Reducing HIV and AIDS in Adolescents: Opportunities and Challenges
Adolescents are critical to efforts to end the AIDS epidemic. Few national AIDS strategies explicitly program for children in their second decade of life. Adolescents (aged 10–19 years) are therefore largely invisible in global, regional, and country HIV and AIDS reports making it difficult to assess progress in this population. We have unprecedented knowledge to guide investment towards greater impact on HIV prevention, treatment, and care in adolescents, but it has not been applied to reach those most vulnerable and optimize efficiency and scale. The cost of this is increasing AIDS-related deaths and largely unchanged levels of new HIV infections in adolescents. An AIDS-free generation will remain out of reach if the global community does not prioritize adolescents. National AIDS responses must be accountable to adolescents, invest in strengthening and monitoring protective and supportive laws and policies and access for adolescents to high impact HIV interventions.
KeywordsAdolescentAdolescentsAdolescenceHIV/AIDSGirlsGenderLiving with HIVInjecting drug useKey affected populationsMales who have sex with malesSexual exploitationEffectivenessInvestment
The World Health Organization defines adolescents as individuals aged from 10 to 19 years . Adolescence is recognized as a period of life characterized by significant physical, physiological, and emotional changes marking the transition from childhood to adulthood . During adolescence, children acquire increased capacity for complex problem-solving and critical thinking, but this maturation process coincides with increased risk-taking as well as increased significance of peer influences on the adolescent [2, 3]. Adolescents today are growing up at a time when access to information and communication is accelerated through a digitally connected world. Today social media can serve as an empowering tool, a social bridge through which alliances are built and as a magnifying glass through which perspectives are quickly shaped about their own reality, identity and about the fulfillment or neglect of their rights. A healthy transition through adolescence is dependent on effective protection, support, education, engagement and nurturing from family, peers and communities . Yet, for millions of adolescents, the second decade of life is a period when distinct social and gender roles are formed and reinforced, and adolescents face increasing social expectations to assume adult roles and responsibilities, often before they are physically or emotionally mature, and often in early adolescence. Between 2005 and 2010, for example, 11 % of adolescent girls and 6 % of adolescent boys aged 15–19 years in developing countries reported sexual debut before the age of 15 . In Latin America and the Caribbean, the proportion of girls engaging in early sexual activity is particularly high. Twenty-two percent of adolescent females in the region reported sexual debut before the age of 15 . Moreover, in 35 countries, more than 1 out of every 3 adolescent girls is married by the age of 18, with the proportion in these countries ranging from 33.6 % in Gabon to 74.5 % in Niger . A consequence of early sexual activity is adolescent pregnancy and parenting. WHO statistics report an estimated 16 million births in girls aged 15–19 years as well as 2 million births in girls under the age of 15 each year . Worldwide, 20 % of adolescent girls have given birth and entered into parenting by the age of 18, while in the least developed countries, as many as 1 in every 3 adolescent girls is a mother by the age of 18 .
All of this implies the need for a critical reflection on the nature and quality of information, support, and services including protection provided to adolescents to ensure their healthy development and safe transition to adulthood. HIV infection and AIDS may be health outcomes but they have complex roots linked to all of these parameters. The epidemic in adolescents therefore offers important insight to the overall priority and wellbeing of adolescents and the opportunities to protect their rights and dignity and improve the quality of their lives.
The HIV Epidemic in Adolescents
An estimated 2.1 million (1.6 million–2.6 million) adolescents aged 10–19 were living with HIV globally by the end of 2011. This estimate includes both adolescents who acquired HIV perinatally and through breastfeeding (mother-to-child transmission) as well as adolescents who acquired HIV behaviorally (eg, through unprotected sex or the sharing of nonsterile injecting equipment). Approximately 85 %–86 % of adolescents living with HIV lived in sub-Saharan Africa in 2011 1.8 million (1.8–2.1 million). Approximately 60 % or 1.3 million (1.1 million–1.8 million) live in Eastern and Southern Africa and 500,000 (390,000–670,000) in West and Central Africa. The next largest number of adolescents living with HIV live in South Asia (110,000 [48,000–180,000]) followed by Latin America and the Caribbean (74,000 [39,000–190,000]), East Asia and the Pacific (69 000 [49,000–110,000]), Eastern Europe and Central Asia (16,000 [11,000–23,000]), and the Middle East and North Africa (11,000 [7800–20,000]) .
About 60% of all adolescents living with HIV are girls and approximately 85 % of these girls are from sub-Saharan Africa, where epidemics are mostly generalized and driven by unprotected heterosexual sex . The epidemic in adolescent girls reflects the strong combined impact of gender and income inequality, early sexual debut, age disparate sexual relationships, and heightened biological vulnerability of adolescent girls [24, 28, 54, 55].
In Eastern Europe and Central Asia, HIV incidence has been increasing since the late 2000s. It is one of only two regions along with the Middle East and North Africa to show growing incidence and the growth in the epidemic in Eastern Europe and Central Asia has been fuelled by unsafe injecting drug use, which often begins during adolescence. In this region, 1 out of every 4 injecting drug users is under the age of 20 . Elsewhere, among people injecting drugs in parts of Nepal in South Asia, initiation into injecting drug use often begins in adolescence (>60 % of current injection drug users began injecting under the age of 20) .
Young men who have sex with men (MSM) are also at a high risk of infection. In the United States, 1 out of every 3 new HIV infections each year occurs in adolescents and young adults (aged 13–29) and 9 out of 10 new HIV infections in adolescents (aged 13–19) in 2010 were among adolescent MSM . In 2010, 69 % of all diagnosed HIV infections in adolescents (male and female) aged 13–19 years in the US were among black adolescents . Structural factors including lower access and utilization of health and HIV services and commodities, notably HIV testing and counseling, ART and STI care among minority groups all with a background of higher levels of STI and HIV in social networks, have also been noted to contribute to the disparity in infections seen among adolescent MSM from racial minorities [13–15]. These distribution patterns have also been linked to lower levels of knowledge of HIV status and complacency about risk among adolescent MSM, high numbers of multiple partners, and drug and alcohol use .
Although data on treatment coverage for adolescents is not available due to lack of data disaggregation and reporting for adolescents, low ART coverage among children (ages 0–14) provide some indication of the inequities in the global response. In 2011, ART coverage among children under 15 years in need of treatment in Sub-Saharan Africa was only 28 % (25 % - 31 %) compared with 54 % (51 % - 59 %) of all eligible adults (15 years and older).
What it Will Take
- (2)Adolescent key affected populations, which include
Adolescents who use drugs;
Children exploited through, and older adolescents involved in, commercial sex; and
Adolescent boys who have sex with other males;
Adolescents living with HIV.
The key questions are what mix of interventions will address their complex needs and how can these be delivered effectively to those in greatest need? A framework for an effective and efficient investment approach to the HIV response was proposed in a landmark article by Schwartlander et al. in 2011 [19••]. Based on evidence around efficacy in reducing the HIV-specific outcomes: transmission risk, morbidity, and mortality, the framework proposes a focus on delivery and promotion of 6 high impact interventions -- condoms, voluntary medical male circumcision [57–59], targeted approaches for key affected populations [60, 61••], prevention of mother-to-child transmission , antiretroviral treatment [63, 64••], and behavior change communication [65, 66] — as the core of the HIV response. The evidence around efficacy of the core biomedical interventions is predominantly from trials involving adults aged 18 and over [57, 59, 60, 61••, 62, 63, 64••]. The trials do not assess effectiveness or the implications and relevance for adolescents who may be at high risk for infection and have significant challenges in accessing, negotiating use of, and adhering to the correct use of these efficacious commodities and interventions [24, 33, 36, 37, 47, 51, 57]. Of special significance therefore for this age group, the Investment Framework includes 2 other key domains for program investment that affect the effectiveness of the core interventions. It notes that community mobilization and changes to the legal and policy environment serve as critical enablers for the delivery and uptake of these interventions of proven efficacy. In addition, the framework notes that sector investments or areas of human development synergy such as education, employment, and economic empowerment, health, child, and social protection, and human rights and gender equality programming reinforce and sustain the impact of HIV-specific investments [19••]. This analysis recommends investment in all 3 of these domains for greater impact in the 3 HIV outcomes, thus providing a helpful tool for analysis of programmatic and leadership investment in relation to adolescents and HIV.
Much of the core vulnerability of the priority groups of adolescents (adolescent girls, adolescent key populations, and adolescents living with HIV) is rooted in structural and socio-economic inequality, failures in protection, and in their limited access to comprehensive sexuality education, accurate information on HIV and AIDS, and high impact HIV and sexual and reproductive health services. Only 30 % of adolescent boys and 19 % of adolescent girls (aged 15–19) in developing countries have comprehensive knowledge of HIV, ie, they can correctly identify 2 major ways of preventing sexual transmission of HIV, identify 2 most common local misconceptions about HIV transmission, and they know that a healthy-looking person can have HIV . In 9 of the countries with the highest prevalence of HIV among adolescents (Kenya, Lesotho, Mozambique, Namibia, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe), while over 60 % of adolescents aged 15–19 knew of a place to get tested for HIV, less than 20 % of adolescent boys and 30 % of adolescent girls have been tested and know their HIV status . In Latin America, adolescent girls aged 15–19 account for nearly 1 out of every 5 births and in this region, unmet need for modern contraception is more than twice as high among adolescent girls aged 15–19 than it is in older women . The most effective tools and services for HIV prevention, treatment and care - condoms, anti-retroviral therapy (accessible following outcomes of an HIV test), needle and syringe programs, medical male circumcision, and basic information on behavioral risk, prevention, and treatment - in practice, are accessible through gatekeepers and their provision and accessibility are enabled or barred through existing laws (eg, age of consent laws) established with the intent to protect the best interests of children and adolescents, but which very often have the effect of inhibiting access to urgent and essential HIV prevention, treatment, and care. In addition, a criminal justice approach to drug use, sex work, and laws that criminalize same-sex relations, and reinforce homophobia in society effectively exclude adolescent key populations from services and make it exceedingly difficult for service providers to provide urgent public health services to these adolescents. Therefore in the case of adolescents, it will take extraordinary leadership and political will to enable more effective and efficient HIV responses to be implemented, targeted to adolescents in greatest need, and sustained based on this investment approach.
Opportunity for Impact
Engagement of adolescents and young people, greater integration of HIV services with existing health, education and social services and initiatives, partnership, and capacity within community groups and mechanisms to support adolescents and ensure their linkage to care, and use of innovative technology and social media are all ways to improve demand, reach, retention, and positive HIV outcomes for adolescents [21–23]. Each priority group of adolescents presents a unique set of challenges to be addressed in the design of the HIV response and programs for these adolescents need to take advantage of platforms and program opportunities relevant to adolescents in each local context in order to improve impact. We look at each group below to highlight the lessons on these challenges and opportunities.
Low social status and low prioritization of the protection of girls, illustrated through widespread early sexual debut, child marriage, and sexual violence, limit girls’ opportunities from educational advancement, social engagement, control of assets, and growth in economic potential . They also influence the risks and choices that girls and their families make in trying to advance against these barriers. A study of adolescent and community member perspectives in communities with high HIV prevalence in Botswana, Malawi, and Mozambique found that many people across age groups identified adolescents’ curiosity, household poverty and income inequality, unregulated access to alcohol, lack of protection, consumerism and violence as the main underlying drivers of high risk adolescent sexual activity including early sexual debut, transactional, age-disparate and multiple sexual partnerships . Similarly, many adolescents, community leaders, and other adults across these 3 countries noted that household poverty motivated adolescents to exchange sex for food and material items to help provide for their families. The material benefits of these transactional relationships often prevented the families from intervening to discourage the adolescents from these engagements. These social factors combine with increased biological vulnerability, low levels of knowledge, and low risk perception in adolescent girls to create exceptionally high levels of vulnerability for adolescent girls as they navigate adolescence and their rapidly evolving sexuality.
In the context of high HIV prevalence, this combination of factors has led to disproportionate levels of HIV infection among adolescent girls. The opportunity for greater impact in reducing HIV risk in adolescent girls lies in efforts to increase action to address the social and structural factors that underpin adolescent girls’ vulnerability while at the same time, programming and strengthening partnerships including those with adolescent girls, to improve knowledge, demand, delivery and utilization of interventions of proven efficacy relevant to girls including male and female condoms, targeted approaches for adolescents exploited through commercial sex and adolescent girls who use drugs, PMTCT, and ART. Financially empowering school-age girls and their families through cash transfers is one mechanism, which can have significant positive impacts on the sexual and reproductive health of girls but this will not happen without changing social norms that continue to hold girls back and harm them [26••]. One such norm is sex and gender-based violence which increases the risk of HIV infection among young women, both directly and indirectly . Globally, an estimated 150 million girls and 73 million boys under 18 have experienced sexual violence . As part of a cross-sectional survey administered to in-school youth in 8 countries in Sub-Saharan Africa (Botswana, Lesotho, Malawi, Mozambique, Namibia, Swaziland, Zambia, and Zimbabwe), 28.8 % of females and 25.4 % of males aged 16 years had experienced sexual violence. . Targeted efforts to change social norms that tolerate gender-based and sexual violence are critical to addressing the high level of vulnerability among adolescent girls.
Currently, because of early access to sexual and reproductive health including family planning and maternal health services and HIV testing linked to ante-natal care (ANC), adolescent girls aged 15–19 are more likely to have tested for HIV than adolescent boys, more likely to know their HIV status, and more likely to be able to access timely ART when they need it . The medical male circumcision platform in high HIV burden and low circumcision countries and programs targeting adolescent key affected populations present unique opportunities to improve HIV testing among adolescent boys and their access to related HIV prevention, treatment, care, and support services. Sexually active and pregnant adolescent girls reached through ANC who are HIV-negative remain at high risk for HIV infection and are in need of enhanced support . Sexual and reproductive health for adolescents and maternal health services are therefore a critical platform for provision of improved support towards primary HIV prevention and provision of condoms, intensified behavioral counselling and follow-up and linkage to treatment, care, and support. These systems have to address the issues of quality of care and acceptability of services to adolescent clients, effective monitoring and reporting, and loss to follow-up through ineffective management of transition and referral.
New and emerging initiatives such as the introduction of the Human Papilloma Virus (HPV) vaccination targeting adolescent girls aged 9–13 years in schools and communities, offer a new platform to reach adolescent girls and boys early with integrated interventions to empower, inform, and link adolescent girls and boys to further counselling and testing, prevention, and care and support services as needed.
Important HIV prevention research is ongoing around microbicides, vaccines, and other pre-exposure prophylaxis [67••, 68]. This research provides a strong reminder of the need to accelerate efforts to strengthen health system accessibility and acceptability to adolescent girls and boys and the capacity of the system to effectively support adolescent clients.
Adolescent Key Affected Populations
Rapid political change in Eastern Europe in the early 1990s led to increased mobility and migration, weakening of community structures and civil society and thus weakening of social support for vulnerable households and individuals in these transitioning economies . It also led to the proliferation of informal and unregulated trade including the trade in sex and drugs . Importantly, the political transition and subsequent reforms led to severe economic pressure pushing millions of families into poverty. For example, in Ukraine GDP in 2000 was estimated to be only 42 % of the GDP in 1989 , and the majority of the population in 2000 was living in poverty . Injecting drug use in adolescents in the region is most prevalent among socially marginalized adolescents including orphaned children, children living in extreme poverty, as well as street-connected and homeless children – who are at very high risk of HIV infection . For example, a multi-city assessment of HIV sero-prevalence among 929 street youth (aged 15–24) in Ukraine found very high rates of HIV prevalence (18.4 % overall). HIV prevalence was considerably higher among sub-groups, namely orphans (26 %), youth with histories of exchanging sex (35 %), youth with sexually transmitted infections (37 %), young people who inject drugs (42 %), and was highest among those who share needles (49 %) . Among 15–19-year-old street youth in St Petersburg, Russia, even higher levels of HIV sero-prevalence have been documented. Among 313 street youths who participated in a cross-sectional survey, 37.4 % were HIV-positive, with prevalence rates as high as 86.4 % among those who reported needle-sharing . In addition, pregnant women who inject drugs are less likely than non-injecting pregnant women to use antenatal care, thus presenting increased risk for infection to their new-borns .
Studies in women involved in commercial sex in North America, East Asia, and South Asia have found that up to 40 % of the women began to sell sex before the age of 18 . Data from Canada, China, India, Nepal, and Thailand show that due to various factors including their biological vulnerability to HIV and heightened vulnerability to physical and sexual violence in the context of sex work, adolescents exploited by and/or involved in commercial sex face heightened risk of HIV infection [36, 37].
The epidemic in adolescent males who have sex with other males (MSM) is still poorly defined in most countries as they are under-represented in studies. Data is therefore absent on adolescent MSM aged 10–14 years and in the case of adolescents aged 15–19, the data is often drawn from studies of limited representativeness and it is aggregated with data on young MSM aged 20–24 . Even then, available aggregate data on young MSM under the age of 25 years shows significantly higher HIV prevalence than HIV in young males in the general population [5, 73, 74]. Similarly, the limited data available on transgender females in Asia Pacific, Latin America, and Europe show significantly elevated risk of HIV infection in this group . Both MSM and transgender populations face high biological risk for HIV infection linked to high network prevalence and high per act transmission probability associated with anal sex [14, 74–77]. In addition, both groups face significant levels of stigma and discrimination affecting their access to and utilization of available platforms for support and services [73, 75, 76]. The iPrex trial examining the effect of daily combination oral pre-exposure prophylaxis (PreP) in MSM and transgender women in 6 countries showed a significant (44 %) reduction in HIV incidence [61••]. This intervention was provided in combination with monthly adherence counselling as well as HIV testing and risk reduction counselling, supply of condoms, and STI care, all of which were well controlled in the trial setting in which service access and quality were assured for all participants [61••]. In January 2011, the CDC issued interim guidance for health care workers on the provision of combination PreP along with other methods for MSM. WHO HIV guidelines on MSM and transgender released in 2011 acknowledged the promise of these findings and urge further research on safety and effectiveness of oral PreP in MSM and transgender populations. Furthermore, the guidelines recommend a targeted approach, grounded in human rights to ensure effective planning and provision of comprehensive services and support to meet their HIV prevention, treatment, and care needs as well as optimal knowledge and utilization of these services .
Whether in schools, on the street, or in health facilities, more often than protection, care, and support, these adolescents face discrimination, exclusion, and in many cases, the threat of violence. Available data indicates that these key populations are currently served better through community and outreach-based programs than by government programs illustrating the impact of discriminatory policies and attitudes on the exclusion of children from regular facility-based services offering one-size fits all services [38, 39].
The response to adolescent key affected populations must fundamentally address the structural inequalities and conditions that make these adolescents so vulnerable, exacerbate their risk for HIV infection, and perpetuate their exclusion from care. In addition to addressing the low level of awareness and negative attitudes among service providers towards the needs of these children, a human rights approach demands action to address legislation and enforcement approaches that foster discrimination and exclusion of these children. Targeted efforts to improve awareness about HIV and demand for proven prevention, treatment, and care interventions in these adolescents and economic livelihoods are also essential. Finally, to improve both targeting and planning of responses for adolescent key populations, data on adolescent key populations must be enhanced, the views of these adolescents taken into account and informing decision-making.
Adolescents Living with HIV
Adolescents who were infected as children and who are now transitioning to adulthood as well as adolescents infected through sexual transmission or injecting drug use need to be reached urgently with care and treatment services. The majority of these adolescents are unaware of their HIV status , do not have the benefit of this knowledge and available support to ensure prevention of onward transmission in their relationships, and they do not have access to treatment to ensure their positive health and dignity. Legal age to consent to medical and other interventions, including HIV testing and counselling, varies across countries from 12 years in South Africa to 21 years in Burundi, Swaziland, Thailand, and Zambia . Age of consent laws have been linked to delayed diagnosis of HIV in adolescents and as a result, have contributed to late entry to care and poorer health outcomes . Adherence in this age group is also a major challenge  linked to psychosocial and emotional development in adolescents. Caregivers are often ill-equipped to address their HIV status and disclosure to adolescents, as well as other evolving needs such as sexual and reproductive health and secondary prevention [23, 41–44].
Only a small proportion of adolescents in low and middle-income countries who are long-term survivors of perinatal infection have access to treatment and most of these receive care through specialized centers that serve a small, generally urban, or peri-urban population. Failure to diagnose HIV infection early delays entry into care and places the partners of these adolescents and children born to HIV positive adolescents at risk for HIV infection [45, 46••]. A study in Zimbabwe found that HIV was the leading cause of hospitalization of adolescents in Harare. In the study, nearly 50 % of adolescents admitted for acute care were HIV positive and the majority had been perinatally infected . Age-related legal barriers to testing (requirement for consent from guardians) play a significant part in delaying or impeding access to testing and treatment in adolescents living with HIV [45, 47]. Scaling up HIV testing and counselling services for adolescents through a variety of testing modalities, such as mobile HIV testing and counselling and provider-initiated testing and counselling in high prevalence settings [48–50] is critical to addressing late diagnosis and delayed entry to care. At the same time, existing quality of care and treatment programs for children must be improved to ensure that they can fully respond to the needs of adolescents as they transition from childhood to adulthood. Improved management of this transition is important for adherence, retention in care, and for overall wellbeing of adolescents [44, 51–53].
Need for Greater Investment in Adolescents
Increasing AIDS-related deaths and unchanged levels of new infections among adolescents are the result of insufficient national and global commitment, prioritization, resources, and strategic action focused on adolescents. Available data illustrates that the HIV prevention response and investment in adolescents has been inadequate and ineffective over the last decade and adolescents are neglected in country scale up efforts for HIV prevention, treatment, care, and support. A review of national-level spending on HIV prevention for young people aged 10–24 in 16 high prevalence countries found that overall investments in youth-specific prevention were, in general, very low. In most countries, prevention for in-school youth represented less than 5 % of prevention spending, while prevention for out-of-school youth represented as little as 0 %–2 % of prevention spending . Similarly, a recent costing analysis indicated a significant funding gap in the global response to reduce mortality and morbidity among adolescents aged 10–19 years in 74 low- and middle- income countries. The financial resources needed to scale-up the delivery of comprehensive adolescent friendly health services in 74 low and middle income countries was estimated at an additional 15.4 billion dollars between 2011–2015 [18•]. This data and trend in investment is concerning because of the significance of adolescents as a demographic group and the importance of adolescent health to overall social wellbeing, productivity, and sustainable development. Nearly 1 out of every 5 people in the world is an adolescent . As the world approaches the deadline for the MDGs and deliberates priorities for the post-2015 development agenda, what is clear is that these long-term development plans will be inadequate from the outset if greater consideration is not given to the extent and quality of investment in adolescents, their development, protection, and health including comprehensive HIV prevention, treatment, and care.
Strengthen political accountability and capacity to expand access to high impact prevention, treatment and care interventions, and improve integrated services for adolescents within existing platforms targeting adolescents (eg,, education, community, health , social protection and child protection)
Work with adolescents and young people to identify and address legal and policy barriers that limit access and utilization of interventions of proven efficacy as well as social norms that increase vulnerability; and
Strengthen systems for monitoring, tracking, and reporting on service delivery as well as broader health outcomes in adolescents.
Conflict of Interest
Susan Kasedde declares that she has no conflict of interest.
Chewe Luo declares that she has no conflict of interest.
Craig McClure declares that he has no conflict of interest.
Upjeet Chandan declares that she has no conflict of interest.