Challenges to health and well-being persist
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Around the world, 5 million young people are living with HIV.  And with 41 percent of new HIV infections occurring among young people, that means every 30 seconds, another young person becomes HIV-positive.  Most live in the Global South in countries that lack the resources to meet their needs. They face widespread stigma in a world that still often misunderstands HIV and fears or blames those who have it – and the majority of HIV-positive youth are women, placing them at an even greater societal disadvantage in many countries. Most deaths from AIDS also occur in low and middle income countries. HIV prevention education, voluntary counseling and testing (VCT), treatment, and care programs can help young people prevent HIV, live with HIV, and reduce related stigma and discrimination – but more programs are needed.
Millions of young people are living with HIV, with some groups more affected
- Young people in every nation, of every race/ethnicity, and at every income level are living with HIV. But the epidemic is more concentrated in some geographic areas and among some populations.
- The vast majority (3.8 million/76 percent) of young people living with HIV or AIDS (YPLWHA) are in sub-Saharan Africa. Many also reside in South and Southeast Asia (500,000/10 percent) and Latin America and the Caribbean (250,000/5 percent). 
- Most youth living with HIV are women. Overall, sixty-four percent of youth living with HIV are young women, while in sub-Saharan Africa, 71 percent of youth living with HIV are young women. 
- Married girls can be at particular risk of HIV. For example, a study in Uganda showed that HIV prevalence was 28 percent for married and 15 per cent for single girls. This study noted that the age difference between the men and their wives was a significant HIV risk factor for the wives. 
- While many countries provide limited data on young men who have sex with men (MSM), in some areas they are known to be at very high risk. For instance, in Cape Town, South Africa, HIV prevalence among MSM is estimated to be four times that of the general population, while in the Bahamas, 25 percent of MSM are HIV-positive. 
- In some countries, young sex workers are also at particular risk of contracting HIV. In a study conducted in St. Petersburg, Russia, 33 percent of sex workers under 18 years of age were HIV-positive. 
- Young people who inject drugs can also be at increased risk of HIV. In a study conducted in Viet Nam, 48 percent of injecting drug users were less than 25 years old, 24 percent of them had started injecting within the previous 12 months, and of these, 28 percent were infected with HIV. 
- Millions of infants have acquired HIV through mother-to-child transmission (“perinatally infected”). While limited data is available, with anti-retroviral therapy, many in the first generation of HIV-positive infants have lived to adolescence and even young adulthood.
- Worldwide, the vast majority of those living with HIV – 80 to 90 percent – are unaware of their status. 
Treatment Needs Remain Unmet and Young People Face Particular Barriers to Access
- According to the Joint United Nations Programme on HIV/AIDS, the needs of young people living with HIV or AIDS are “underestimated and largely unmet.” 
- Countries with the highest numbers of young people living with HIV are also among the world’s neediest countries.
- In sub-Saharan Africa, less than 40 percent of people who need treatment for HIV/AIDS are receiving it.
- In North Africa and the Middle East, less than 15 percent of those who need treatment are receiving it.
- In Latin America and the Caribbean, only about half of those who need treatment are receiving it. 
- Without regular treatment, those with HIV are not only more vulnerable to progressing to AIDS, but are more likely to transmit HIV to their sexual partners. 
- The cost of HIV treatment and medications is a major barrier to care for HIV-positive youth who are financially dependent on parents or are struggling to support themselves. 
- Many health facilities require parental permission or notification for minors to receive care, a major deterrent for young people seeking testing, counseling, and other HIV-related healthcare services. For instance, in Africa, only 4 of 22 countries that responded to a World Health Organization survey had provisions allowing minors to access HIV testing without parental permission. [1,7]
- Many health clinics don’t practice youth-friendly services such as flexible hours, confidential services, and careful case management. 
Young People Living with HIV face diverse challenges and have different needs
- Because HIV-positive young people may have weakened immune systems, co-infections with tuberculosis or malaria can threaten their health.
- Tuberculosis is a common cause of illness and death among people living with HIV, even among those receiving treatment, with sub-Saharan Africa accounting for 78 percent of HIV-related TB. 
- Also in sub-Saharan Africa, the greatest number of co-infections between HIV and malaria occur in female adolescents. Pregnant adolescents are particularly vulnerable, and their fetuses and infants are gravely endangered. [8,9]
- Youth who were perinatally infected with HIV may experience challenges to health throughout their lives, including delayed development. They may also struggle particularly with puberty, developing sexuality, and making decisions about sexual activity. 
- Young people living with HIV have particular reproductive and sexual health needs Many young people who are living with HIV are sexually active, some with HIV negative partners. Some may be at risk for other STIs, including at risk for cervical cancer caused by HPV. Some wish to become parents, while some wish to prevent pregnancy. All need accurate information about family planning options and HIV prevention methods in order to make healthy decisions and protect the health of loved ones. 
- Young people make up 70 percent of those who inject drugs. Young drug users are less likely than older ones to have access to drug treatment services, and are more likely to experience strong barriers to consistent health care (such as homelessness, poverty, and incarceration) than non-drug-users. 
HIV- and AIDS-related Stigma Leads to Discrimination, with Vulnerable Populations at Greater Risk
- AIDS-related stigma refers to prejudice, discounting, discrediting, and discrimination directed at people perceived to have AIDS or HIV, and the individuals, groups, and communities with which they are associated.  Stigma against HIV-positive people can be found not only among individuals and communities, but in laws and policies around the world.
- Within the public health policy framework, those living with HIV are often treated merely as patients or even as “transmission vectors” who are responsible for transmitting the disease and should be avoided – rather than as multifaceted humans with the right to make decisions regarding policies that affect them. 
- Globally, only 34 percent of young people ages 15-24 have comprehensive and correct knowledge of how HIV is transmitted – leaving these youth not only vulnerable to HIV, but to believing myths about HIV and HIV-positive people. 
- Stigma against people with HIV directly contributes to the epidemic where HIV-positive people or people at risk of HIV are reluctant or afraid to seek treatment and testing. 6, 12 For instance, in Lesotho, young people report being afraid to get an HIV test because health care workers accuse them of being promiscuous. 
- Gender bias together with HIV stigma create an unsafe environment for many young women living with HIV. Women living with HIV or AIDS are more likely to have experienced physical and sexual violence from a partner. Fear of partner violence can lead to nondisclosure of HIV and to the delay of treatment or non-adherence to treatment.  The same social norms that prevent women from refusing unwanted sexual advances or negotiating safe sex also leave them vulnerable after they become HIV-positive. 
- One-third of countries do not have laws in place to protect those living with HIV from discrimination. 
- Among the regions where the largest numbers of people living with HIV reside, many have laws which create obstacles to effective HIV prevention. In South and South East Asia, 90 percent of countries have such laws; in sub-Saharan Africa, over 50 percent; and in South and Central America, over sixty percent.  For instance, the free travel of people with HIV is restricted in 51 countries, while over 30 have laws which criminalize the transmission of HIV. 
- Eighty countries around the world consider homosexuality a crime – an impediment to gay, lesbian, bisexual, and transgender individuals who are seeking care, and to programs that serve them. 
Programs can fight stigma and respond to the needs of young people living with HIV – but are scarce
- In South Africa, a nationwide initiative to create youth-friendly services has enabled public health workers to better respond to youth needs, leading to a statistically significant rise in clinic visits by adolescents ages 10-19. [9,16]
- Although HIV stigma is widespread, programs can help reduce it among healthcare workers, service providers, and the public. In Nicaragua, a broad media campaign aimed at reducing stigma led to a 20 percent reduction in stigmatizing attitudes among young people.
- At the Pediatric Infectious Diseases Clinic and the Adult Infectious Diseases Clinic at Kampala Hospital, a 2003 needs assessment of 100 young people living with HIV, ages 10 to 19, revealed that youth preferred to be treated differently from children and adults. As a result, a peer support group began addressing the psychosocial needs of that age group. Currently, more than 250 adolescents attend peer support meetings twice a month. The emphasis is on living successfully with HIV/AIDS and anticipating productive adult lives.
- Programs which involve people living with HIV and AIDS can lead to better services and more meaningful programs for YPLWHA. A detailed study of the involvement in programs of people living with HIV in four countries (India, Zambia, Ecuador, and Burkina Faso) found that involvement could lead to improved programs as well as improved psychological and physical health for those involved.
For people living with HIV and AIDS, there are some positive developments. More than 5 million people are currently receiving HIV treatment, and there was a 30 percent increase in the number of people receiving treatment in 2009.  Many countries are taking steps to reduce stigma: over 92 percent of governments reported to UNAIDS that they address stigma in their HIV strategy.  But there is still a great deal of work to be done. With full access to holistic and nonjudgmental health care services, youth living with HIV or AIDS can lead long and full lives. All young people, including those who are HIV positive, have the right to information and services that can help them stay healthy and protect themselves and their loved ones.
By Emily Bridges, Director, Public Information Services, and Nicole Cheetham, Director, International Division
With contributions from Liz Bayer and Sarah Robbins
Advocates for Youth © November 2011
- United Nation’s Children’s Fund (UNICEF). Opportunity in Crisis: Preventing HIV from early adolescence to young adulthood. New York: Unicef; 2011. Accessed November 1, 2011 from http://www.unicef.org/publications/files/Opportunity_in_Crisis-Report_EN_052711.pdf
- Joint United Nations Programme on HIV/AIDS (UNAIDS). “Global Report 2010, Core Slides, Slide 11.” Accessed on November 1, 2011 from http://www.unaids.org/documents/20101123_epislides_core_en.pdf.
- Nour NM. Health Consequences of Child Marriage in Africa. Emerging Infectious Diseases, 2006: Vol. 12, Number 11.
- Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO). AIDS Epidemic Update 2009. Geneva: UNAIDS, 2009. Accessed November 1, 2011 from http://data.unaids.org/pub/report/2009/jc1700_epi_update_2009_en.pdf
- Joint United Nations Programme on HIV/AIDS (UNAIDS). Getting to Zero: 2011–2015 Strategy. Geneva: UNAIDS, 2010. Accessed November 1, 2011, from http://www.un.org.np/sites/default/files/2011-08-17-UNAIDS-Strategy-en.pdf
- Joint United Nations Programme on HIV/AIDS (UNAIDS). Global Report. Geneva: UNAIDS, 2010. Accessed November 1, 2011, from
- Global Youth Coalition on HIV/AIDS (GYCA). Living Positively: Young People Living with HIV and the Health Sector Response. New York: GYCA, 2008. Accessed November 1, 2011 from http://www.youthaidscoalition.org/docs/livingpositively2008.pdf
- Brabin L and Brabin BJ. HIV, malaria and beyond: reducing the disease burden of female adolescents. Malaria Journal, 2005; 4: 2. Accessed November 1, 2011 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC548285/
- National Center for Infectious Diseases. “Interaction of HIV and Malaria.” Centers for Disease Control and Infection. Accesssed on November 1, 2011 from www.cdc.gov/malaria/ppt/Malaria_HIV_Rick_website.ppt
- AIDS Education and Training Centers (AETC). “The HIV Perinatally-Infected Adolescent: A Developmental Approach.” AETC, 2004. Accessed on November 1, 2011 from http://www.aids-ed.org/aidsetc?page=etres-display&resource=etres-272
- UNFPA and WHO. Sexual and reproductive health of women living with HIV/AIDS: guidelines on care, treatment and support for women living with HIV/AIDS and their children in resource-constrained settings. Geneva: WHO, 2006. Accessed November 1, 2011 from http://www.who.int/hiv/pub/guidelines/sexualreproductivehealth.pdf
- Young People Most at Risk of HIV: A Meeting Report and Discussion Paper from the Interagency Youth Working Group, U.S. Agency for International Development, the Joint United Nations Programme on HIV/AIDS (UNAIDS) Inter-Agency Task Team on HIV and Young People, and FHI. Research Triangle Park, NC: FHI, 2010. Accessed November 1, 2011 from http://www.unfpa.org/webdav/site/global/shared/iattyp/docs/Young%20People%20Most%20at%20Risk%20of%20HIV.pdf
- Avert.com. “HIV & AIDS Stigma and Discrimination.” Accessed November 1, 2011 from http://www.avert.org/hiv-aids-stigma.htm
- GNP+, UNAIDS. 2011. Positive Health, Dignity and Prevention: A Policy Framework. Amsterdam, GNP+. Accessed on November 11, 2010 from http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2011/20110701_PHDP.pdf
- Joint United Nations Programme on HIV/AIDS (UNAIDS). Securing the Future Today. Geneva: UNAIDS, 2011. Accessed November 1, 2011 from http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2011/20110727_JC2112_Synthesis_report_en.pdf
- South Africa Department of Social Development. NAFCI – The National Adolescent Friendly Clinic Initiative. Accessed November 1, 2011 from http://ppdafrica.org/docs/southafricaadolescent.pdf
- Pulerwitz J et al. Reducing HIV-Related Stigma: Lessons Learned from Horizons Research and Programs. Public Health Reports, 2010; 125(2): 272-281. Accessed on November 1, 2011 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2821857/?tool=pubmed
- Birungi H, Mugisha JF, Nyombi J, et al. Sexual and reproductive health needs of adolescents perinatally infected with HIV in Uganda. Unpublished paper. Population Council, The AIDS Support Organization, 2008.
- Cornu, C. The Involvement of People Living with HIV/AIDS In Community-Based Prevention, Care and Support Programs in Developing Countries. The Population Council Inc. and the International HIV/AIDS Alliance, 2003. Accessed November 1, 2011 from http://www.popcouncil.org/pdfs/horizons/plha4cntryrprt.pdf