Mitigating Risk

Gaps in Research

1.: Effective programs (as described here) must be expanded to reach many more young people, especially young people who are most neglected such as very young adolescents, out-of-school youth, young people living with HIV, homeless and rural youth, as well as lesbian, MSM and transgender adolescents and other key populations.
2.: Greater efforts are needed to help young people personalize HIV risks
3.: Sex education and condom promotion programs need to take into account the different motivations among young men and women for engaging in unsafe sex.
4.: Clear policies and legislation supporting access to information and sexuality education are needed to reduce the risk of HIV transmission among young people.
5.: Interventions are needed to counter gender norms, such as those which value girls’ sexual ignorance and virginity, which place girls at risk for HIV transmission.
6.: Interventions are needed to reduce cross-generational sex and marriage.
7.: Further interventions are needed to help female OVCs reduce risky sexual behaviors and protect them from sexual violence.
8.: Interventions are needed for adolescents to reduce acceptance of gender-based violence and stigma against people living with HIV.
9.: Interventions are needed to bring men and women, youth and parents together to focus on the positive aspects of sexuality.
10.: Teachers need increased training and clear educational policies regarding sexuality education to effectively provide HIV education.
11.: Skills training is needed to improve confidence in negotiating condom use for girls and confidence in condom application for boys.
12.: While mobile phones have been shown to be effective in increasing adherence for adults on antiretroviral therapy, more implementation science research is needed on how to effectively employ mobile phones and websites for adolescent HIV prevention, treatment and care and whether adolescents have adequate access via mobile phones.
13.: Non-discriminatory education sector policies on HIV are needed, with regular reviews, updates and implementation.
14.: Programs are needed to change family gender norms to give brothers and sisters equal access to household resources and pocket money, to reduce the need for transactional sex.
15.: Interventions, policies and budgets are needed to reduce sexual coercion and rape of both boys and girls, create awareness in communities that violence against children is unacceptable, strengthen child statutory protection systems, and conceptualize and implement appropriate child protection services in developing countries. Access to post-exposure prophylaxis in case of rape when the perpetrator is HIV-positive is also needed.

1. Effective programs (as described here) must be expanded to reach many more young people, especially young people who are most neglected such as very young adolescents, out-of-school youth, young people living with HIV, homeless and rural youth, as well as lesbian, MSM and transgender adolescents and other key populations. [See also Orphans and Vulnerable Children] Studies found adolescent girls did not know that anal sex increased the risk of HIV acquisition, did not use condoms, and did not know that oral sex carries a low risk of HIV acquisition. Out-of school-youth were at high risk of early sexual debut. A scan of sex education curricula found that information on key aspects of sex such as information on condoms in addition to negative, fear-based curriculum were prevalent and that less than half of out of school youth were reached. In some countries, pornography was the principal source of information about sex and pornography often depicts condom-free sex and gender inequality, with men in domineering roles (Day, 2014).

Gap noted, for example, globally (Plan, 2015), in Kenya, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe (Pitorak et al., 2013); Eastern and Southern Africa (UNESCO, 2013; Stroeken et al., 2012); Nigeria (Aboki et al., 2014); Burundi (Athena et al., 2015); Sierra Leone (Day, 2014); Kenya (Rositch et al., 2012); Uganda (Hampada et al., 2014); Kenya (Harper et al., 2014); Botswana (Majelantle et al., 2014); Bahamas (Pinder-Butler et al., 2013); Lao PDR (Sychareun et al. 2011); Pakistan (Nasir, 2014; Farid-ul-Hasnain and Krantz, 2011); Cameroon (Tarkang, 2015; Tsala Dimbuene and Kuate Defo, 2011); Jamaica (Ishida et al., 2011); Yemen (Al-Serouri et al., 2010); Zambia (Carnevale et al., 2011); Nepal (Upreti et al., 2009); Nicaragua (Manji et al., 2007); Ethiopia (Sisay et al., 2014; Alemu et al., 2007; Erulkar et al., 2006); over 30 countries in Africa and four countries in Asia (Dixon-Mueller, 2009).

2. Greater efforts are needed to help young people personalize HIV risks . Studies found that knowledge about HIV prevention was superficial and that young people believed that they were not personally at risk of HIV acquisition despite risky behaviors and that condoms were not used because of “trust in partners.” Another study found that one adolescent girl reported she did not need to test for HIV as the only people at risk for acquiring HIV were those “who go to beer halls and pubs – prostitutes” (Ferrand et al., 2011). Married adolescent girls who had not become pregnant were significantly less likely to have had HIV testing and counseling (HTC) yet reported high rates of coerced sex within marriage, associated with acquiring HIV. Adolescents in one study suggested visiting hospices or people who were sick with HIV to understand more about HIV.

Gap noted, for example, in Thailand (Watthayu et al., 2014); Tanzania (Tolley et al., 2014; Lyimo et al., 2013); Kenya (Undie et al., 2012); Ethiopia (Cherie et al., 2012); Ghana (Amo-Adjei, 2012); Zimbabwe (Ferrand et al., 2011); Uganda (Mathur et al., 2015; Kayiki and Forste, 2011);Taiwan (Tung et al., 2010); Malaysia (Anwar et al., 2010); South Africa (Tenkorang et al., 2011; Anderson et al., 2007, Stadler et al., 2007); and Burkina Faso, Ghana, Malawi and Uganda (Biddlecom et al., 2007).

3. Sex education and condom promotion programs need to take into account the different motivations among young men and women for engaging in unsafe sex. Studies found that boys complained about reduced sensation with condoms to cover their fear of losing their erection when putting on a condom; girls believed that unsafe sex proved their love and trust in their partner

Gap noted, for example, in Thailand (Vuttanont et al., 2006); Brazil (Mane et al., 2001, Juarez and Martin, 2006); South Africa (Moyo et al., 2008); Mozambique (Machel, 2001).

4. Clear policies and legislation supporting access to information and sexuality education are needed to reduce the risk of HIV transmission among young people. Studies found that sex education was lacking, particularly among street children who are at high risk of HIV acquisition.

Gap noted, for example, globally (Todesco and Gay, forthcoming 2016); in Iran (Hedayati-Moghaddam et al., 2015); Antigua and Barbados; Bahamas; Bolivia; Columbia: Costa Rica; Chile; Dominica; Ecuador; El Salvador; Guyana; Haiti; Honduras; Jamaica; Mexico; Nicaragua; Panama; Paraguay; Peru; Venezuela; Dominican Republic; Santa Lucia; Suriname; Trinidad y Tobago; and Uruguay (DeMaria et al., 2009); India (Menon, 2013; McManus and Dhar, 2008). Zimbabwe (Shroufi et al., 2013).

5. Interventions are needed to counter gender norms, such as those which value girls’ sexual ignorance and virginity, which place girls at risk for HIV transmission. [See also Transforming Gender Norms] Studies found that gender norms valued sexual ignorance of girls and therefore girls were at risk of HIV acquisition. Some studies found that women did not know anything about HIV until they became HIV-positive. Girls are taught to surrender power to meet cultural expectations of being a good girl or good woman. Boys derive status from having multiple sexual partners.

Gap noted, for example, in South Africa (Jewkes and Morrell, 2012; Selikow et al., 2009); Ghana (Sommer and Acatia-Armah, 2012); 29 countries in Africa and Latin America (Clark et al., 2006); a review of more than 150 studies (Collins and Rau, 2000; Gupta et al., 2003 cited in Gillespie and Kadiyala, 2005); South Africa (Bhana and Pattman, 2011); Zimbabwe (Feldman and Masophere, 2003); Ethiopia, Malawi, and Haiti (Mathur et al., 2003); and Tanzania (Silberschmidt and Rasch, 2001).

6. Interventions are needed to reduce cross-generational sex and marriage. Studies found that young women relied on older men to pay their school fees in exchange for sex. Numerous studies found significant numbers of young girls having sexual relationships with older men, who are more likely to be HIV-positive and seek sexual partnerships with younger women. Studies also found that due to poverty, parents encouraged transactional sex and that efforts are needed to address parental pressures.

Gap noted, for example, in a review of Nigeria (Aboki et al., 2014); Swaziland (All In to End Adolescent AIDS, 2015a); 45 quantitative and qualitative studies in Sub-Saharan Africa (Hope, 2007); Liberia (Atwood et al., 2011); Botswana, Namibia and Swaziland (Cockcroft et al., 2010); Botswana, Malawi and Mozambique (Underwood et al., 2001); Tanzania (UNICEF et al., 2011a; Silberschmidt and Rasch, 2001); Zimbabwe (Munjoma et al., 2010); Peru (Sandoval et al., 2009); Cameroon (Hattori and DeRose, 2008); Uganda (Chimoyi and Musenge, 2014; Nobelius et al., 2011; Samara, 2010); South Africa (Ott al., 2011; Jewkes et al., 2002 cited in Jejeebhoy and Bott, 2003); South Africa and Uganda (Geary et al., 2008; Katz and Low-Beer, 2008); Burkina Faso, Ghana, Malawi and Uganda (Bankole et al., 2007); Botswana (PHR, 2007a); Kenya (Longfield et al., 2004); Ghana (Goparaju et al., 2003); Zimbabwe (Gregson et al., 2002).

7. Further interventions are needed to help female OVCs reduce risky sexual behaviors and protect them from sexual violence. [See also Orphans and Vulnerable Children] Studies found that female orphans had higher rates of early sexual debut and were more likely to have had coerced sex.

Gap noted, for example, in Egypt (Nada and Suliman, 2010); Kenya (Machera, 2009);Rwanda (Boris et al., 2008); South Africa (McGrath et al., 2009; Thurman et al., 2007); South Africa and Swaziland (Poulsen, 2006); Tanzania (UNICEF et al., 2011a); Zimbabwe (Kang et al., 2008; Birdthistle et al., 2008; Nyamukapa et al., 2008; Dunbar et al., 2010).

8. Interventions are needed for adolescents to reduce acceptance of gender-based violence and stigma against people living with HIV. A study found high rates of stigma among adolescent girls. A nationally representative survey of youth in Tanzania found high rates of acceptance for a husband to beat his wife if she goes out without telling him; argues with him; burns food; or refuses to have sex with him. In 35% of countries with data available, more than 50% of women and men report discriminatory attitudes toward people living with HIV (UNAIDS, 2015e).

Gap noted, for example, in Brunei Darussalam; Indonesia; Malaysia; the Philippines and Timor-Leste (UNESCO, 2012c); Lao PDR (Thanavanh et al., 2013); India (Kumar et al., 2012 cited in Thanavanh et al., 2013);Cameroon (Arcand and Wouabe, 2010); Tanzania (UNICEF et al, 2011a); Thailand (Ishikawa et al., 2011a); Bolivia, Chile and Mexico (Lopez Torres et al., 2010).

9. Interventions are needed to bring men and women, youth and parents together to focus on the positive aspects of sexuality. Studies found sexual education focuses on disease, burdening girls with prohibitions, yet neglecting boys.

Gap noted, for example, in South Africa (Soon et al., 2013); India (Guilamo-Ramos et al., 2012); Kenya (Njoroge et al., 2010).

10. Teachers need increased training and clear educational policies regarding sexuality education to effectively provide HIV education. A study found that teachers did not have adequate training and support to provide HIV education; students preferred health personnel to provide AIDS education and that the Ministry of Education did not have clear policies on what can be taught.

Gap noted, for example, in Kenya (Njue et al., 2009).

11. Skills training is needed to improve confidence in negotiating condom use for girls and confidence in condom application for boys.

Gap noted, for example, in Uganda (Nobelius et al., 2012).

12. While mobile phones have been shown to be effective in increasing adherence for adults on antiretroviral therapy, more implementation science research is needed on how to effectively employ mobile phones and websites for adolescent HIV prevention, treatment and care and whether adolescents have adequate access via mobile phones.

Gap noted globally (Pettifor et al., 2013); in Uganda (Swahn et al., 2014; Wiens et al., 2012).

13. Non-discriminatory education sector policies on HIV are needed, with regular reviews, updates and implementation. Practices that require disclosure of HIV status for access to education should be prohibited and confidentiality policies are needed.

Gap noted globally (UNESCO and GNP+, 2012).

14. Programs are needed to change family gender norms to give brothers and sisters equal access to household resources and pocket money, to reduce the need for transactional sex.

Gap noted, for example, in South Africa (Jewkes et al., 2012).

15. Interventions, policies and budgets are needed to reduce sexual coercion and rape of both boys and girls, create awareness in communities that violence against children is unacceptable, strengthen child statutory protection systems, and conceptualize and implement appropriate child protection services in developing countries. Access to post-exposure prophylaxis in case of rape when the perpetrator is HIV-positive is also needed. [See also Strengthening the Enabling Environment] In most countries of Eastern and Southern Africa, the age of consent for sex is 16. Despite these restrictions, more than 10% of girls have had sexual debut before age 15. A study found that in a sample of more than 1,000 males and more than 1,000 females, large numbers had experienced high rates of physical punishment, emotional abuse and touching of sexual organs when not wanted or sex due to force or coercion prior to age 18 and that incident HIV infections were more common in women who suffered emotional abuse, sexual abuse and physical punishment. Sexual abuse in men was associated with alcohol abuse and depression. Other studies found high rates of sexual coercion and high-risk behaviors among street children. “Few children disclose abuse, fewer still seek services and report to authorities, virtually no children actually receive services and perpetrators rarely suffer consequences” (Sommarin et al., 2014: S213). Most research does not provide adolescent-specific data on violence, instead listing results for ages 15 to 49. Reviews have not found evidence that preventive responses have had an impact on rates of sexual abuse. Effective programs in the US and Canada have not been assessed for adaptation in other countries.

Gap noted globally (Sommarin et al., 2014; Palmer, 2014) and for example, in Eastern and Southern Africa (UNESCO, 2013); Cambodia, Haiti, Kenya, Malawi, Swaziland, Tanzania and Zimbabwe (Sommer et al., 2015); Ghana (Bingenheimer and Reed, 2014); Egypt, South Africa, Nigeria, Mauritania, Zimbabwe, Swaziland (Meinck et al., 2015); Nigeria (Folayan et al., 2014a); Ethiopia (Mekuria et al., 2015); Tanzania (Mmbaga et al., 2012); Botswana, Lesotho, Malawi, Mozambique, Namibia, Swaziland, Zambia, Zimbabwe, Tanzania, South Africa (Andersson et al., 2012); South Africa (Jewkes et al., 2010b); Egypt (Nada and Suliman, 2010); India (Bal et al., 2010); Namibia, Swaziland, Uganda, Zambia and Zimbabwe (Brown et al., 2009).