of condoms at subsidized prices-increases both the demand for condoms and their supply (83, 95). Social marketing can make condoms better known, more affordable, and widely available through shops, pharmacies, and other retail outlets. In studies young people often say that they prefer private-sector sources-especially retail outlets- as their source of condoms (224, 237).

Population Services International	JHU/CCP
Left: In an AIDS-prevention campaign in Côte d'Ivoire, rival football stars join together to promote condom use. Right: In Kenya a counselor hands out educational materials to football fans as part of a campaign to involve more young men in preventing HIV/AIDS.

Some social marketing programs have successfully focused on adolescents, including the Social Marketing for Adolescent Sexual Health (SMASH) Project in Botswana, Cameroon, Guinea, and South Africa. This program relied on radio and television messages, designating youth-friendly outlets where young people could buy condoms and receive counseling, and outreach activities such as peer counseling and youth clubs. As a result of the SMASH project, in all four countries awareness of condoms increased, while personal barriers to condom use, such as shyness about buying condoms and difficulty discussing use with a partner, diminished (296).

Some social marketing programs are making the female condom available, although on a limited basis. The female condom is a female-controlled contraceptive method that can prevent HIV/AIDS (117). Experience with social marketing of female condoms in Zambia and Zimbabwe suggests that women need considerable counseling and other support to keep using them (5, 84, 258). Even at subsidized social marketing prices, female condoms are still much more expensive than male condoms, and too costly for many adolescents (84, 291). Many public facilities make male condoms available free of charge, but not female condoms (229).

Dual Protection: Avoiding Pregnancy and HIV/AIDS Condoms are the only contraceptive method that provides dual protection-that is, protects against both pregnancy and most STIs, including HIV. Using condoms along with another family planning method for extra pregnancy protection also constitutes dual protection. Practicing sexual abstinence and avoiding penetrative sex are other ways to avoid STIs and pregnancy (138). What Family Planning Programs Can Do By promoting dual protection, family planning programs can help prevent unintended pregnancies among youth and at the same time contribute to controlling the spread of HIV/AIDS (21, 95). WHO has urged family planning programs to do more to address prevention of HIV/AIDS and other STIs (417). Programs can stress that condoms can be effective against HIV and some STIs when they are used correctly and can assure that good-quality condoms are widely available at reasonable cost (291). Family planning programs can best encourage condom use among young people by promoting positive attitudes towards condoms at the time people are starting sexual activity-before young people establish patterns of high-risk behavior. Programs also can serve as important links to HIV testing and counseling (74). This link may be crucial because people need to know that they and their partner are not infected before they stop using condoms and begin to use a different contraceptive method. Condom use is likely to be most consistent at the beginning of relationships and then to decline once the partner is perceived as "safe" (197, 279). The dual protection strategy of using condoms to protect against infection and another method for contraception faces obstacles, however, particularly among young people. For many people, use of one method-much less two-can be difficult enough. Many adolescents cannot afford two methods or cannot obtain them both. Also, adding a second method may impair consistent use of the first (47, 319). Despite obstacles, more young people are using condoms (162). Studies around the world document these increases. In Tamil Nadu, India, the proportion of young men who used condoms with casual relationships rose from about 45% in 1996 to nearly 70% in 1998 (162). In Brazil the percentage of young men who reported using condoms the first time they had sex rose from only 5% in 1986 to 50% in 1999 (162). Also, in Uganda ever-use of condoms rose from 15% in 1989 to 55% in 1995 among men ages 15 to 19 and from 6% to 39% among women in the same age group (14). Condom use appears to be more acceptable among younger men than among older men (162). The adolescents who use condoms more consistently are those more likely to have the self-confidence to insist on condom use with their partners, to take personal responsibility for condom use, to have greater control over their impulses, and to begin condom use when they are young (66, 86, 197, 302). Other attributes associated with consistent condom use include having talked with parents about condoms, associating with peers who encourage condom use, having high educational aspirations, high parental income, generally adopting a healthy lifestyle-for example, not drinking alcohol or taking drugs (181, 191). Queensland AIDS Council "Cover up when it heats up," urges this Australian poster promoting condoms for safer sex among youth. Condoms provide dual protection against pregnancy and HIV/AIDS. Assessing Condom Effectiveness A recent expert workshop assessing research on the effectiveness of male condoms concluded that condoms have been proved effective in preventing "HIV transmission in both men and women who engage in vaginal intercourse." The researchers concluded that male condoms were also proved effective in "reducing gonorrhea among men" (262). It is generally accepted that, when used correctly all the time, condoms prevent most STIs, including HIV (440). They offer less protection, however, against herpes, human papilloma virus (HPV), and other STIs that can be transmitted through skin-to-skin contact between parts of the body not covered by condoms (95). Scientists estimate that male condom effectiveness for pregnancy prevention in the "best case," that is, when used correctly and consistently, is 3 pregnancies per 100 women in the first year of use and in typical use is 14 pregnancies (117). The female condom appears to be somewhat less effective than the male condom in preventing pregnancy (138). Its effectiveness against HIV and other STIs has not been fully assessed, however. Microbicides? If microbicides were available, they could offer dual protection (417). Microbicides are chemical products that, for dual protection, would be administered vaginally before sexual intercourse to kill HIV and other STI pathogens and at the same time disable or kill sperm. Unfortunately, no microbicides exist for use today. While over 50 such products are in various stages of testing, none is expected on the market within the next five years (293, 294). Developing microbicides is challenging. For example, the product must not irritate the vaginal lining. Nonoxynol-9, the widely-used spermicide, was thought to be effective against HIV. Recent research, however, found that when the product was used by sex workers-who would use it much more frequently than most other women-nonoxynol-9 was associated with vaginal lesions, thereby increasing the likelihood of HIV transmission (161). Even if a microbicide were found to be safe and effective for adults, its safety, efficacy, and acceptability for adolescents would still need to be assessed.

Voluntary Counseling, Testing, and Referral

Early testing for HIV/AIDS offers many benefits, especially for young people, but in most countries it is still rare. Especially as treatments become more available for HIV infection, early testing and counseling could lead to timely care, improve the medical management of HIV-related illnesses, and provide an opportunity to reduce perinatal transmission of HIV.

Debate continues over whether taking the HIV test leads to safer behavior (404). Some researchers have demonstrated that, once aware of their HIV-positive status, some infected people change their behavior to avoid transmitting HIV (385). In addition, starting antiretroviral therapy as soon as possible lowers the viral load (102) and may therefore reduce the risk of transmitting HIV. For those who test HIV-negative, testing can provide an impetus to develop a plan for avoiding infection.

Nevertheless, few young people get tested, even in countries with the most severe HIV/AIDS epidemics. There are several reasons. First, testing facilities are scarce in many countries. Second, treatment for HIV-positive persons is often lacking, so why bother to be tested? Third, the stigma of HIV infection can discourage many young people, as it does many adults. Regardless of age, many do not seek testing until they develop symptoms or a spouse or sex partner dies of AIDS (433). They may have been transmitting HIV to others for years.

Among youth, further barriers to voluntary testing include lack of information, perception of low risk, lack of confidentiality, costs, transportation problems, and laws that require parental consent (116, 121, 286). A US study found that the number of adolescents who were tested for HIV/AIDS rose by 150% when parental consent was no longer required (235). Some countries impose administrative requirements that can discourage voluntary testing for HIV (57).

In testing for HIV, ensuring medical confidentiality is essential. The right to confidentiality is recognized by the UN Convention on the Rights of the Child (202). Yet confidentiality is often compromised. In Kenya, for example, nearly one-third of adolescents studied received their test results either in a letter or from their parents, instead of privately from a health care provider (130). In Russia efforts to trace HIV-positive cases can leave trails that compromise confidentiality (136).

Testing programs need to develop strong referral networks to help youth regardless of their HIV status. In particular, test sites can be linked with programs that help people who are HIV-negative plan how they will avoid risk and with programs that help the HIV-positive obtain medical care. Voluntary testing also provides an opportunity to refer young people for other reproductive health care, especially for pregnancy prevention and STI treatment. Referral systems are rare, however (130). Providing better referral for youth may require more extensive assessment, staff training, and clinical follow-up care than for adults (311).

Hugh Rigby for JHU/CCP

In Kampala, Uganda, a health care center offers a range of reproductive health services covering sexually transmitted infections, HIV, and family planning. Health centers need to make young people feel welcome and comfortable.

Psychological and ethical issues. Being tested for HIV/AIDS is stressful for anyone and especially so for young people (185, 311). Young people who test positive want to maintain a belief in their own invincibility but are suddenly confronted with their own mortality. It may take them months to accept their situation and to seek treatment (337). It is encouraging, however, that young people at high risk of HIV infection are more likely than other young people to seek testing and to return for the results-perhaps because they are aware that their behavior has placed them at risk (309, 383).

Many young people who test HIV-positive need special support and counseling. In many countries, however, if any HIV/AIDS counseling is offered at all, most testing facilities offer it only in single short sessions, where there is little opportunity to explore problems (286, 311). Many health care providers recognize that the quality of counseling needs improvement (91).

Providers can address young people's concerns about testing by talking with them about the process and by role-playing possible scenarios such as how to tell a partner or parents or how to face various possible test results (337). Providers also can help adolescents develop a strategy for remaining healthy, including a