Efforts to combat HIV in East and South Africa must focus here

The celebration of World AIDS Day in 2020 was held in the midst of a global pandemic. It served as another reminder that humans are not only susceptible to pathogens, but also to the political, social and economic inequalities that determine vulnerability to infections.

HIV remains a major global public health challenge, and COVID-19 added. This is especially the case in East and South Africa – the epicenter of the HIV epidemic, with 800,000 new HIV infections each year, just under half of the total global number. Progress in eliminating AIDS in the region by 2030 was already lagging behind targets before COVID-19 and government blockades rejected it even more. The blockades have slowed the delivery of services in testing, treatment and care.

It is estimated that such disorders will have a significant effect on mortality at the population level. HIV-related deaths could increase up to 1.06 times a year if the disorder affects half of the population living with HIV / AIDS.

Although AIDS-related mortality among adolescents and young people is generally declining in the region, the mortality rate remains high among girls and young women. Progress in preventing HIV transmission is still too slow, with girls aged 10 to 19 accounting for 83% of new HIV infections. They are more vulnerable to HIV because of their unequal cultural, social and economic status in society. Recent estimates are that girls and women in this age group are approximately twice as likely to be infected with HIV as their peers.

Reducing the rate of HIV infection among girls and young women in the region is a crucial priority. But the impact will be limited if the structural drivers that shape risky behaviors and undermine prevention responses are not addressed.

Our book, HIV prevention among young people in South and East Africa: new evidence and intervention strategies examines efforts to confront and reduce high levels of new HIV infections among young people in East and South Africa. Taking a multidimensional approach to prevention, we discuss many of the challenges facing these efforts, with a particular focus on the structural and social drivers of HIV.

Structural drivers of HIV risk

The book presents evidence from East and South Africa that provides valuable insights on how to reduce the risk of HIV among young people. It discusses which interventions work, why both limitations and gaps in our knowledge work.

The chapters in this book discuss the structural drivers of HIV infection for adolescents and young adults. Structural drivers are social and cultural norms, values, networks and institutions that influence HIV epidemics. They include restrictive laws and policies, such as laws on the age of consent and criminalization of people of different sexes and sexual orientations. Other drivers are adult-targeted HIV services that adolescents find intimidating and poor quality services that discourage receiving services.

Social issues such as poverty and poor education, harmful gender norms, stigma and discrimination also trigger transactional sex. Cultural norms such as forced marriage increase the risk of contracting HIV. The availability and promotion of alcohol and drugs are also factors. Each of them can affect the more immediate determinants of HIV risk – such as the pattern of sexual behavior and ill health.

Evidence gathered in the book shows that keeping girls in school not only reduces the risk of HIV, but also delays marriage and pregnancy and improves mental health. Similarly, reducing heavy alcohol use has benefits for other health outcomes – it reduces unsafe abortions and transactional sex. Structural interventions provide girls and young women with the skills, knowledge and capacity to reduce their risk of acquiring HIV.

Addressing primary social vulnerabilities to HIV has a major impact. It can change risk patterns, increase access to health care, promote autonomy and agency, and improve adherence to HIV treatment. Current “structural-type” interventions that have shown promise include revenue generation, cash transfer programs, and livelihood support. Others encourage young girls to stay in school and improve their life skills to keep girls safe.

Targeting and collaboration

Targeting adolescents and reducing their risk will be key to determining the course of the epidemic in sub-Saharan Africa. Governments must work together and find ways to increase targeted investment in prevention, diagnosis and treatment. Interventions can make a difference not only by reducing the risk of HIV, but also by empowering girls and women to better manage their health and well-being.

Increased emphasis on structural approaches will make it even more important that different sectors and stakeholders work together. This may happen through existing mechanisms, or it will be necessary to create new cooperation mechanisms or involve new partners.

Program implementers, the lobby industry, and pharmaceutical companies will need to establish alliances and partnerships with researchers and other groups not previously directly involved in HIV prevention programs, such as community development or microcredit organizations. This will allow them to develop, test and evaluate structural approaches.

We don’t need innovative solutions – we have to do what we know works efficiently and consistently. The focus should be on the “farthest” first, so that no one is left behind.