HOW SERIOUS IS HIV FOR ADOLESCENTS AND YOUNG PEOPLE?
Young people (10-24 years) and adolescents (10-19 years), especially young women and young key populations, are disproportionately affected by HIV. AIDS is now the leading cause of death among young people in Africa and the second leading cause of death among young people worldwide.
Globally in 2018, 1.65 million adolescents were living with HIV and an estimated 190,000 were newly infected with HIV. The situation is especially dire for adolescent girls, who account for 74% of the adolescents acquiring HIV. The number of adolescents living with HIV rose by 30% from 2005-2016. Every day an estimated 1,400 adolescents and young people become infected with HIV.
The majority of young people with HIV are in low- and middle-income countries, with 84% in sub-Saharan Africa. In fact, half of 15–19-year-olds with HIV in the world live in just six countries: South Africa, Nigeria, Kenya, India, Mozambique, and Tanzania.
In the U.S., adolescents and young people accounted for 21% (7,891) of the 37,968 new HIV diagnoses in 2018. Most new HIV diagnoses among youth (92%) were among young gay and bisexual men. Of that 92%, 78% were among young gay and bisexual men of color (Black/African American and Hispanic/Latino.
Youth with HIV are the least likely of any age group to be aware of their infection, be retained in care, and have a suppressed viral load. Addressing HIV in youth requires that young people have access to the information and tools they need to make healthy decisions and reduce their risk for getting HIV, and to get treatment and stay in care if they have HIV.
WHY ARE ADOLESCENTS AND YOUNG PEOPLE PARTICULARLY AT RISK FOR HIV?
Adolescence and young adulthood are critical periods of human development and are marked by rapid physical, hormonal, neural, psychosocial, cognitive, emotional, sexual, and reproductive transitions and maturation. The following factors contribute to the global burden of HIV among adolescents and young people:
Policy and legal barriers. Particularly for those under 18 years, requirements related to the age of consent often prevent access to a range of health services, including HIV testing and counseling, harm reduction, and other essential services. Such barriers also limit adolescents’ ability to exercise their right to informed and independent decision-making.
Unprotected sex: Excluding perinatal transmission from birthing person to child, unprotected sex is the most common route of HIV infection for young people, followed by sharing infected needles. For some, this is a result of not having the correct knowledge about HIV and how to prevent it, highlighting the need for HIV and sexual and reproductive health education. For others, it is the result of being pressured or forced to have unprotected sex or to inject drugs.
Early sexual debut: The age of sexual debut is rising, showing a positive change in attitudes among young people with regards to sexual behavior. However, it is still relatively low in many countries, particularly in Africa, and lower among adolescent girls than boys in low- and middle-income countries. Child marriage is a key driver of early sexual debut, and in some settings up to 45% of adolescent girls reported that their first sexual experience was forced.
Low HIV and sexual health knowledge: If young people are able to access comprehensive sexuality education (CSE) before becoming sexually active they are more likely to make informed decisions about their sexuality and approach relationships with more self confidence. CSE is also known to increase adolescent girls’ condom use, increase voluntary HIV testing among young women, and reduce adolescent pregnancy, especially when linked with non-school-based, youth-friendly sexual and reproductive health services provided in a stigma-free environment.
Not using condoms: Condom use among young people and adolescents remains relatively low. Studies in sub-Saharan Africa between 2010-2015 report less than 60% of young women (aged 15-24 years) with multiple partners used a condom during their last sexual intercourse in 19 of 23 countries.
Older partners: Intergenerational sex (when young people have sexual relationships with older people) is thought to be an important driver of the HIV epidemic in sub-Saharan Africa. Older partners are more likely to have HIV, therefore risking exposure to young people, and are more likely to expose a young person to unsafe sexual behaviors such as low condom use.
Young sex workers: Research shows that adolescents under 18 who sell sex are highly vulnerable to HIV and other sexually transmitted infections (STIs), have higher levels of HIV and STIs than older sex workers, and have limited access to services such as HIV testing, prevention, and treatment. Young sex workers face many of the same barriers to HIV prevention as their older counterparts including the inability to negotiate condom use and legal barriers to HIV and sexual health services, which are amplified by their age. Read more about HIV among sex workers.
Young transgender people: HIV risk among young transgender people is related primarily to sexual behavior, especially unprotected anal sex. Some young transgender people also sell sex or inject street drugs, silicon, and hormones, putting them at even higher risk of acquiring HIV. Experiences of stigma, discrimination, abuse, exploitation, and violence, including sexual violence, are common. Read more about HIV and transgender people.
Young men who have sex with men: Available data suggest that young men who have sex with men (MSM) have greater HIV risk than both heterosexual young people and older MSM. Young MSM are often more vulnerable to the effects of homophobia (manifested in discrimination, bullying, harassment, family disapproval, social isolation, and violence), as well as criminalization and self-stigmatization. This can have serious repercussions for their physical and mental health and their ability to access HIV testing, counseling, and treatment. Read more about HIV and MSM.
Young people who inject drugs: Current methods of gathering and reporting data make it impossible to calculate a reliable global estimate of the number of young people who inject drugs (PWID). A significant proportion of young PWID become infected with HIV within the first 12 months of initiation. Young PWID are more likely than older people to lack knowledge about safer injecting practices and HIV prevention, and to be unaware of risks to their health. There are often age restrictions on accessing harm reduction services, forcing young PWID away from services and denying them help to overcome their addiction. Read more about HIV and PWID.
PREVENTING HIV INFECTION AMONG ADOLESCENTS AND YOUNG PEOPLE
Comprehensive sexuality education (CSE)
The status of CSE varies throughout the world and is insufficient in many countries. In 2015, UNAIDS and the African Union included age-appropriate CSE as 1 of 5 key recommendations for improving the HIV response. In the same year, many countries in Asia and the Pacific, West Africa, and Europe were revising their policies and approaches to scale up CSE.
Schools have the potential to provide detailed education on HIV/AIDS and other sexual and reproductive health issues. More progress needs to be made to ensure there is equality in access to schools by both girls and boys and to prevent them from dropping out.
Opportunities to obtain knowledge about HIV/AIDS and sexual health are extremely limited for young people not in school. Youth clubs have the potential to provide HIV knowledge, but their small, localized reach means their impact is limited on a large scale.
Encouraging condom use
One of the most important prevention responses is to make condoms and water-based lubricants available and accessible to youth. Condoms are highly effective in preventing a person from getting or transmitting HIV infection if used the right way every time during sex. Read more about how to use condoms the right way: external condoms and internal condoms.
Targeted, age-specific programs and messaging
Young people respond much better to HIV and sexual and reproductive health services that are specific to their age group. Research shows that targeted counseling to encourage behavior change among young people is more effective than only handing out commodities such as condoms.
The influence, power, and control that many adults have on the lives of young people means that engaging various stakeholders such as parents, healthcare providers, teachers, and community leaders is key to HIV prevention for young people.
HIV counseling and testing
Historically, national HIV/AIDS programs have struggled to persuade people at higher risk of HIV to periodically test for HIV. This is especially true among adolescents and young people, who often underestimate their HIV risk. Increasing access to HIV counseling and testing is vital to prevent further transmission of HIV among young people. Mobile and community testing initiatives are a successful way of reaching young people who are less likely to voluntarily visit regular healthcare settings.
HIV counseling and testing services must be open at appropriate times (after school/college) and be at appropriate venues where young people feel safe enough to go alone. Healthcare workers must be trained to meet the needs of young people so that they do not face stigma, judgement, or a breech in confidentiality. Young people need extra support to transfer to treatment if they test positive, as they may otherwise get lost in the treatment cascade. Find an HIV testing site near you.
Peer mentors and educators
Young people have the potential to be great peer educators and to help in the design of HIV-related services and programs. Technology and social media are consistently being proven as effective ways to engage young people in sharing HIV knowledge.
ANTIRETROVIRAL THERAPY (ART) AMONG ADOLESCENTS AND YOUNG PEOPLE
Adolescents have special requirements for comprehensive care, including psychosocial support and sexual and reproductive health, and may face significant barriers to accessing and remaining in treatment and support services. Health services should reflect the following key considerations of youth development:
- Emerging autonomy but limited access to resources
- Dramatic increase in quantity and variety in social relations potentially increasing vulnerability
- Movement from dependence to interdependence, balancing autonomy and connection
- Developing self and sexual identity, including capacity for self-direction
- Enhanced but evolving cognitive ability and greater impulsivity
- Gap between biological maturity and assumption of adult roles
In North America and Europe, there is a large jump at 18 years of age, when people with HIV are moved from pediatric to adult services and allocated a new healthcare provider. In other regions, defining the age that an adolescent is ready to move on to adult services is less simple and remains a problem among many service providers.
Young people who have had HIV since birth can face challenges in the transition from pediatric treatment services — where parents and guardians have primary responsibility for their care — to adult treatment services where they will need to take much greater responsibility for their own care.
For young people who may have been taking treatment for some time, changing antiretroviral medication (ARV) regimens and doses during adolescence is another complex issue that results in young people not adhering to their treatment. As young people grow, their dosages must be increased to reflect increases in their weight and height.
For adolescents who were not diagnosed in childhood and who may have acquired HIV during adolescence, laws and policies on the age of consent for HIV testing prevent many adolescents from knowing their HIV status and therefore accessing HIV treatment. Late diagnosis of HIV is a particular issue for adolescents who also belong to other key populations (for example, if they inject drugs), as they are often reluctant to seek testing and treatment services because of stigma and discrimination.
ADHERENCE TO ART
Adherence is a major challenge for adolescents and young people. Despite the availability of effective treatment, adolescent-specific services are rarely available and often healthcare providers have little experience of providing services for young people. They may not understand the needs of adolescents living with HIV and may have judgmental attitudes towards those who are sexually active.
Research studies have identified a number of interventions that can have a positive impact on adolescents’ adherence to ART, including:
- Counseling and education
- Use of adherence support devices such as beepers and mobile apps
- Financial incentives
- Peer support
- Directly observed therapy
However, more research is needed in this area and overall adherence support must be scaled up for young people to sustain treatment as a form of prevention and stop transmission to others.
THE BOTTOM LINE
Youth with HIV are the least likely of any age group to be aware of their infection, be retained in care, and have a suppressed viral load. Young people (10-24 years) and adolescents (10-19 years), especially young women and young key populations, are disproportionately affected by HIV.
Adolescence and young adulthood are critical periods of human development and are marked by rapid physical, hormonal, neural, psychosocial, cognitive, emotional, sexual, and reproductive transitions and maturation.
Adolescents and young people are underserved by HIV services, have high risk of interruption in treatment, and suboptimal continuity of treatment and adherence.
Adolescents have special requirements for comprehensive care, including psychosocial support and sexual and reproductive health, and may face significant barriers to accessing and remaining in treatment and support services.
With early testing and treatment, adolescents and young people can live long and healthy lives and prevent HIV transmission to others.
CDC: HIV and Youth
WHO: HIV and youth
HIVInfo.NIH.gov: HIV and Specific Populations: HIV and Children and Adolescents
Reviewed May 2021Print PDF