Despite impressive overall results in the past decade's response to HIV, especially in terms of dramatically increased treatment coverage for people living with HIV and a 40% reduction in the number of children infected with HIV due to vertical transmission between 2001 and 2011 (UNAIDS, 2012), efforts to prevent HIV sexual transmission and transmission due to sharing of contaminated injecting equipment have achieved more limited success.
Adolescents continue to be at high risk of HIV in various settings. While between 2001-2011 an overall global reduction of 19% in the number of new infections was observed in young people between 15 and 24 years of age, the number of adolescents (10-19 years) living with HIV increased over the same period (UNAIDS, 2012). Progress will need to rapidly increase if the world is to meet its target of a 50% reduction in infections in adolescents and young adults (as compared to 2009) by 2015.
Adolescent girls have a particularly high vulnerability to and risk of HIV infection in countries with generalized epidemics and high prevalence, due to a combination of factors including biological vulnerability, low attendance rates at secondary school, sexual violence, child marriage and other social norms that limit gender equality.
In all types of epidemics across the globe, (generalized high and hyper-prevalence, low prevalence and concentrated), male-to-male sex, injecting drug use and sex work by males, females and transgendered people fuel HIV incidence among adolescents.
Many factors continue to hamper HIV prevention, testing, treatment, care and support among adolescents globally. HIV testing rates are low - for example, survey data in sub-Saharan Africa shows that only 15% of female and 10% of male adolescents have been tested for HIV and received their results (Opportunity in Crisis, 2011). Access to testing and other services is further complicated by consent laws that prohibit uptake of testing by adolescents without their parents' or guardians' consent. School-based and community-based services tailored to the sexual and reproductive health needs of adolescents remain scant. Conservative attitudes in most societies prevent delivery of effective education and other knowledge and behavior change programmes, and send mixed messages about issues pertaining to sex, sexuality and drug use amongst adolescents.
The challenges of addressing the needs of adolescents living with HIV are numerous. Whether infected at birth or as an infant due to vertical transmission, or adolescents infected due to unsafe sex or injecting practices, uptake of and adherence to treatment are low. Services geared towards the needs of adolescents living with HIV, including psychosocial services to support disclosure and issues related to becoming sexually active as an HIV positive person are also few and far between.
An approach that integrates programming in the arena of health, education and protection can be helpful. The 2011 HIV Investment Framework (Swartlander et al., 2011), published in the Lancet (REF), provides an analysis of the proven effectiveness of interventions targeted at reducing HIV risk, transmission and morbidity/mortality.
Six basic programmatic activities fall into this category:
- Male and female condom promotion and distribution
- Male circumcision of heterosexual males in high HIV prevalence settings
- The use of antiretroviral drugs to prevent mother to child transmission (PMTCT)
- Treatment with antiretroviral therapy
- Targeted approaches for those involved in the sex trade, males who have sex with other males, and people who inject drugs (including harm reduction interventions such as methadone substitution therapy and needle and syringe exchange)
- Behaviour change communication (including comprehensive sexuality education that begins in primary school and extends through secondary school)
In addition to the "basic programmatic activities" the Investment Framework grouped another set of activities to reduce HIV risk, transmission and morbidity/mortality under two categories:
1) Critical Social and Programmatic Enablers to enhance the effectiveness of the basic programmatic activities. For adolescents, these could include protective laws and policies, especially towards protecting adolescents living with HIV and sexual minorities from discrimination, policies which emphasize public health approaches over criminal justice to combat drug use, engagement of adolescents themselves in planning, delivery and monitoring of results;
2) Development Synergies. Broad development approaches for adolescents can contribute to reduced vulnerability, risk and impact of HIV, including programmes aimed at gender equality, extending secondary education to all girls and boys, and the strengthening of social protection, especially broad legal reform to protect adolescents from violence and other forms of exploitation, expansion of health insurance, and various approaches to income protection for families affected by AIDS, as an element of broader HIV-sensitive social protection programmes.
Applying this investment framework to adolescent HIV prevention, treatment, care and support can mean the promise of better results. Without such adjustments it is unlikely that the agreed targets will be reached. It is time for an invigorated and focused attention to HIV in adolescents 10-18 years of age if we are to achieve the target of 50% reduction in HIV infections in adolescents and young people, as well as achieving the target of universal coverage of treatment, care and support for all people.
UNICEF, with its unique mandate to protect the rights of all children 0-18 years of age, and its multisectoral approach emphasizing protection, education and health of all children, has a lead role to play within the UN system and the UNAIDS family of Co-Sponsors. A tighter, more focused strategy to address HIV in adolescents, supporting countries to apply the analysis used in the HIV Investment Framework, matched against the unique epidemiological context of each country, can make a difference. Addressing the challenges of HIV in adolescents across health, education and protection can anchor HIV programming globally in the Convention on the Rights of the Child (CRC).
No adolescent should be restricted from having an HIV test due to age of consent laws. Protective laws and policies must be in place to achieve gender equality. Laws criminalizing homosexuality should be reformed. And drug use must be tackled first and foremost as a public health challenge that threatens the development of our adolescents and youth into productive adults. Sexual exploitation of all children, including adolescents, must be reduced and adult abusers punished. And those adolescent girls, boys and transgendered people engaged in transactional sex must have their health care needs met and be provided with the educational and economic opportunities to leave the sex trade and help them reach their full potential as adults.
While there is ample evidence to guide a more robust HIV response for adolescents, there continue to be gaps in knowledge that must be addressed through ongoing research, particularly operational research in the context of expanded programmes. But gaps in knowledge should not hamper scaling up of what we know works. It is time for a revised global strategy for addressing HIV in adolescents; a strategy that provides useful guidance to help us all achieve the results we want.
UNAIDS. Together We Will End AIDS, 2012
Opportunity in Crisis, UNICEF et al 2011
Schwartlander B, et al. The Lancet, 377 (9782), 2011