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We have a twofold task this afternoon: to deepen our understanding of just how susceptible young people are to the risk of HIV infection, and as we do so to identify
actions we could take in our home countries to reduce that susceptibility.

The AIDS Generation

Some months ago, in what
amounts to a severe judgement on modern society, a major publication referred to today’s young people as “the AIDS generation” (Kiragu, 2001, p.1). The young are people who have never known a world
without AIDS. They are people who are themselves extremely susceptible to HIV infection, with a significant number of them having already progressed to full-blown AIDS. With some 12 million young people
being infected with the disease, almost one-third of those currently living with HIV/AIDS are aged 15–24 (UNAIDS, 2001a). In some countries it seems possible that more than a third of the 15 year-olds
will die of AIDS-related illnesses in the coming years. For countries with high rates of infection the prognosis is even worse. In Zimbabwe, it can be expected that half the 15-year old boys born in
1997 will die of AIDS before they reach the age of 50 (UNAIDS, 2001a, pp. 23–24), while in the absence of treatment 90 percent of Botswana girls and 88 percent of the boys who were aged 15 in the year
2000 are likely to die of the disease. In Zambia, even if HIV risk drops by 50 percent by the year 2015, more than half the boys now aged 15, and approximately the same proportion of girls, will die of
AIDS (Kiragu, 2001, p. 56).

Bleak as these statistics are, they do not tell the whole grim story. The susceptibility of young people to HIV infection is
characterised by remarkable gender differences. From age 15 onwards, AIDS cases and infection rates rise very steeply for girls. There is also a sharp rise for boys, but the increase is much less than
for girls (Figure 1). In very many parts of the world, this leads to HIV prevalence among young women aged 15–24 being several times higher than among males belonging to the same age group. Thus, in
India the estimated prevalence rate for 15–24 year-old girls is 0.4 to 0.8 percent, whereas for boys it is 0.1 to 0.6 percent. In Kenya, the infection rate for young women ranges from 11.1 to 15.0
percent and for young men from 4.3 to 8.5 percent. Brazil, on the other hand, shows a different pattern, with prevalence rates for young men (0.6 to 0.8 percent) being higher than those for young women
(0.2 to 0.3 percent) (UNAIDS, 2000, Annex 2). The differences that have been observed show the importance of customising responses to the situations within a country or region.

While certain principles may apply across many parts of the world, such as that young females tend to be at greater risk of HIV infection than young males, countries need to
be aware of the their own specific situations and take steps accordingly.

A second feature of young people’s susceptibility to HIV infection is that a great deal of
the infection occurs during the years of schooling or very shortly thereafter. Figure 1 shows the cumulative AIDS cases for Zambia up to the end of 1999. These are cases of full-blown AIDS, a condition
that does not develop until several years after the primary infection with HIV. The relatively high levels of AIDS below age 5 are due, for the greater part, to parent-to-child transmission. The
majority of children infected in this way will die before their fifth birthday, though a small proportion may survive on into their school years and even into late adolescence and young adulthood. The
occurrence of AIDS between ages 5 and 14 is minimal, though it does occur and seems set to become an ever greater problem. Projections from South Africa show that among 5–9 year-olds deaths from AIDS
now equal and will soon surpass deaths from all other causes combined, while in about another decade this will also be the case among 10–14 year-olds (ABT Associates, 2001).

We must also remember that, if AIDS is manifesting itself at an increasing rate among those aged 15–24, the long period that elapses between the initial infection with HIV
and the appearance of clinical AIDS means that HIV must have been contracted at a very young age, when the individual was in primary or lower secondary school. This very sombre fact points to the
importance of strategies that address the knowledge and behaviour needs of children while they are still young. Waiting until they are older is leaving it too late.


The Silent Epidemic

More than nine-tenths of those who are HIV positive are not aware that they are infected, and the proportion is
higher in the most seriously affected countries. This may even be more true of youth than of adults, because of simplistic assumptions about youth being a time of generally good health.

When HIV first enters the human system, flu-like symptoms may manifest themselves for a brief period, but these quickly subside. Thereafter the infected individual looks and
feels no different from others, though all the time the immune system is gradually succumbing to the onslaught of the virus. This asymptomatic period accounts for about 80 percent of the time between
the initial infection and eventual death from AIDS (World Bank, 1997, p. 19). For the greater part, the disease is invisible at this stage and can be detected only by relatively sophisticated and often
unavailable HIV tests. For many years, the young person may be carrying the virus, with the immune system steadily losing its ability to protect the body against a variety of illnesses. Throughout this
period there is also capacity to transmit the infection to others, but the infected person is not aware that they constitute such a threat. The potential to transmit infection is highest when viral
loads in the blood are high, a condition that occurs on two occasions—in the period shortly after initial infection and in the period when full-blown AIDS has developed. Since new HIV infections are
occurring at very high rates among young people, it follows that young people may form a special highly infectious group, with enhanced potential to spread the disease among themselves and to others,
without their being aware that they might be doing so.

A second reason why we refer to the silent, invisible epidemic is because of the reaction of society. Fourteen
years ago, Jonathan Mann, the esteemed director of the Global Programme on AIDS, said that we were dealing with three epidemics:

  • The silent epidemic of HIV that, for the greater part, is spread by that most basic of human activities, sex.
  • The second epidemic of the illness of AIDS, which is still devastatingly incurable.
  • The third epidemic of the adverse social reaction to persons infected with or affected by the disease (Walrond, 2000, p.59).

While there has been some improvement over the years, the social reaction to HIV/AIDS still tends to be very adverse. Countries deny that they have a problem of AIDS.
Communities do not want to hear about the disease in their midst. Families and individuals go to great lengths to attribute a sickness or death to any cause other than AIDS.

In addition, through an intolerable violation of their basic human rights, persons with AIDS and those in their immediate families frequently experience stigmatisation and
discrimination. They are alleged to have brought the problem on themselves through their immoral behaviour and hence are regarded as being culpable and blameworthy. Some have been abandoned by their
families. Others have lost jobs. Others are ostracised by communities. Some have even faced physical violence which, in a notorious South African case, eventuated in murder.


Testing and Health Services

Given the silence inherent in the epidemic and the climate of silence, denial and discrimination that
society creates, there is little incentive for young people to seek to know their HIV status or to come out into the open about it. They seem to be caught whichever way they turn. They receive little
real encouragement to go for counselling and testing. Often these services are not available. Where they are, young people may fear to make use of them, lest they be seen doing so, thereby tacitly
admitting that they have some sort of problem. In a related vein, in their anxiety and embarrassment about sex, they are reluctant to present themselves for medical attention when they experience
sexually-related problems. They fear they will be proffered judgemental, moralising advice and they cannot be certain that the testing and necessary drugs will be available.

These considerations draw attention to two key components that should be integral to every HIV prevention strategy that targets young people:

  • adequately resourced health services to which young people can have recourse at times and in a manner that they do not perceive as constituting a threat. The services
    provided, the personnel providing them, and the circumstances under which provision is made should be friendly to young people who may present themselves for attention; and
  • more widely available voluntary testing and counselling services, with great attention to the need for counselling that will provide emotional support to an anxious
    young person, and for absolute confidentiality, not merely in regard to the test results but also in the circumstances and set-up of the testing facilities.

Both of these are areas where policy-makers, through their interest and action, could contribute to substantial control and reduction of HIV transmission.


Responding to a Dangerous Lack of Knowledge

The physical, psychological and emotional changes that are intrinsic to the development
of young people contribute in special and virtually unavoidable ways to their vulnerability to HIV infection. These range from the delicate, thin, easily lacerated membranes in the immature genital
tract of a girl, through lack of experience and assurance on the part of both boys and girls, to an almost compulsive urge to experiment, take risks, and show oneself as an adult. It is not easy to
address these factors. But other factors that contribute to adolescent and youth vulnerability can be addressed.

One of these is ignorance. Even though most young
people allege that they know something about AIDS, many show themselves ignorant in ways that could be lethal for them. For instance, in several countries, including those with high prevalence rates, a
significant proportion of youth do not know any way of protecting themselves against HIV/AIDS. This has been found to be the case for 51 percent of girls and 35 percent of boys, aged 15–19, in Tanzania;
in Bolivia, the percentages were 33 percent for girls and 26 percent for boys, while in Bangladesh the figures stood at the extraordinarily high level of 96 percent for girls and 88 percent for boys
(UNICEF, 2000, p. 6). Another aspect of this potentially fatal lack of knowledge is the large number of young people who believe that HIV infection will show in the appearances. In Vietnam, 50 percent
of girls aged 15–19 do not know that a person with HIV may look healthy. In Nepal, 80 percent of girls of this age do not know that a person who looks healthy can be infected with HIV and can transmit
it to others. More than half the girls in South Africa and Lesotho, where the prevalence levels are particularly high, are also in danger of being deceived by the healthy appearance of a partner into
thinking that he could not be infected with HIV (UNICEF, 2000, p. 7).

This ignorance extends to various areas of sexual activity. In Caribbean countries,
where sexual activity begins at a young age, many young people seem to be well informed on HIV transmission, with almost all of them knowing that the virus is spread through sexual intercourse.
According to their understanding, however, intercourse refers exclusively to vaginal penetration. They do not know that oral and anal intercourse and any other way of sharing bodily sexual fluids also
constitute high-risk activities.

A characteristic feature of youth is a sense of invulnerability, the “it won’t happen to me” syndrome. Young people apply this to
sexual encounters as readily as they do to fast driving or turning to drugs for stimulation. Outside of Africa, Haiti’s HIV prevalence of 5.2 percent is the highest in the world. Yet in Haiti 63 percent
of sexually active girls, those aged 15–19, believe that they are not at risk of contracting the disease (UNICEF, 2000, p. 7).

A final area where the knowledge and
sexual practices of youth may lead to disaster arises from the trust they show in each other when they enter into a relationship. Establishing a relationship is a wonderful and very beautiful thing. In
fact it is so valuable and marvellous that it needs to be safeguarded. A major safeguard is to abstain from sexual intercourse (whatever its form) until marriage, but where this is not done to use a
condom or other barrier that will prevent HIV transmission. Frequently, young people are reluctant to follow this latter course of action, feeling it betrays a lack of trust in their partner. And in
several instances, they may stop using condoms after some weeks or months of a relationship, protesting that there is no longer any need, that they are faithful to each other. What they often do not
know is whether that fidelity is absolute, and also what the sexual history of the partner was before they came together.

These illustrations and situations show
that ignorance about HIV risks is very widespread, especially in the early years of sexual activity. Much more needs to be done to ensure that young people are provided with accurate information and to
keep them alert to the risks they might encounter. As UNICEF rightly says, “the overwhelming message is that information about AIDS and its deadly danger is not getting out or is not being absorbed”
(UNICEF, 2000, p. 6). There is urgent need for sustained information and education campaigns that will put correct information before young people, in a way that will speak to them, and that will help
them make these messages their own.

Unfortunately, adult attitudes to providing youth with information are often ambivalent. Many adults do not speak about sexual
matters with their children. Many do not want such matters to be discussed in schools. Many believe, quite wrongly, that information and education about sex will lead to sexual experimentation and
promote immoral behaviour. They are afraid to let the young people know about sexual matters, but they are quick to react negatively should any mishap, such as HIV infection, occur.

Policy-makers must take the lead in responding to both the information needs of young people and the anxieties expressed by older generations. They must be fearless in
promoting information, education and communication campaigns. At the same time, they must remain sensitive to cultural, traditional and religious concerns and ensure that the messages that are
propagated accord with the best values from these. In this regard, it should help policy-makers to know that HIV/AIDS information and education programmes do not lead to increased sexual activity. Quite
the contrary, they have been found to contribute to delaying the onset of sexual activity, reducing the number of sexual partners, and lessening unwanted pregnancies and STDs (UNAIDS. 1997, p.5).


Capitalising on Peer Influence

Very many young people feel compelled to behave in ways that will be approved by their colleagues and
peers. They are very sensitive to the opinions of their peers and are reluctant to deviate from peer norms. This happens as much in the sexual as in other areas of their lives. This heavy influence of
peers and of the group has negative and positive aspects. Negatively, some may engage in sexual practices, including those that risk transmitting HIV, because their peers do the same and this seems to
be expected of them. Thus, in Kenya, male adolescents whose friends were sexually active were found to be seven times more likely to be sexually active themselves (Kiragu, 2001, p. 22). Positively,
significant peers can influence their colleagues to desist from sexual activity or to take the measures needed to protect themselves against HIV transmission.

The
strength of peer influence is such that every effort should be made to make full use of it for the purposes of HIV prevention. Education and communication programmes directed towards HIV prevention
amongst young people are more likely to succeed if they involve the participation of young people themselves, or of those close to them in age. This participation should embrace two aspects. First,
young people themselves should have a large say in the content of what is to be presented. Nobody knows their needs, aspirations and concerns better than they. Second, they should play an important role
in the actual presentation of material. Young people listen to one another and can speak a language that strikes an immediate chord with their age-mates. Involving young people in programme development
and presentation recognises the powerful socialising influence that the youth have over each other and seeks to win over to its side the potency of peer pressure. Because the messages are not coming
from outsiders but from contemporaries or peers themselves they are more readily assimilated into the peer culture and norms.

Examples of the good that can be
achieved in this way come from Uganda and Zambia. In both countries, young people run, write and edit newspapers—”written by young people for young people”. With the aim of educating the youth about
HIV/AIDS, as well as sexual health and reproductive issues, these publications speak to young people in ways that few teachers or parents could. In both countries also, pro-life “youth alive”
organisations reach out to young people to influence positive attitudes and behaviour change, through educating and sharing with their peers on HIV/AIDS and other issues related to health and life. It
is significant that the two countries where these initiatives are in full swing, Uganda and Zambia, are also countries that show significant decline in HIV prevalence among those aged 15–19,
particularly among girls.

Most countries are rich in their experience of youth activities and initiatives. Many of these are worthy of more support than they
currently receive. Many others could also be initiated. What is needed is to challenge young people to play a greater role in the planning, design, implementation, monitoring and evaluation of
programmes that will enhance the ability of their peers to adopt sexual behaviour that will protect them from HIV infection. And having challenged them in this way, the action must be followed through
by facilitating their access to the necessary resources and, equally important, by giving them their head and allowing them to proceed in ways they think fit.

Jesuit Solidarity Fund, Uganda
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