HIV and prevention challenges among adolescent girls and

HIV and prevention challenges among adolescent girls and young women Presented at the PACT Preconference meeting, 21/07/18, IAS 2018, Amsterdam Dr. Chewe Luo MD, PhD, FRCP Associate Director, Programmes, Chief HIV Section, UNICEF Headquarters, New York UNICEF/UN070230/Chisiza Presentation outline Results to date and state of the epidemic Where are we headed? Global commitments Understanding determinants of infection What do we need to do? Conclusion HIV investments have resulted in fewer deaths and new child infections among children PMTCT Coverage and number of new HIV infections among children aged 0-14, 2000-2017 New HIV infections 90% 400,000 79%80% 77%78% 80% 60% 300,000 50%

250,000 39% 200,000 150,000 25% 100,000 17% 50,000 3% 1% 1% 1% 1% - 4% 6% 300,000 60% 250,000 52% 49% 50% 45% 70% 41% 200,000 60%

50% 40% 30% 20% ART Coverage 71% 67% AIDS-related deaths 36% 31% 150,000 27% Data source: Global AIDS Monitoring 2018 and UNAIDS 2018 estimates 30% 22% 100,000 17% 13% 10% 50,000 7% 10% 0% 40%

1% 1% 2% 2% - 20% Number of AIDS-related deaths 450,000 350,000 PMTCT Coverage ART Coverage Number of new HIV infections PMTCT Coverage Paediatric ART coverage and number of AIDS-related deaths among children aged 0-14, 2000-2017 10% 3% 4% 0% HIV and prevention challenges among adolescent girls and young women UNICEF | for every child We have more to do to achieve epidemic control Although there are less new infections in younger children, for adolescents the decline has flatlined Number of new HIV infections by age group, 20002017 Age 0-4 Age 15-19 450,0002000; 421,440 400,000

350,000 2008; 317,442 300,000 250,000 200,000 150,000 100,000 50,000 2000 2001 2002 2003 Data source: UNAIDS 2018 estimates 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

2014 2015 2016 2017 HIV and prevention challenges among adolescent girls and young women UNICEF | for every child We have to address multiple vulnerabilities in adolescent girls and young women to radically change the trajectory towards the 75% reduction, down to <100,000 new infections Estimated number of new HIV infections among adolescent girls and young women (15-24 years); 2010-2017 trends with 2017-2020 projections and targets Shaded Infections: status-quo scenario 500000 Infections averted: Super-Fast Track scenario Infections: Super-Fast Track scenario 400000 300000 200000 100000 0 2010 2011 2012

2013 2014 2015 Data source: UNICEF analysis of UNAIDS 2018 estimates 2016 2017 2018 2019 2020 HIV and prevention challenges among adolescent girls and young women UNICEF | for every child There were 340,000 new infections among adolescent girls and young women, in 2017 Infections among AGYW is almost a quarter (21%) of all adult new infections 82% of these infections occurred in sub-Saharan Africa Proportion > a quarter in sub-Saharan Africa (28%) Outside sub-Saharan Africa, AGYW represent 10% of new infections Key populations and their partners represent about 40%of new infections outside sub-Saharan Africa HIV and prevention challenges among adolescent girls and young women UNICEF | for every child In three regions, adolescent girls experience more new infections than adolescent boys Percent distribution of new HIV infections among adolescent girls and boys, by region, 2017 Girls 15-19

Boys 15-19 Eastern and Southern Africa West and Central Africa Eastern Europe and Central Asia Middle East and North Africa Latin America and the Caribbean South Asia Western Europe East Asia and the Pacific 0% Data source: UNAIDS 2018 estimates 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% HIV and prevention challenges among adolescent girls and young women UNICEF | for every child HIV and prevention challenges among adolescent girls and young women UNICEF | for every child

In many countries adolescent girls are at higher risk than boys for HIV infection Proportion of new adolescent HIV infections occurring among adolescent girls, 2017 Data source: UNAIDS 2018 estimates About 2.4 million adolescent girls and young women are living with HIV in 2017; 2.0 million live in sub-Saharan Africa Distribution of adolescent girls and young women aged 15-24 living with HIV, by region, 2017 Eastern MiddleEurope East and LatinSouth America Western Europe; North America; and Central Asia; North Africa; and the 12,659 ; 0.54% 18,328 ; 0.78% Asia; 41,683 ; 3.58% East Asia

and 7,000 ; 0.30% Caribbean; 1.77% the Pacific; 3.85% 4.12% West and Central Africa; 22.81% Data source: UNAIDS 2018 estimates Distribution of adolescent girls and young women aged 15-24 living with HIV in sub-Saharan Africa, by country, 2017 25.64% South Africa; 24.74% Zimbabwe; 4.48% Eastern and Southern Africa; 62.25% Zambia; 4.62% Nigeria; 14.87% United Republic of Uganda; 5.82% Mozambique; Tanzania; Kenya; 6.10% 8.19% 5.53%

HIV and prevention challenges among adolescent girls and young women UNICEF | for every child Getting ahead of HIV with adolescent girls HIV Prevalence among adolescent girls and young women aged 15-24 by age, six countries, 2013-2017 15-17 35% 18-19 20-22 23-24 29% 30% 25% 20% 18% 17% 14% 15% 5% 0% 11% 10% 10%

6% 5% Lesotho 5% 3% 4% Malawi 2% 3% Data source: Demographic & Health Surveys (DHS) 2013-2017 8% 7% 5% Mozambique 10% 9% 8% 14% 5% Namibia 4% 6% 3% Zambia

Zimbabwe HIV and prevention challenges among adolescent girls and young women UNICEF | for every child Adolescents living with HIV receive inadequate access to antiretroviral therapy Percentage of adolescents aged 10-19 living with HIV who were on ART in 2017, by age and sex, 40 countries 100% 90% 80% 70% 60% 61% 50% 41% 37% 40% 31% 30% 20% 10% 0% Adolescents 10-14 Adolescents 15-19 Boys 15-19 Girls 15-19 2018 HIV Estimates UNICEF | for every child

Where are we headed ? 2016 HIV High Level Forum Commitments In 2016, the world committed to ambitious HIV: Prevention targets a) Children (start free) - <20,000 new infections in 2020 b) Adolescents &young women (stay free) - <100,000 in 2020 Treatment Targets Children and adolescents (AIDS Free) Provide life long HIV treatment to 95% of children and adolescents living with HIV How we perform in the remaining 29 months around adolescents and young women will drive our ability to achieve epidemic control by 2030. HIV and prevention challenges among adolescent girls and young women UNICEF | for every child HIV Prevention Coalition and 2020 Roadmap commitment 75% reduction in HIV infections to < 500 000 infections by 2020 at population level < 100, 000 in adolescent girls and young women Understanding determinants of infections Gender norms that promote sexual ignorance among girls Girls have lower correct knowledge about HIV risk 60% are sexually active by age 18 Older sexual partner and lower condom use Intimate partner violence (as high as 30%) Injection drug use (about 50% under 18) Multiple vulnerabilities of AGYW - early sexual debut, teenage pregnancy, school drop out Magnified in OVCs Associated later sexual risk taking

Biological risk factors Hardee et at 2014; Karim et al 2018 Cycle of HIV transmission, results from a phylogenetic study, KwaZulu-Natal, South Africa, 2016 urce: Centre for the AIDS Programme of Research in South Africa, 2016. UNICEF | for every child In sub-Saharan Africa, fewer girls and young women report condom use than boys and young men Percentage of adolescents and young people aged 15-24 who have multiple partners and reported using a condom, by region, 2010-2017 Adolescent girls and young women 60% 56% 49% 50% 40% Adolescent boys and young men 38% 35% 29% 30% 29% 20% 10% 0% Eastern and Southern Africa

Data source: DHS and MICS 2010-2017 West and Central Africa South Asia HIV and prevention challenges among adolescent girls and young women UNICEF | for every child Women and girls are having sex before age 20 Median age of first sexual intercourse among women aged 20-24, 38 countries, 2010-2017 20 Age 19 18 17 16 15 i l i r li ti nd tan bia ala pa pia bia we as r u na tho y a go nin ai r ia bia lic da s o nia s h w on on bia lic ir e a ola ea ne ad go ue r ia e r u nis am tem Ne thio ami bab dur Pe ha s o Ken To Be H ige am pub gan F a nz a lade ala er o ab lom pub 'Iv o M ng uin Leo Ch Con biq Libe Nig u G M G A e

N a n e e d G ra Z R B ha G ua m E N im o U in Ta ng L am Co c R ote g H k Z Ca G er oz i Af Ba an ur Si M at C c B i r in oc m m

Do De o ng Co Data source: Demographic & Health Surveys (DHS) 2010-2017 HIV and prevention challenges among adolescent girls and young women UNICEF | for every child Up to 23% of girls experience forced sex during adolescence Percentage of girls aged 15 to 19 years who ever experienced forced sex, 40 countries, 2005-2016 25% 20% 15% 10% 5% 0% a a n a e e ia ia a s ia o s la d s lic al a o

n wi ia ia iti e e oo and ine han ong and abo ala ber an Ha bw iqu c ip eon mb mib eny ura ger Tog ine go ha oro ub ep C a b i n u G C w G M Li nz n p N i d a g L a K m r b m N ep G Z N lip A o R on am U ial im z a d P rra hi Ta C nR he H Z

t C P r o e n a to M e a Si of ic ua in p. m q e m E o To .R D ao em S D er Data source: DHS and Multiple Indicator Cluster Surveys (MICS) 2005-2016 a a a e v a ia ar an an an ne an a d i

di al pi bi s t j t t t In em hio am Le ldo bo nm hs k is bai k ra z s t Et G o m y a ak aji er U gy r a o fM a M z r u T Az C m G Ky Ka Ti lic o ub ep R HIV and prevention challenges among adolescent girls and young women UNICEF | for every child What do we need to do? We have programming guidance to inform action Situation analysis Adolescent girls and young women in the context of the network of transmission Options menu Context-specific programming

considering local epidemic patterns & resource availability Core prevention programs OPTIONS MENU Menu options HIV prevention outcomes Impact Condoms School-based prevention (in context of comprehensive sexuality education) Interpersonal communication Pre-exposure prophylaxis HTS, ART, VMMC for men Policy, legal change Policy & structural action Dimension of change Community mobilization Multi- and new media Norms, know how, skills

Support choices of young women who have agency Enhanced leadership Safer sex negotiation (condom use) Reduced HIV incidence Biological factors Reduce susceptibility and transmissibility Cash transfers / incentives Gender norms & GBV prevention Sexual and reproductive health and rights Fewer partners/ more partnerbb choice (less risky partners) Structural factors

Enhance agency among young women Consistent use of ARVs for prevention (ART, PrEP, PEP) More men go for HIV/health services (HTS/ART & VMMC) Synergistic effects on education, GBV, gender norms, SRHR TheMobiliz Core Package Community Mobilization & Norms Change Additive Funding VMMC Additive Funding TX for Men Reduc e Risk

of Sex Part ners Characterization of male partners to target highly effective interventions (HTSART, VMMC) e Comm unities Empowe for r change Girls & Young Wome n SchoolBased Intervention s Streng then Fami lies and reduce risk Youth-friendly sexual and

reproductive health care (Condoms, HTC, PrEP, Contraceptive Mix, Postviolence care) Social Asset Building Social Protection (Cash Transfers, Education Subsidies, Combination Socio-Economic Approaches) Parenting/ caregiver Programs GF AGYW INTERVENTIONS- Summary of Investments (2018-2020) Introduction of new innovations: Status of PREP policies and implementation, in 2018 Countries reporting PrEP availability by type of availability Data source: Global AIDS Monitoring 2018 Note: Alternative sources include pilot studies, research, private providers, HIV and prevention challenges among adolescent girls and young women UNICEF | for every child Introduction of new innovations: Uptake of self testing among adolescents and young people Data source:Dr Peter MacPherson, IAS Vancouver, 2015 UNICEF | for every child Conclusions

Our understanding has improved Scale up responses must: Be based on the key drivers of the epidemic and what works Also leverage existing investments in other sectors Define coordination and management structures for accountability More data work needed for size estimation especially for adolescent and young key populations We need better assessments of who is being left behind for better impact and saturation of the various interventions Participation of adolescents in the design of our programmes is key Thank You Acknowledgements: Damilola Walker Chibwe Lwamba Aleya Khalifa UNICEF/SUDA2014-XX228/Noorani

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