SEATTLE – They are curious, impulsive and renownedly reckless. Studies have indicated they remain blissfully unaware of their risks, and unequipped to face them. Now, their numbers are growing fastest in countries that are home to great risks — where rates of HIV infection are among the world’s highest and where current approaches to testing and treatment already fall short of need. Soon, the coming generation of teenagers will be, Dr. Shannon Hader pointed out here on Wednesday, “the largest group of young people ever to walk the face of the planet.”
The prospect of that coming “youth bulge,” an explosion of teenagers, particularly in southern Africa, across the landscapes of countries that are struggling now to control the spread and impacts of HIV, is daunting, Dr. Hader, who is director of the Division of Global HIV and TB at the U.S. Centers for Disease Control and Prevention, noted in an opening talk here. But it is one that offers a choice, she added, between viewing its potential outcomes as “dividend or disaster.”
The disaster outlook is, perhaps, easier to envision. Dr. Hader cited findings collected through the ZIMPHIA door-to-door surveys and testing coordinated by ICAP at Columbia University, in Zambia, Malawi, and Zimbabwe, showing that people who know they have HIV do well — getting treatment and staying on it — but that the people least likely to know they have HIV are young people — boys and girls — and men. Dr. Hader cited findings from the Centre for the AIDS Programme of Research in South Africa showing a vicious circle of teenage girls and young women getting HIV from relationships with slightly older men — the girls and the men remaining unaware of their own infection — and the young women eventually having relationships with, and transmitting the infection to men of their own age. And Dr. Hader cited findings from the Ring and ASPIRE trials which could not determine whether month-long topical HIV protection through vaginal rings were effective for teenage girls and young women because they didn’t use the devices, and indicated that they did not believe they needed to be protected from the virus. Adding to those vulnerabilities, Dr. Hader said, are fast-growing trends of urbanization across southern African countries exposing young people to situations that can include isolation from support systems, unemployment, transactional sex, and sexual violence,with challenging access to health services.
In spite of all of this, not everyone sees disaster in an expanding population of young people, Dr. Hader said. She gave the example of the South Africa based cell phone service provider MTN, which saw dividends in tailoring both its marketing and products to adolescents, using what they know about them. Teenagers are complex and diverse, Dr. Hader acknowledged, but fast-developing technology has given them much in common, too, including, she said, expectations of “instant communication and transparency,” as well as opportunities for web-based learning. At the same time, Dr. Hader said, studies to determine the most efficient and effective populations among whom to scale up access to medical circumcision have found that boys 10-14 are the easiest age group to reach. She also pointed to the U.S. President’s Emergency Plan for AIDS Relief-led “DREAMS” initiative, that aims to reach teenage girls and young women with interventions that include pre-exposure prophylactic use of antiretroviral drugs — or PrEP.
In the possibilities that targeted and evidence-based interventions offer a growing generation that is easier to reach than ever before, Dr. Hader said, she sees dividends, “If,” she added with emphasis, “we act fast and use data.”
A CROI themed discussion the next day highlighted some of the ways that could be done, with findings from:
- the HPTN 071 PopART for Youth study in Zambia showing that a home-based approach to HIV testing and prevention services raised the rates of young people who knew their HIV status from just a little more than a quarter of them to 90 percent;
- GHESKIO in Haiti showing that adolescents who had recently been diagnosed with HIV and assigned to a community peer-group got into care quicker, and stayed in care at higher rates;
- and from the SEARCH trial in rural Kenya showing that social connections among young women with HIV increased the chances that they would get into and remain in care.
At the same time the discussion also highlighted a danger, with an analysis of data from Kenya, Uganda, and Tanzania indicating pregnant teenagers were less likely to remain in care for HIV. While the data may reflect the transfer of some young women to antenatal care-supported HIV services, it also highlights another consideration in reaching a growing population of teenagers — the need for integrated HIV, sexual health, and reproductive health services, audience members, as well as the presenter of the findings, Harriet Nuwagaba-Biribonwoha of ICAP noted.