Greetings,
Welcome to Week 2 of the Youth Forum on Pregnancy Prevention in a Time of AIDS. First, thanks to Ward Cates of FHI for providing his helpful comments during Week 1.
Now, let me introduce our guest for Week 2, which will focus on "Especially Vulnerable Youth: Focus on Young Women and Girls." We are privileged to have with us Dr. Lynn Collins, MD, PhD, MPH, a Technical Adviser on HIV/AIDS at the United Nations Population Fund (UNFPA), focusing on women and AIDS, and linking HIV/AIDS with sexual and reproductive health. Dr. Collins is a family medicine physician who also holds a doctorate in sociology from Columbia University, USA and a masters degree in international health from the University of Michigan, USA. She has been working in health and development for the past 30 years, within the UN system and academia. She has a special interest in cross-cultural issues, the subject of her PhD thesis. Prior to joining UNFPA she was an attending physician at the Columbia University Presbyterian Medical Center where she completed her medical studies and clinical residency.
Dr. Collins begins our week with opening remarks below. Throughout the week, feel free to send questions or comments to her, as well as submit your own experiences, findings or lessons learned on the topic of the week. You may also comment on issues that arose the previous week. For those just joining the forum, remember that you can simply click "reply" to this e-mail and post your comment, or log into the forum with the username and password you received.
I look forward to this second week of discussions.
Best regards,
Ed Scholl
Forum Moderator
On behalf of YouthNet, The INFO Project, and the Implementing Best Practices in Reproductive Health Initiative/World Health Organization
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Thank you to YouthNet, the INFO Project, and WHO for inviting me to be the guest panelist this week for the online forum. I am delighted to participate and offer any insights that I can. I want to provide some background thoughts and information about the topic for this week: "Especially Vulnerable Youth: Focus on Young Women and Girls."
With heightened vulnerability due to poverty, gender inequality, and lack of prevention information and services, young women and girls are particularly vulnerable to unintended pregnancy and to HIV infection. The statistical picture is sobering:
- Almost 1.7 million young women became HIV infected in 2004 alone.
- Three out of four new HIV infections among young people aged 15 to 24 are young women — around 5,000 - 6,000 new infections each day. Almost two-thirds of all young people now living with HIV/AIDS are adolescent girls.
- Despite a shift toward later marriage in many parts of the world, 82 million girls in developing countries who are now aged 10 to 17 will be married before their 18th birthday.
- Worldwide, some 14 million adolescent girls between ages 15 and 19 — both married and unmarried — give birth each year.
- Pregnancy is a leading cause of death for adolescent girls aged 15 to 19 worldwide, with complications of childbirth and unsafe abortion being the major factors.
- For both physiological and social reasons, girls aged 15 to 19 are twice as likely to die in childbirth as those in their twenties. Girls under age 15 are five times as likely to die as those young women in their twenties.
Apart from their biological susceptibility, young women and girls face a host of obstacles to the enjoyment of sexual and reproductive health such as:
- lack of knowledge about sexual and reproductive health and the means to prevent unintended pregnancy and sexually transmitted infections including HIV
- social constructions of femininity that compromise the ability of young women and girls to address sexual issues or to negotiate safer sex
- inadequate access to sexual and reproductive health information and services, especially youth-friendly ones
- limited economic opportunities, that can result in sex for survival
- sexual coercion, often including sexual debut
- gender-based violence and trafficking
- generally lower status in society, including lower levels of education
- inability to negotiate terms of sexual relations due to lack of empowerment
- expectations of motherhood, often immediately after marriage at an early age
- forced child marriage
Safer sex prevents against unintended pregnancy and sexually transmitted infections including HIV. The United Nations General Assembly Special Session (UNGASS) on HIV/AIDS, in its Declaration of Commitment, called for "reducing risk-taking behaviour and encouraging responsible sexual behaviour, including abstinence and fidelity; expanded access to essential commodities, including male and female condoms…" (Para 52). While clearly there is much to be accomplished through safer sex, we must recognize that for many young women and adolescent girls, safer sex is difficult to practice, since it is predicated on the ability to exercise rights, a condition not realized by many adolescent girls and young women.
Recommending abstinence, including delaying age at sexual debut, does not offer protection when one is coerced into sexual activity. The first sexual experience for many adolescent girls, sadly, is often forced. In several countries with a high rate of HIV infection, adolescent girls are married off in their teens to prevent sexual promiscuity and out-of-marriage pregnancy. But clearly, marriage does not confer protection on adolescent girls or young women. Recent studies in Africa indicate that young married women are at higher risk of HIV infection than their unmarried peers. Husbands of married girls tend to be older and more sexually experienced, and therefore more likely to be infected than unmarried or younger male counterparts. Even when they know about the infidelity of their older husband, young wives are often unable to refuse sex or insist upon condom use because to do so, would indicate a lack of trust, and undermine childbearing
Some valuable sources regarding early marriage are on the Web sites of the Population Council and the International Center for Research on Women, including the following:
Condoms, both female and male are effective in preventing sexually transmitted infections, including HIV, and in preventing pregnancy. However, sexually active young women often find it nearly impossible to insist that their partners consistently use condoms, and female condoms are not yet widely available. (For more background on condoms and HIV prevention, see the UNFPA/WHO/UNAIDS position statement in the forum community library or here (PDF, 274K).
Conceiving children at young ages poses risks for young women, but now there is the additional risk of HIV infection. Trying to prevent HIV transmission while conceiving obviously poses particular problems. Some microbicides are under development that would enable protection from HIV transmission without interfering with conception, but these products are under research and not expected to be on the market for quite some time. Sperm washing is technologically feasible, but has limitations. HIV voluntary counseling and testing can help partners become aware of their status, but can also provide a false sense of security, since staying HIV negative is not guaranteed. Young women often fear disclosing their status to their partners for fear of recriminations. The postpartum period is also one of considerable risk for young women, since partners may have sought other non-pregnant partners and acquired HIV during their partner's pregnancy, since some cultures expect women to cease sexual relations during pregnancy. For young women who are living with HIV childbearing is a right, but there are disturbing reports of forced abortion or sterilization. More must be done to ensure that women living with HIV are aware that with appropriate treatment, care and support, there is less than a two percent rate of transmission to their children, and that healthy labor and delivery, and postpartum care can be achieved.
Many young women and adolescent girls face multiple intersections of vulnerability beyond their age and female status, including sex work, injecting drug use, and being trafficked. These young women and girls can exercise few human rights and are often least able to access sexual and reproductive health services. They face multiple barriers to service access including social stigma and discrimination, judgmental health provider attitudes, prohibitive legislation, and inappropriate infrastructure location and hours.
Action to prevent HIV infection among young people must not place undue burden on just girls and young women. Here are some other key issues to keep in mind:
- Male responsibility for their own behaviour and caring about their partners' health and well-being is essential.
- Legislation that prohibits young people without parental consent from accessing sexual and reproductive health services, including HIV voluntary testing and counseling and condoms, needs to be challenged.
- We all need to rethink how we can better link sexual and reproductive health information, counseling, and services with HIV prevention, treatment, care, and support.
There are many proposals for addressing pregnancy in the era of the AIDS epidemic, some of which entail broad structural changes to end gender inequality and poverty. We all need to be mainstreaming gender concerns into HIV prevention programming, protecting and promoting women's reproductive rights, increasing access to information about sexual health for young people, eliminating gender-based violence, eliminating stigma and discrimination, incorporating HIV prevention strategies into sexual and reproductive health services, including condom use, advocating for national policy and legal changes, and increasing access to care, treatment, and support for HIV young women and girls who are living with HIV.
We would love you to share your experiences with:
- how young women and adolescent girls are facing the sexual and reproductive health challenges in the era of AIDS
- how young men and boys figure in
- how best to tackle the major structural issues of gender inequality, poverty, stigma, and discrimination
- how to empower young women and adolescent girls, and
- how to reach out to those young women and adolescent girls who are most vulnerable.
I look forward to seeing your postings in the next few days and to providing any additional insights that I can.
Sincerely,
Lynn Collins
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