Oagile Bethuel Key Dingake
Through the leadership of UNAIDS, the African Think-Tank on HIV, Health and Social Justice (the Think-Tank) was created in March 2015 to provide a platform for strategic thinking, leadership and collaboration to support, expand, and accelerate action and results on human rights and social justice in the context of HIV across the African continent. I believe it is imperative that the Think-Tank includes among its priorities the issue of adolescent girls and young women.
The Think-Tank has 20 members. It is a diverse regional group of 11 men and nine women, experts and advocates on HIV, human rights, and social justice, including justices, lawyers, medical doctors, members of civil society and key population networks, academics, faith-based organizations, and law and policy makers.
Adolescent girls and young women are at high risk
At the epicentre of the HIV epidemic in southern Africa, adolescent girls and young women aged 15–24 contribute a disproportionate ~30% of all new infections. This age–sex disparity in HIV infection continues to sustain unprecedentedly high incidence rates, and preventing HIV infection in this age group is a prerequisite for achieving an AIDS-free generation and attaining epidemic control.
In eastern and southern Africa, girls account for 80% of all new HIV infections among adolescents, and HIV/AIDS is the leading cause of death for girls aged 15–19. With 7,000 girls and young women aged 15–24 infected every week, the goal of an AIDS-free generation cannot be achieved without a dramatic new approach to this population. After years of neglect, a global convergence is emerging around the urgency of going beyond biomedical interventions to address the social and economic factors driving HIV risk for adolescent girls and young women. Whether this new attention can catalyze reductions in new HIV infections represents a fundamental challenge for controlling the AIDS epidemic and there is a dearth of evidence-based interventions to reduce their risk.
The exclusion of adolescents in biomedical research is a huge barrier. School and community-based education programmes are commonplace in many settings, yet few have been evaluated and none has demonstrated efficacy in preventing HIV infection. Promising data are emerging on prophylactic use of anti-retrovirals and conditional cash transfers for HIV prevention in these populations.
Understanding the complex factors that drive adolescent girls and young women to engage in sexual relationships with older men is challenging, but may be critical in terms of adequately addressing the prevention needs of these key populations. In many cases, young women have reported feeling flattered by the attention of older men, and many relationships are likely to be built on genuine romantic connections. In other instances, young women may be motivated primarily by the increased financial or social capital available through engaging in relationships with older men; indeed, many adolescent girls and young women report involvement in these “transactional relationships,” which have significant additional implications for HIV risk.
Beyond engagement in age-disparate relationships, other risk factors for HIV infection in young women include early sexual debut, few years of schooling, food insecurity, loss of a family member, and experience of gender-based violence. Many of these factors may mediate their effects on HIV acquisition via increasing the relative value of financial capital available through engagement in transactional relationships with older men. However, independent pathways of risk mediation are also likely to exist. Food insecurity, for example, may also make young women biologically more susceptible to HIV.
Recommendations for the Think-Tank
At a time when global funding for the AIDS crisis has leveled off, the recent surge in attention to preventing HIV in adolescent girls and young women is remarkable. The African Think-Tank is seeking to expand its partnership with ambitious targets. The expected success will require sustained commitments and new approaches if real impact is to be achieved.
A realistic roadmap is necessary to ensure a comprehensive, coordinated response and sustained financial commitments from international donors, national governments, implementing partners, and affected communities. To make these goals attainable and not simply aspirational, we should adopt a longer-term plan that builds on the following policy options:
• Target and involve adolescent girls and young women in the design, implementation, and monitoring of programs that should help build their capacity, including for younger adolescents ages 10–14, and mobilize investments to reach those girls and young women at highest risk of HIV.
• Develop strategies for country buy-in to build locally appropriate and sustainable programs. This means working with different levels of government (local, district, provincial, national) as well as trained female mentors and health-care workers, civil society organizations, women leaders, and faith- based organizations.
• Expand public-private partnerships to leverage investments in adolescent girls, young women, and to finance a wider range of programs to address their needs. This means seeking out new partners (private sector, UN agencies and other multilateral partners, and national governments), and leveraging other programs and sectors (including economic, financial services, agriculture, and communications).
There is an urgent need to meet the HIV prevention needs of adolescent girls and young women. Concerted efforts to expand the prevention options available to these young women in terms of the development of HIV-specific biomedical, structural and behavioral interventions are urgently needed for epidemic control. In the interim, a pragmatic approach of integrating existing HIV prevention efforts into broader sexual reproductive health services is a public health imperative.
The emergence of international partnerships focused on HIV in adolescent girls and young women represent an ambitious effort to go beyond biomedical interventions to address the social and economic factors that put this population at risk of infection. It remains to be seen, however, if these initiatives can demonstrate impact in a short timeframe, and build toward sustainable programs.
The African Think-Tank offers the following comparative advantages: a) ability to articulate, from an African reality point of view, the issues of human rights and social justice for adolescent girls and young women; b) a proven capacity in multiple sectors through its diverse membership; and c) a capacity to engage concurrently at multiple levels including global, regional, country and local levels on common issues and thereby realize synergies. The Think-Tank’s convening and advocacy roles, and unique set of partnerships at all levels, allows for collaborative, innovative and real-time solutions to the challenges, obstacles and constraints to advancing social justice.
O. B. K. Dingake is a judge of the High Court of Botswana and of the Residual Special Court for Sierra Leone. This blog is based on a speech he delivered in Maputo, Mozambique in June 2017 titled, “Leaving no one behind – Contextualising the role of leadership in expanding HIV and health services for adolescent girls and young women and testing for men”.
Please address correspondence to O. B. K. Dingake. Email: email@example.com