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Challenges around HIV Prevention with and for Adolescents in Eastern & Southern Africa

Challenges around HIV Prevention with and for Adolescents in Eastern & Southern Africa. Consultation on Advancing UNAIDS Support to Empowering Young People to protect themselves from HIV infection New York – 26-27 October 2009 Presented by Rick Olson UNICEF Regional HIV Prevention Specialist

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Challenges around HIV Prevention with and for Adolescents in Eastern & Southern Africa

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  1. Challenges around HIV Prevention with and for Adolescents in Eastern & Southern Africa Consultation on Advancing UNAIDS Support to Empowering Young People to protect themselves from HIV infection New York – 26-27 October 2009 Presented by Rick Olson UNICEF Regional HIV Prevention Specialist Eastern & Southern Africa Regional Office

  2. Estimates of New Infections in Eastern and Southern Africa, 2007 (Source UNAIDS RST) ESA new infections, 1.5 million Global new infections, 2.7 million Rest of the world 1.2 million (43%) Eastern & Southern Africa 1.5 million (57%) • Total priority countries: • 8 countries had 90% of new infections in 2007 of the ESA total

  3. How the epidemic looks from Nairobi … (Kenya 2008 HIV Prevalence by Province) What does the national average 7.1% actually mean? Who’s reality does it translate? Great variation by geography ranging from 1% to 15% across provinces Kenya 7.1%

  4. HIV Incidence by Modes of Transmission

  5. Traditional View of HIV Prevalence among Young People - 15-24 Zambia MOT – YP 15-24 – 12.6% (2006)

  6. Analysis of Disaggregated HIV Prevalence Rates in Young People 15-24(Recent DHS data) Data suggests getting ahead of the Virus among the 15-17 age group

  7. HIV Prevalence among Females (15-24) Comparing those In Union and Never in Union (Source: recent DHS Data) Which adolescent girls? Those “in-union” or in schools?

  8. HIV Prevalence among Males (15-24) Comparing those in Union and Never in Union (Source: recent DHS Data 199-2006) Note: the frequency of males 15-24 (especially 15-19) is very low. In union would mean more frequent Intercourse and transmission is probably from In-union female partner.

  9. HIV Prevalence rates among Females 20 to 24 Based on Wealth and Education Levels(source: UNICEF ESARO DHS cross-tabs) Challenge –old paradigm of risk and vulnerability and apply a differentiated response - For example - need to recognize that many young females have agency within sexual relationships, especially those based on transactions for “desired needs”.

  10. South Africa – 2005 Household Survey DataAge Disparate Sex and HIV PrevalenceFemales 15-29(with 18.5% of girls 15-19 & 34% of women 25-29 have partners over 5 years) Difference in prevalence from the differential seems to wears out over times

  11. Analysis of age difference and HIV status in couples in Swaziland (2007) SWAZILAND HIV Prevention Response and Modes of Transmission Analysis

  12. HIV prevalence among couples living in the same household by age gap, in Zambia (2007) Source DHS – Presented in Zambia HIV Prevention Response and Modes of Transmission Analysis

  13. Trends in Comprehensive Knowledge Females aged 15-19(Knowing 5 things about HIV) Information (Source: Demographic Health Surveys 1999-2005)

  14. Tanzania Females & Males 15-19Comprehensive Knowledge & Accepting Attitudes

  15. HIV Prevalence Female & Male Age Bands – Tanzania(AIS Data 03/04 & 07/08)

  16. Risk Reduction Skills Trends of condom use at last higher risk sex Females aged 15-19 Skills (Source: Demographic Health Surveys 1999-2006)

  17. Some Condom Supply Trends

  18. Condom Negotiation?

  19. Widespread assumption that sex is something natural and automatic, especially for men, and that safer sex is easy or obvious. Condom promotion needs to move from an negative fear based AIDS/disease discourse to one of pleasure, sexual skill and eroticism Adapt experiences around eroticizing safer sex Need new and more creative modes for delivering pleasure/desire norms and communication modes (romance novels, soaps, etc) Pleasure, safer sex and sexual skill “ … just telling people to use condoms is like telling someone to use a saddle to ride a horse – there’s a lot more to both safe sex and horse riding!” – personal testimony of a sex worker in Mongolia, told to The Pleasure Project by Cheryl Overs, Making Sex Work Safe trainer/educator

  20. Percentage of Adults Supportive of Condom Education for Children 12-14 Source: Recent DHS

  21. Access & Young People and HTC Malawi National HIV Testing week – 2006 Over 100,000 test – 41% young people 15-24 Services

  22. VCT Scale Up - Zambia • VCT – evidence – effective for secondary & primary prevention for those who test positive Primary prevention • depends on effective prevention risk counseling (process and exposure) How sensitive to adolescent females are these services?

  23. Male Circumcision – an Interagency Response

  24. Multiple partner trends among females aged 15-19 years from 1999-2005 EPE (Source: Demographic Health Surveys 1999-2005)

  25. Multiple Partner Trends - Males 15-24

  26. MCP behaviour- prevalence linked to interviewing technique: Swaziland & Zambia Percent reporting 1, 2, 3 partners in the last 3 months – 2006 (Ngudzeni ADP) • 2006-07 Swaziland DHS (nationally) • Females reporting more than one partner in the last 12 months: 2.3% Sources: James, V. and R. Matikanya (2006). Protective Factors: A Case Study for Ngudzeni ADP (Swaziland), World Vision Australia/Swaziland.; Central Statistical Office [Swaziland] and ORC Macro (Unpublished). Swaziland Demographic and Health Survey, 2006-2007. Calverton, Maryland, Central Statistical Office and ORC Macro. Zambia Priorities for Local AIDS Control Efforts (PLACE) survey Compared ZSBS (2005) data with Place data collected in Mongu & Kapiri Mpushi - the ZSBS Household survey data found no females 15-24 reporting 2 or more sexual partners in the past 4 weeks, while PLACE method found 12% of females in both sites reported 2 or more partners over the past 4 weeks

  27. GBV - Analysis & Action Sexual violence is defined as “any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a person’s sexuality using coercion, by any person regardless of their relationship to the victim,

  28. Recognize Female Agency - Contextual Issues - Sex & Exchange - Illustrative quotes from ‘Women’s bodies are shops’- beliefs about transactional sex and implications for understanding gender power and HIV prevention” Mexico AIDS Conference presentation Others say those are ‘shops’. [female private parts]…you go to sleep with a man, he must give you money…you can even bargain in advance… so isn’t that a shop? Us women are so developed/empowered…I mean he gives you money and then he leaves you with your thing & yet you both get the pleasure…to me, I see them as cheated. I think, men just get a loss. [FGD, out of school young women]. 30 Source: Tanzania Study - J. Wamoyi1,2, A. Fenwick, M. Urassa, W. Stones; University of Southampton, UK

  29. Who is infecting young women & working on their Positive Behaviours

  30. Trends among 15-24 year old people in high prevalence countries: Selected sexual behaviours among women and men (1990 -2007) from national surveys & (2000-2007) prevalence data (UNAIDS) Legend ▲ Statistically significant increase▼ Statistically significant decrease ↔ No evidence of decrease # Semi-urban and urban areas were combined in analysis of urban data ## Analyses based on data in South Africa surveillance report ¶ Analyses based on data reported in Zambia 2005 surveillance report (urban and rural data combined) • ** Had sex by age 15 (15-19 year olds) • *** Had sex with a non-regular partner in the last year • (15 -19 year olds) • **** Used condoms the last time they had sex with • a non-regular partner (15-24 year olds) • Statistically significant increase

  31. Summary of Interventions and settings for scaling – up prevention with young people • * KEY: need to follow good practice in terms • of content and process & exposure levels

  32. TA on Programming Redesignthe School as a Setting for Delivering a Comprehensive Response to HIV Promote with: MOE/NAC NGOS FBOS Dev. Partners Prevention Programme Workplace Programme School Care & Support (OVC/ART) VCT/SRH Services Community – Enabling & Protective

  33. Prioritization Challenge • 23% of all new infections in Malawi among females 15-25 (MOH 2005 EPI Estimates) • 33% of all new infections in Namibia among females 15-24 (UNAIDS NAM 2007) – 4456 per year – 360 per month – 12 per day…. Can we “find them”? • Do they have the capacity to reduce or avoid risk behaviours and can we deliver that – capacity to affect proximate as well as distal determinants

  34. Consensus around Behavioural Outcomes- Delay sexual debut Reducing age disparate sexual partnerships Reduce numbers of sexual partners – particularly concurrent partners Increase consistent condom use Increase coverage and utilization of testing & counselling services Increasing knowledge of HIV sero status Increasing male circumcision Critical to focus on content, quality intensity of preventions inputs

  35. Strengthening Results Based ProgrammingPromoting “evidence based inputs to generate outputs and behavioural outcome results ”– recognizing the importance of content and quality of intervention Intervention principle: the more inputs (mix of activities & channels) with consistent messages, supported by consistent and complementary skills developed - in a variety of settings for the focus population(s) [ages and sex] – the higher the probability of relevant output and outcome results Reduced HIV, STI & Pregnancy Impact Increased consistent use of condoms Outcome behaviour Increased self- efficacy to insist on condom use Output Results Increased self-efficacy in using condoms Increased self- efficacy to obtain condoms Practice insisting on condom use in role plays Specify steps to using condoms consistently & Correctly (3 C’s) Practice putting condoms on wooden penis Identify “safe” places to obtain condoms Input Content

  36. Regional HIV Prevention Programming Priorities • Promote a priority focus of prevention activities to increase risk perceptions among young females 15-19 (& their partners) around key behaviours & relationships • Expand efforts to increase comprehensive HIV risk avoidance and risk reduction knowledge and skills among females 15-19 (& their partners) • Address social norms which increase young womens’ risk of infection or limit their ability to act (communities & men) • Focus on intensifying comprehensive prevention efforts in high prevalence “hot spots” in countries • Build prevention activities into the treatment scale up – eg. quality adolescent sensitive prevention risk counselling & within VCT and PMTCT services – linked to adolescent senstive referral system

  37. Revised UN Response – Increasing coverage and utilization – while addressing risks and vulnerabilities in select settings … Possible country level example for comprehensive response to HIV prevention programming with and for adolescents Services Skills Enabling & Protective Environment Monitoring & Evaluation UNICEF UNFPA UNAIDS Information Adolescent UNESCO WHO

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