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On Thursday, January 26, the Bill and Melinda Gates Foundation announced a $750 million commitment to the Global Fund to Fight AIDS, Tuberculosis and Malaria. As funding for HIV programming around the world declines, this news could not be timelier.
At the end of 2010, an estimated 34 million people were living with HIV, 5 million of whom are between the ages of 15 and 24. While the number of new HIV cases continues to rise, funding for HIV/AIDS programming is on the decline. According to the Boston Globe, the governments ofItaly andSpain will not meet their HIV/AIDS funding pledges this year due to the European financial crisis. The U.S government’s funding to the President’s Emergency Plan for AIDS Relief will be cut by 2 percent in 2012. In November, before this new $750 million commitment from the Gates Foundation, the Global Fund to Fight AIDS, Tuberculosis and Malaria had announced that it would not issue any new grants until 2014.
Bill Gates said, “These are tough economic times, but that is no excuse for cutting aid to the world’s poorest. The Global Fund is one of the most effective ways we invest our money every year.” This donation will raise the Gates Foundation’s total investment in the fund to $1.4 billion.
This blog is the first of a series of entries about FHI 360’s work with adolescent girls and microbicides.
Almost one-quarter of all people living with HIV are less than 25 years old, and youth (ages 15-24) account for 41% of all new HIV infections. Adolescent girls are particularly vulnerable; females comprise more than 60% of all young people living with HIV. In sub-SaharanAfrica, girls are three to five times more likely to be infected with HIV than boys of the same age. Factors such as lack of education, involvement in cross-generational or transactional sexual relationships, pressure to contribute to a family income, and early marriage all contribute to girls’ risk of becoming infected.
New female-initiated HIV prevention methods, including oral and topical microbicides, are urgently needed to address young women’s vulnerability. Unfortunately, adolescent girls are often excluded from studies that explore the effectiveness of these types of methods. There are numerous challenges to recruiting and retaining young women in HIV prevention trials. For example, adolescents might be too young to legally consent to trial participation, and their participation is often opposed by their communities.
However, there are many important scientific, programmatic and ethical reasons to include adolescents in studies on female-initiated HIV prevention methods. Without research on the effectiveness and acceptability of microbicides among adolescents, regulatory bodies are unlikely to allow microbicides to be marketed to adolescents. The failure to include younger adolescents in most microbicide trials also is resulting in missed opportunities for HIV prevention programming. And, given the high HIV incidence rates among female adolescents and the challenges they face in using other risk-reduction methods, including young women in clinical microbicide trials is also a matter of social justice.
To address these issues, FHI 360 is currently conducting a ground-breaking study, “Adolescents Women and Microbicide Trials: Assessing the Opportunities and Challenges of Participation,” in Tanzania and India among young women ages 15-21. This multiphase study is (1) exploring the differences in HIV risk among girls ages 15-17 versus those ages 18-21; (2) evaluating the factors that lead to the exclusion of adolescent girls from HIV prevention trials; and (3) aiming to determine the acceptability of microbicide use among this population. When the study is done, researchers will recommend whether or how trials on microbicides and other HIV prevention methods should be adapted to include adolescent participants. This study is one step toward increasing adolescent girls’ autonomy and decreasing their risk of HIV.
Ariana Childs Graham is the coordinator of The Coalition for Adolescent Girls, a partnership of nearly 40 international organizations that seeks to influence standards of practice across diverse sectors of programming in development and humanitarian contexts in order to ensure that the needs of adolescent girls are met.
ACG: I was a bit of a dreamer with a strong sense of social justice. My mom helped me temper my tendency toward indignation and self-righteousness and learn how to channel that outrage into taking action. But sometimes that cost me. In junior high, for instance, I started a recycling campaign at my school. Since my peers were slow to catch on, I spent my free time hauling Styrofoam trays out of the trash. Needless to say, my social standing took a bit of a nosedive.
When I wasn’t crushing cans and proselytizing to my friends, I was soaking in the world around me. I was fascinated by the countries, cultures and languages of our vast world. I studied Chinese, Spanish and Russian. When the opportunity came up to do a month-long exchange with Moscow School 45, I grabbed it and was transformed by it. I got to connect with others across language and cultural boundaries. I got to see with my own eyes what I had been reading about in newspapers about the political upheavals of the formerSoviet Union. And I got to have fun, too.
IYWG: How did you first learn about sex? What were you told? Who gave you this information? What else do you wish you had been told?
ACG: In my house, thanks to my supportive parents, sexuality was regarded as just another part of life. From a fairly young age, they gave me age-appropriate books, they talked with me and they let me ask questions, or at least let me know that I could. Of course, there were times when I was uncomfortable, but I always knew I was safe.
My church was also very progressive. In seventh grade, the religious education curriculum focused on sexuality and relationships, a precursor to what is now the Our Whole Lives curriculum. Chris, the husband of the associate minister, and Bonnie, a parent and member of the congregation, taught the class. They had the grace, patience and strength of character to help a bunch of self-conscious tweens navigate the ins and outs of sexuality. There, I learned to trust myself. With all the influences of my ever-expanding adolescent world, that was no small feat. That is where some abstinence-only approaches miss the mark, imposing a single path when there are so many to take.
IYWG: We have a few questions for you about the state of the world’s youth today.
First, what do you think is the biggest issue young people face today?
ACG: To boil it down to a single issue is an impossible feat, but climate change and environmental degradation are emerging as critical issues that young people face. As the environment shifts, previous livelihoods are no longer viable and young people are forced to migrate from rural areas to urban centers to support themselves and their families. This even heightens the risk of being trafficked, especially, but not only for adolescent girls. Climate change also has significant implications for food security, as we saw in the drought-driven crisis in the Horn of Africa. Drought-related shocks that used to happen every 6-10 years now occur every 3-5 years and the effect is devastating.
IYWG: Why is it so important to focus on adolescent girls as a specific youth population?
ACG: Adolescence is a time when a girl must cross a series of thresholds, thresholds that determine the direction of her life. Yet, adolescent girls are often invisible. Program implementers, donors and policymakers assume that the needs of adolescent girls are being met under the youth umbrella. In reality, girls are being overlooked and can’t access services. Household duties prevent them from participating. Travel to a program site may be too dangerous. Their husbands or parents may not give them permission. The obstacles girls face are too many to count.
IYWG: What is one thing about adolescent girls that you wish you better understood?
ACG: The situation for adolescent girls is dire, and so, as advocates and program implementers, we often match that severity with stark sobriety, rightfully focusing on safety, health and education. But what puts a smile on a girl’s face? What brings her joy? What makes her laugh? These questions, while seemingly frivolous at first glance, need to be asked in order to serve the whole girl.
IYWG: How did you get started in the field of YSRH? Why is the health and well-being of young people especially important to you?
ACG: With a background in international human rights law, I have always been interested in how international human rights mechanisms can articulate protections and responsibilities. I believe it is everyone’s right to live full, healthy lives, and realize their full potential. In turn, I believe that we have a responsibility to create the conditions that support this.
IYWG: What inspired you to begin your work with The Coalition for Adolescent Girls?
ACG: Coalitions have the power to move an agenda forward and have an impact. The Coalition for Adolescent Girls, in bringing together program implementers, technical experts and advocates is able to frame the issues and reach targets that can affect the lives of adolescent girls.
It is remarkable to be a part of a group where partners check their organizational priorities at the door in order to speak with one voice. Working with the keen minds and dedicated hearts of adolescent girl champions and experts is just the icing on the cake.
IYWG: Finally, what do you think is the most important thing that could be done to improve the health and well-being of adolescent girls today?
ACG:We must engage in a more holistic approach to adolescent girls’ needs instead of reinforcing programmatic silos. Health and well-being is connected to economic livelihoods and security which is connected to education which is connected to leadership opportunities and so on. We must understand the unique constellation of identities, experiences and characteristics that each girl embodies instead of assuming that one size fits all.
Last year, the sexual and reproductive health needs of young people received much-deserved international attention. For example, UNICEF dedicated its 2011 State of the World’s Children Report to adolescents, the new executive director of UNFPA proclaimed his commitment to the reproductive health of youth during one of his first public appearances, and the 2011 International Conference on Family Planning dedicated an entire section of the conference program to the topic of youth sexual and reproductive health (YSRH). The renewed commitment to YSRH is refreshing and inspiring, but we probably all agree that more needs to be done.
Adolescents face mounting public health challenges; approximately 5 million young people are currently living with HIV, and childbirth is still the number one cause of death of girls ages 15–19. And yet, most of us working in the field of adolescent sexual and reproductive health—whether as professionals, peer educators, or advocates—have a strong sense of strategies for improving YSRH that work, and those that don’t. During the 2011 annual Interagency Youth Working Group (IYWG) meeting, participants discussed strategies that have proven successful, as well as those that have not, and developed a set of recommendations for YSRH donors.
From January 25 to 27, 2012, we will host an online discussion titled, What’s Next? Maintaining the Focus on Youth: A Dialogue with YSRH Donors. This e-forum will be facilitated by representatives from donor organizations that support youth sexual and reproductive health, as well as by young people themselves. The e-forum will provide the opportunity for us to share the strategy recommendations developed at the IYWG meeting as well as to gather additional feedback and suggestions from those of you who were unable to attend the meeting. This is our chance to engage in meaningful conversations with members of donor organizations about how we can maintain the focus on young people and ensure that their SRH needs are met.
This interview, with Dr. Robert Blum, is the second interview of our “Youth—My Past, and Their Future” series. Dr. Blum is an expert in adolescent reproductive health and is the William H. Gates, Sr. Professor and chair of the Department of Population, Family and Reproductive Health at Johns Hopkins Bloomberg School of Public Health. You can also read the first interview of this series here.
RB: As a teenager I was extremely social. I went to the same school from the third grade on, and we developed a very close knit group of friends. While I was a good student, studying was not my passion and I would much rather have been outside on a sunny day playing with friends than completing assignments.
I have many favorite memories growing up, but more than any other, one that shaped my view of the world was traveling. Starting when I was about 12, I traveled with my parents. When I was 16, I spent the summer hitch-hiking around Ireland, sleeping in farmhouses and cow pastures and living off of the kindness of others.
IYWG: How did you first learn about sex? Do you remember what information you were given? What else do you wish you had been told?
RB: This is a bit of a difficult question to answer since I do not recall really “learning about sex.” I think I discovered it on my own. I grew up in New York City and starting in the seventh grade, we used to have parties at people’s homes where boys and girls would dance together. By eighth grade, I had a girlfriend; and by the ninth grade, parties were as much about “making out” as anything else. I do not think for one moment I thought about STIs, pregnancy, HIV (which did not exist in the 1960s), or just about anything else that came from romantic relationships. The chasm between making out and sexual intercourse was too great for me to even contemplate.
IYWG: What do you think is the biggest issue young people face?
RB: Unemployment. We see a dramatic transition occurring around the world with the young people relocating from rural to urban areas at an unprecedented rate. They come looking for an education, opportunities and jobs that frequently are not there, which leads to a cascade of negative outcomes both for young people and for their communities. I believe we greatly need to improve access to education, the quality of education and the duration that young people are in school. So, too, we have to couple education with new vocational opportunities.
IYWG: What is one thing about youth that you wish you understood better?
RB: I wish I better understood the disinhibiting effect that social media have for young people. I cannot fathom how someone could send nude pictures of themselves through the Internet believing that it would be a private experience. Neither can I imagine how social media can be a vehicle for unimaginable interpersonal cruelty among young people, and that perpetrators believe they can remain anonymous.
IYWG: Please share a little about your work with youth. How did you get started in the field of youth sexual and reproductive health? Why is the health and well-being of young people especially important to you?
RB: I would say that it was never part of my career trajectory to work with youth. When I went to medical school, I envisioned entering internal medicine or family practice and working on an Indian Reservation in the Southwest where I had done extensive volunteer work as a medical student. During my clinical rotations as a medical student I found that I gravitated toward young children and I spent more and more time “after hours” hanging out with them on the wards, playing with them and getting to know them. There was one particular young boy who was three years old who had a terrible disease—rhabdomyosarcoma—and I got to know him and his family well over the months I was on the ward and he was in the hospital. It was that experience more than anything that lead me to pediatrics. And so it was in pediatrics that I had encounters that led me to adolescent medicine, neither of which had anything to do with sexual or reproductive health. I got to know a 16-year-old girl who had cystic fibrosis for the two years before her death. And there was a 14-year-old boy who I got to know quite well who had leukemia, and he, too, later died. But both of these young people taught me how to live in the shadow of uncertainty.
When I went into adolescent medicine, I had my first clinical encounters with girls 13 to 16 years of age in a community clinic; when they came for pregnancy checks I was astounded by the number who appeared indifferent to whether or not they were pregnant. I wanted to better understand how that could be, that some would simply not care whether or not they would bear a child. Understanding sexual decision-making became one of the threads of my research life and, subsequently, I wanted to better understand why so many reared in adversity go on to do well. This is the fundamental notion of resilience and understanding factors that protect young people from harm, I believe, can help us develop better services, programs, interventions and support.
IYWG: What do you think can be done to change young people’s risky sexual behaviors? How can youth be encouraged to adopt protective behaviors?
RB: I think that we know quite a fair amount about how those who are in school are less likely to be engaged in risky sexual behaviors. Those who see a future are likewise less risk-taking. Those who have opportunities and role models do better. Very honestly, I do not think it’s rocket science, but I also do not think it has a lot to do with focusing on sex or sexual behaviors themselves. We know enough to be able to say that most interventions that are focused specifically around sexual risk-taking do not work very well. I do not think this is rocket science but I do think we have built an entire industry around the provision of programs and interventions for young people that are ineffective.
IYWG: What key issue must be addressed in order to improve the health and well-being of today’s youth?
RB: Education and jobs.
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