Youth, Wealth and HIV Prevention

Nyovani Madise

Nyovani Janet Madise is a senior research scientist at the African Population & Health Research Center (a research partner of the Guttmacher Institute) in Nairobi, Kenya. She is in New York today to participate in a United Nations panel on youth as part of the 40th session of the Commission and Population and Development.


I just arrived in New York, among other reasons to participate in a panel discussion today titled "Preparing the Next Generation—Safeguarding Adolescents' Healthy Transition to Adulthood." The panel is a side event on the occasion of the meeting of the UN's Commission on Population and Development.

My recent work has focused on solving what at first glance may seem like a contradiction: The poorest adolescents in Africa engage in riskier sexual behavior, but, according to recent evidence, the wealthiest adolescents have the highest rates of HIV. I suspect that this may be because wealthier young people can afford to have sexual relationships with more partners, thus increasing their exposure to the virus.

Nyovani Janet Madise is a senior research scientist at the African Population & Health Research Center (a research partner of the Guttmacher Institute) in Nairobi, Kenya. She is in New York today to participate in a United Nations panel on youth as part of the 40th session of the Commission and Population and Development.

I just arrived in New York, among other reasons to participate in a panel discussion today titled "Preparing the Next Generation—Safeguarding Adolescents' Healthy Transition to Adulthood." The panel is a side event on the occasion of the meeting of the UN's Commission on Population and Development.

My recent work has focused on solving what at first glance may seem like a contradiction: The poorest adolescents in Africa engage in riskier sexual behavior, but, according to recent evidence, the wealthiest adolescents have the highest rates of HIV. I suspect that this may be because wealthier young people can afford to have sexual relationships with more partners, thus increasing their exposure to the virus.

But what does this mean for HIV prevention? Should policymakers and program planners shift course to focus on the rich instead of the poor? The high prevalence of HIV among young people in Sub-Saharan Africa has created an urgency to identify programs that can prevent new infections. Key to the design of such programs is a better understanding of the risks young people take, as well as the ways in which they try to protect themselves.

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To better gauge what young people know about HIV/AIDS, where they get their information and what they are doing to protect themselves, my organization, the African Population and Health Research Center, partnered with the Guttmacher Institute and four African research institutions to survey nearly 20,000 young Africans in Burkina Faso, Ghana, Malawi and Uganda. We chose these countries because they represent different regions of Africa and different stages of the HIV epidemic.

From these nationally representative surveys of 12-19 year olds, we were able to take a closer look at the link between wealth and HIV risk in the four countries. We asked those who were sexually active how old they were the first time they had sex, how many sexual partners they had had and whether or not they had used condoms. (By the way, the data from this project are now available to other researchers.)

We found that, across the board, wealthier adolescents were more likely to have used a condom the last time they had sex than their poorer counterparts, although they did not necessarily have more sexual partners. Similarly, wealthier girls in Burkina Faso, Ghana and Malawi became sexually active later than their less-affluent peers (evidence from Uganda was not significant). This link was not as strong among young men.

First and foremost, these results tell us that the relationship between poverty and AIDS is not a simple one. At the national level the picture becomes puzzling because some of the wealthiest countries in sub-Saharan Africa (such as South Africa and Botswana) have some of the highest HIV prevalence rates in the world. At the micro level, HIV prevalence rates derived from Demographic and Health Surveys and other population-based HIV surveys in a number of African countries show a positive relationship between wealth and HIV prevalence. This association appears more pronounced among young women than young men.

So what needs to happen? Poverty appears to influence early sexual debut, especially among young women, and the poor are less likely to be using condoms. In spite of efforts by national HIV prevention programs to reduce or eliminate the cost of condoms in many African countries, adolescents still report cost as a reason for not using them. HIV prevention programs must identify ways of making the poor less vulnerable to risky sexual behavior and such programs need to take account of strong social and cultural contexts that influence young people's sexual behavior.

Commentary Sexual Health

Fewer Teens Are Having Sex, But Don’t Pop the Champagne Yet

Martha Kempner

The number of teens having sex may be less important than the number having protected sex. And according to recent data from the Centers for Disease Control and Prevention, condom use is dropping among young people.

Every two years, the Centers for Disease Control and Prevention’s Division of Adolescent and School Health (CDC-DASH) surveys high school students to gauge how often they engage in perceived risky behaviors. The national Youth Risk Behavior Surveillance (YRBS) is wide ranging: It asks about violence, guns, alcohol, drugs, seat belts, bicycle safety, and nutrition. It also asks questions about “sexual intercourse” (which it doesn’t define as a specific act) and sexual behaviors.

Started in 1991, this long-running study can provide both a picture of what high school students are doing right now and a historical perspective of how things have changed. But for more than a decade, the story it has told about sexual risk has been the virtually the same. Risk behaviors continually declined between 1991 and 2001, with fewer high school students having sex and more of them using condoms and contraception. But after the first 10 years, there has been little change in youth sexual risk behaviors. And, with each new release of almost unchanging data, I’ve reminded us that no news isn’t necessarily good news.

This year, there is news and it looks good—at least on the surface. The survey showed some significant changes between 2013 and 2015; fewer kids have ever had sex, are currently sexually active, or became sexually active at a young age. More teens are relying on IUDs and implants, which are virtually error-proof in preventing pregnancy.

In 2015, 41 percent of high school students reported ever having had sexual intercourse compared to 47 percent in 2013. The researchers say this is a statistically significant decrease, which adds to the decreases seen since 1991, when 54 percent of teens reported ever having had sexual intercourse.

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Another change is in the percentage of students who had sex for the first time before age 13. In 2015, 4 percent of high school students reported this compared to almost 6 percent in 2013. This is down from a full 10 percent in 1991. As for number of overall partners, that is down as well, with only 12 percent of students reporting four or more partners during their lifetime compared to 15 percent in 2013 and 19 percent in 1991. Finally, the percentage of students who are currently sexually active also decreased significantly between 2013 (34 percent) and 2015 (30 percent).

These are all positive developments. Delaying sex can often help prevent (at least temporarily) the risk of pregnancy or STIs. Having fewer partners, especially fewer concurrent partners, is frequently important for reducing STI risk. And those teens who are not currently having sex are not currently at risk for those things.

While I want to congratulate all teens who took fewer risks this year, I’m not ready to celebrate those statistics alone—because the number of teens having sex is less important to me than the percentage of teens having sex that is protected from both pregnancy and sexually transmitted infections. And that number is lower than it once was.

Among sexually active teens, there were no significant positive changes in measures of safer sex other than an increase in the number of sexually active high school students using the IUD or implant (up to 4 percent from 2 percent in 2013).

Moreover, some results indicate that today’s teens are using less protection than those who were teens a decade ago. The most telling finding might be the percentage of teens who used no method of contraception the last time they had sex. This decreased between 1991 and 2007 (from 17 percent to 12 percent), inched up to 14 percent in 2013, and stayed the same in 2015 (14 percent). There was also little to no change in the percentage of high school students who say that either they or their partner used birth control pills between 2013 (19 percent) and 2015 (18 percent) or those who say they used the contraceptive shot, patch, or ring (5 percent in 2013 and 2015).

For me, however, the most distressing finding is the backward progress we continue to see in condom use. The prevalence of high school students who used a condom at last sex went up from 45 percent in 1991 to 63 percent in 2003. But then it started to drop. In 2015, only 57 percent of sexually active high school students used condoms the last time they had sex, less than in 2013, when 59 percent said they used condoms.

It’s not surprising that teens use condoms less frequently than they did a decade ago. In the 1990s, the HIV epidemic was still front and center, and condoms were heavily promoted as a way to avoid infection. As this threat waned—thanks to treatment advances that now also serve as prevention—discussions of the importance of condoms diminished as well. The rise of abstinence-only-until-marriage programs may have also affected condom use, because these programs often include misinformation suggesting condoms are unreliable at best.

Unfortunately, some of the negative messages about condoms inadvertently came from public health experts themselves, whether they were promoting emergency contraception with ads that said “oops, the condom broke”; encouraging the development of new condoms with articles suggesting that current condoms are no fun; or focusing on teen pregnancy and the use of highly effective contraceptive methods such as long-acting reversible contraceptives (LARC). The end result is that condoms have been undersold to today’s teenagers.

We have to turn these condom trends around, because despite the decreases in sexual activity, young people continue to contract STIs at an alarming rate. In 2014, for example, there were nearly 950,000 reported cases of chlamydia among young people ages 15 to 24. In fact, young people in this age group represented 66 percent of all reported chlamydia cases. Similarly, in 2014, young women ages 15 to 19 had the second-highest rate of gonorrhea infection of any age group (400 cases per 100,000 women in the age group), exceeded only by those 20 to 24 (489 cases per 100,000 women).

While we can be pleased that fewer young people are having sex right now, we can’t fool ourselves into believing that this is enough or that our prevention messages are truly working. We should certainly praise teens for taking fewer risks and use this survey as a reminder that teens can and do make good decisions. But while we’re shaking a young person’s hand, we should be slipping a condom into it. Because someday soon (before high school ends, for more than half of them), that teenager will have sex—and when they do, they need to protect themselves from both pregnancy and STIs.

News Family Planning

House Republicans Wield Appropriations Process Against Title X Funding

Christine Grimaldi

“It is particularly foolish to target Title X at a time when the nation is at the precipice of a public health emergency resulting from the Zika virus,” National Family Planning & Reproductive Health Association President and CEO Clare Coleman said in the group’s response.

Republicans in the U.S. House of Representatives are once again using the appropriations process to target Title X federal family planning services for low-income people.

House Appropriations Committee Chair Hal Rogers (R-KY) touted how the fiscal year 2017 Labor, Health, and Human Services (LHHS) funding bill would gut what he called a “controversial” federal program. To the contrary, many low-income people in the United States regard Title X as their only means to obtain critical health care, including family planning services, contraception, well-woman visits, cancer screenings, sexually transmitted infections screenings, and other preventive services.

Title X grants serve a highly vulnerable population—more than 90 percent women, nearly three-fifths people of color, and mostly uninsured or young, according to the U.S. Department of Health and Human Services’ (HHS) 2014 family planning annual report. The grants go to a network of more than 4,100 health and community service agencies. Centers that are funded by Title X are “particularly good” at providing women with the most effective contraceptive methods, like intrauterine devices and implants, according to the Guttmacher Institute.

Nevertheless, the draft bill would eliminate $286 million from Title X and another $108 million for federal Teen Pregnancy Prevention grants, according to a spokesperson for Appropriations Committee Democrats.

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Democrats will “raise strong objections” at Thursday’s subcommittee markup of the bill and again at next week’s planned full committee markup, the spokesperson told Rewire in an email.

If precedent holds, their voices will be heard. Republicans unsuccessfully targeted Title X funding in last year’s LHHS funding bill. The latest bid marks the fifth attempt to do so in seven years, according to a statement from the National Family Planning & Reproductive Health Association (NFPRHA). Yet, none of the proposed eliminations have ever been enacted into law, said the spokesperson for Appropriations Committee Democrats.

“Republicans need Democratic votes in Congress and the signature of a Democratic president in order to enact [a]ppropriations law, and Democrats will not vote for bills that contain divisive, poison pill riders and eliminations like this, which target women’s reproductive rights,” he said.

A spokesperson for Rep. Tom Cole (R-OK), chair of the Appropriations subcommittee with jurisdiction over the bill and a vocal reproductive health care foe who recently targeted AmeriCorps’ questionable abortion controversy, did not return Rewire’s request for comment; nor did a spokesperson for Rogers.

Title X funds can’t be used for abortion care. But because about a quarter of the funds go to Planned Parenthood affiliates, anti-choice Republicans have used Title X as a political football for years, starting in 2011 when the GOP threatened a government shutdown over the issue.

NFPRHA cautioned that the proposal could not come at a worse time for the 4.1 million people who depended on Title X funding in 2014, according to the most recent available data from HHS. U.S. Zika cases are on the rise, even as Congress remains deadlocked on a funding plan to address the sexually transmitted virus linked to microcephaly and other severe fetal brain defects.

“It is particularly foolish to target Title X at a time when the nation is at the precipice of a public health emergency resulting from the Zika virus,” NFPRHA President and CEO Clare Coleman said in the group’s response. “For the House to propose defunding the very provider network that is being called upon to address and control the risk to women who may be seeking to prevent pregnancy is absurd.”