Young people in danger

In the worst-affected countries, young people are especially at risk. In sub-Saharan Africa, as in many countries in the industrialized world and elsewhere, people embark on their sexual lives when they are in their teens-often in their early or mid-teens. In Kenya, for example, one study of nearly 10 000 schoolgirls between the ages of 12 and 24 reported that on average, girls lose their virginity when they are between 14 and 15 years old. And yet to date, there is no reproductive health education in schools that would prepare girls to avoid early sex or to adopt safer sexual practices.

The Population Reference Bureau estimates that every year babies are born to 14% of young women aged 15-19 in sub-Saharan Africa, compared with 6% of young women in other less developed countries and just 3% in the industrialized world. Many of these births are outside of marriage. A recent study in Namibia showed that close to 40% of births were to unmarried women. Single motherhood was not associated with ignorance or marginalization-over a third of single mothers were educated to secondary level or beyond, compared with just over a quarter of married mothers.

High levels of teen pregnancy, and pregnancy outside of marriage, do tell us two things: young people are very sexually active, and few of them use condoms. If young people are having unprotected sex with several partners, or if their single partner has ever had other partners, they are exposed not just to pregnancy but to infection with sexually transmitted diseases, including the one that can kill them: HIV.

Recent HIV surveillance data show how early this exposure can occur and how devastating its consequences can be. In Rwanda, over 4% of both boys and girls aged 12-14 in one community study already tested positive for HIV. In South Africa, the number of pregnant girls under 15 tested for HIV in 1997 was relatively small, but a distressing 9.5% of them were found to be infected with the virus. Among the far greater number of pregnant South Africans tested in their late teens, nearly 13% were HIV-positive.

Often, girls become infected at younger ages than boys. A recent community-based study in one area of Kenya showed that 22% of 15-19-year-old girls in the general population were already infected with HIV, compared with just 4% of boys of the same age. In a Zambian study of young city-dwellers in the same age group, HIV infection was reported in 12.3% of the girls and 4.5% of the boys. In the next-higher age bracket, 20-24 years, a study in Ethiopia found that 35.4% of young women were infected-three times higher than the 10.7% rate among the men.

This age gap at infection indicates that young girls are getting infected through sex with older men. Many girls may choose such relationships because they come with gifts, money or other favours attached. But some will simply have been powerless to resist. In Kenya, one young woman in four said she lost her virginity because she had been forced to. In the Democratic Republic of Congo, the proportion was close to a third. Unwilling sex with an infected partner carries a high risk of HIV infection for girls. When the vagina is dry or when force is used, abrasions and cuts are more likely and the virus can more easily find its way into the bloodstream. What’s more, condom use is unlikely in such situations.

(Source: Taha et al. AIDS 1998 12:197-203)

As infection rises in the general population, so does the likelihood of encountering an infected partner (especially an older partner) early in one’s sexual career. Over time, then, new infections become increasingly concentrated in the youngest age groups. In a recent study in Malawi, HIV prevalence had built up to high levels in older age groups, but the bulk of new infections were occurring in younger women.

People continue to be at risk for HIV throughout their sexually active lives, and all should benefit from services and information that allow them to reduce their risk of infection. However, efforts to promote safer behaviour are especially crucial for young people, who in mature epidemics are those at greatest risk. Prevention efforts also seem to have a greater chance of success among younger people than among people whose sexual habits are well ingrained. For example, following active condom promotion and education campaigns in school and among youth groups, dramatic declines have been recorded in infection rates among teenagers in Uganda and Tanzania.