Exemplars in tackling HIV in sub-Saharan Africa

The challenge is profound: every week, 4,200 adolescent girls and young women in sub-Saharan Africa acquire HIV. In 2020, of every six adolescents (15- to 19-year-olds) in the region newly acquiring HIV, five were girls. In 2019, over 23,000 adolescent girls and young women died from AIDS-related illnesses, making it the second leading cause of death after maternal mortality in sub-Saharan Africa that year.

There are glaring gaps in comprehensive knowledge about how to prevent transmission of HIV and other sexually transmitted infections, with fewer than one in three young people having accurate knowledge about HIV transmission and prevention in sub-Saharan Africa. The evidence shows that awareness is lowest among poor, less educated young women living in rural areas.

Adolescent girls, particularly those who experience multiple marginalizations, shoulder disproportionate care burdens and face unequal gender power dynamics, are at greater risk of acquiring HIV and dying from AIDS-related illnesses. Now, the multidimensional crisis of Covid-19 is magnifying these inequalities: surges have been reported in gender-based violence, coerced child marriages, and teenage pregnancies; and millions of young girls have lost access to school and might not return.

How can we ensure that Africa’s adolescent girls and young women stay safe from HIV? The good news is that from subSaharan Africa’s pioneering exemplars, we know what works. The key learning is that to ensure adolescent girls are safe we need to help them be strong , prioritizing their agency. The evidence shows that this is most effectively supported through a comprehensive package we have dubbed “Education Plus”: it combines universal quality secondary school completion along with violence-free school environments, access to comprehensive sexuality education, the protection of sexual and reproductive health and rights and access to related services, and young women’s economic empowerment through successful school-to-work transitions. What are the exemplars to build from?

In Botswana, policy reform in secondary schooling showed length of education had a causal effect on new HIV infection. It was found that "additional years of secondary schooling had a large protective effect against HIV risk, particularly for girls, meaning that increasing progression through secondary school could be a cost-effective HIV prevention measure in HIVendemic settings, in addition to yielding other societal benefits." For girls, each additional year of schooling resulted in the risk of contracting HIV dropping by 11.6 per cent. By expanding free and compulsory secondary education, Botswana produced a cumulative lifetime risk reduction for HIV among students of approximately one-third. Effects of secondary school on reduced sexual risk-taking behaviour and rates of HIV infection – lead to an impressive 50 per cent decline in new cases of HIV in South Africa and other studies showed declines in new HIV infections among higher educated young people in Uganda, Zambia, and Zimbabwe.

Exemplars show that ensuring all girls complete secondary school can be achieved, but requires a multi-faceted approach. A UNICEF study found that universal secondary education could only be achieved by enabling “Multiple and Flexible Pathways.” Even before COVID-19, almost 34 million adolescent girls in the sub-Saharan Africa were not in secondary school - that is, 38 per cent of girls 12 to 14 years old and 61 per cent of those 15 to 17 years old. Across the region in the past decade, however, investments and advocacy for gender parity in primary education, by removing barriers to attendance, have paid off, with some sub-Saharan African countries achieving or nearing gender parity in enrollment at the primary level. To protect girls from HIV, lessons learnt need to be applied, and the same attention needs to be given, to gender equality in secondary education.

Exemplars show too that education, whilst essential, is not enough. A review of PEPFAR’s DREAM’s Innovation Challenge found that successful interventions “addressed multiple underlying structural factors simultaneously” by combining provision of education with life skills, promotion of the rights of girls, and support for girls to lead.

Comprehensive Sexuality Education programs have been successful in helping to reduce adolescent HIV cases in Senegal, Nigeria and Mozambique. In Tanzania, the Cash Plus Model for Safe Transitions to a Healthy and Productive Adult hood program by the government, comprising livelihoods and life skills training, mentoring and asset transfer, with linkages to strengthened government-run HIV and sexual and reproductive health (SRH) services, was successful in increasing genderequitable attitudes, contraceptive knowledge, and delays in sexual debut.

As these exemplar programs have shown, whilst each component delivers important results, it is the layering of these components that secures the required reduction in HIV infection and enables other transformative positive social outcomes too. What now needs to follow is the scaling up of the combined package, as policy, properly resourced, across the whole continent. That's why, together with my colleagues, heads of UNESCO, UN Women, UNICEF, and UNFPA, we at UNAIDS are co-leading the Education Plus Initiative, a high-level political advocacy initiative for adolescent girls' and young women’s education and empowerment in sub-Saharan Africa. The initiative, which was launched with African leaders at the 2021 Gender Equality Forum, is supporting African governments and decision-makers to rapidly scale up multisectoral policies, actions, and smart investments to respond to the urgency of effectively preventing HIV among adolescent girls and young women in the region. Because the evidence shows that only by coming together can we enable change on this scale, African and global leaders from communities, civil society organizations, business, unions, faith groups and the media, are joining forces in support of adolescent girls and young women to generate an unstoppable momentum for transformation.

The exemplars demonstrate that the challenge is not that we do not know what is needed to ensure Africa’s adolescent girls can protect themselves from HIV; rather, the challenge is to guarantee that the initiatives, policies, and support that have been shown to be effective are provided to all adolescent girls, in all their diversity. Young women have been vocal in powerfully challenging the marginalization they face; the evidence shows that by listening to them, and co-curating with them solutions that center their agency and their rights, we can end AIDS by 2030.