There’s a lot of good news about HIV/AIDS. Worldwide there has been a steady decline in the number of people between the ages of 15 and 24 being infected with HIV. The decline has been linked to behaviour changes such as waiting longer to become sexually active, having fewer multiple sex partners and using condoms in multiple partnerships.
In South Africa, however, this is not the case. The drop in the number of adolescent girls and young women becoming HIV positive is too slow and too little. In 2012 11.4% of young women aged 15 to 24 were HIV positive compared to 2.9% of young men. Four years earlier, this figure sat at 13.9% for young women compared to 3.6% of young men.
And when you put this in the context of the global picture it is equally as startling: 42% of new HIV infections occur in people aged between 12 and 24. Nearly 80% of these young people live in sub-Saharan Africa. And more than 70% of these infections occur in adolescent girls and young women.
Not only do these adolescent girls and young women have higher rates of HIV, they also acquire infection between five and seven years earlier than their male peers.
The quest to stem these infections is an important part of reducing the high rates of HIV among adolescent girls and young women in sub-Saharan Africa. Knowing your HIV status is an important part of this. But in South Africa this knowledge remains very low. Less than 50% of young people know their status. South Africa is worse off than many other countries.
So how can the country ensure that more adolescent girls are able to test for HIV and, where necessary, start taking antiretrovirals?
The answer lies in implementing extensive combination prevention programmes in high-prevalence settings for both men and women. This needs to include early antiretroviral treatment, provision of pre-exposure prophylaxis and medical male circumcision. There also needs to be a concerted effort to promote knowledge of HIV status, comprehensive age appropriate education in schools, economic empowerment and easy access to sexual and reproductive health services.
Why are women so vulnerable
The persistently high gender imbalance of HIV among young people has led to an increase in research to understand the disparate burden and associated risks facing adolescent girls and young women.
A number of contributory factors have been identified.
Part of the disconnect among women about their HIV status and their vulnerability relates to their perceptions that they have a low risk to HIV. This in turn perpetuates vulnerability to HIV, particularly in situations of high household poverty levels and unemployment.
Living in a society where patriarchy is embedded and gender inequality is rife also plays a major role. In these settings young women and girls are often limited from reaching their full potential because they do not finish school. Studies have shown that premature school leavers are more disadvantaged and that women who finish school have better job opportunities and the ability to make better life decisions.
Much attention has been paid to the role that age-disparate heterosexual relationships may play in this gender imbalance. Several studies show when there are larger age differences among sex partners, there is a higher chance of condoms not being used. This in turn leads to higher rates of sexually transmitted infections among adolescent girls and young women.
Cycle of HIV transmission
A recent study involving women living in areas where HIV prevalence is as high as 66% among women in their 30s shows that the greatest difference in HIV prevalence is among men and women in the younger age groups. This reinforces the notion that women on average acquire HIV at a younger age than men.
The study helped explain a continuous “cycle of HIV transmission” between older men and younger women. But this transmission heightens the vulnerability of adolescent girls and young women to HIV.
This is because most younger women (aged 15 to 25) had male partners on average up to nine years older than them. Adolescent girls and young women in these age-disparate relationships are generally unable to negotiate safer sex practices involving the use of condoms, increasing the chance of them contracting HIV.
These women who acquire HIV, over time once they reach the age of 25, also have relationships with men of their own age who in turn acquire HIV. These men then have new relationships with younger women aged 15 to 25, spreading the virus and contributing to the cycle of HIV transmission.
Programmes that work
South Africa has made substantial progress in the large scale roll-out of HIV prevention and treatment programmes and has the largest antiretroviral programme in the world. But young women are uniquely vulnerable to infection, and preventing HIV acquisition in this key population is a public health imperative.
Understanding the cycle of transmission and the sexual networks that drive HIV transmission could help design programmes to reduce HIV infection in adolescent girls and young women.
There are many programmes which could help adolescent girls and young women making an informed decision. These programmes also increase and retain their attendance in schools, reduce teenage pregnancies and gender-based violence and increase economic opportunities for young people. Most importantly they interrupt the cycle of transmission and decrease new HIV infections.
While these programmes exist, in many instances they are not delivered in the most appropriate way that ensures they influence young women’s thinking.