Advancing sexual and reproductive health and rights of young women at risk of HIV

Current approaches to HIV prevention typically target people who are identified as, or self-identify, with being at risk. In Africa, 74% of new HIV infections are among adolescent girls aged 15–19 years, and AIDS-related illnesses are the leading cause of death among adolescent girls and women of reproductive age.¹ Hundreds of millions of dollars spent on developing and testing biomedical interventions to prevent HIV in women have not succeeded in reducing HIV incidence. Consequently, reaching the UN targets for reaching all women and adolescent girls with comprehensive HIV prevention services by 2020 and eliminating AIDS as a public health threat by 2030 challenges us to rethink existing strategies.²

The WHO Department of Reproductive Health and Research convened a consultation to solicit expert opinion on action needed to reduce HIV risk for young women in the context of promising but underused linkages with comprehensive and holistic approaches to improving sexual and reproductive health and rights (SRHR).³ We highlight three key elements from these deliberations.

The first element is the understanding of the factors that increase risk or augment protection. Interventions that show promise in reducing HIV acquisition are linked to those that enable girls to stay in school, delay early marriage, eschew unwanted pregnancy, effectively engage boys and men, and nurture economic independence by academic and vocational training.⁴ By enabling young women to have control and choice over their sexual and reproductive health and rights, such approaches could break the cycle of disadvantaged gendered relationships and reduce pervasive gender-based and intimate partner violence.

Well designed and correctly implemented comprehensive sexuality education programmes can also generate positive changes in sexual behaviour and reduce negative health outcomes, including HIV.⁵ In addition to improving access to HIV testing and comprehensive SRHR services, including condom distribution and screening for reproductive tract infections, investments for HIV prevention should therefore support comprehensive sexuality education in schools and venues that reach out-of-school youth. Furthermore, meaningfully engaging young women throughout the development, implementation, and evaluation of policies and programmes will improve programme quality and policy relevance.⁶ The implementation of new biomedical interventions for HIV prevention such as pre-exposure prophylaxis (PrEP) for adolescent girls and young women will only be successful and sustainable within a context of combination prevention, education, and gender-empowerment.

The second key element is the strengthening of the evidence base. Discontinuing what does not work is a crucial priority to shift resources to support evidence-based practices. Youth centres, peer education, and abstinence-only education have not made much impact on sexual and reproductive health; conversely, innovative multisectoral approaches that integrate health, education, and social protection show promise.^7,8 Programmes that positively engage boys and young men on issues of sexuality and respectful relationships with girls and women have begun to change gender norms and male behaviours.⁹

Adolescent girls might be at increased risk, especially when the vaginal microbiome is perturbed through infection and harmful practices such as douching.¹⁰ Yet surprisingly little is known about the role of reproductive tract infections and inflammation on the risk of HIV. Further research on the biological susceptibility of adolescent girls in addition to behavioural, social, and gender-related science can illuminate other potentially effective interventions for the introduction and uptake of HIV prevention interventions.

The third and final element is the need for a meaningful change through intersectoral collaboration. The Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–30) and other WHO strategies offer opportunities to advance HIV prevention for young women through transformative changes in protection of their SRHR and wellbeing. Even if not every programme or policy can cover all aspects of SRHR, including HIV, the responsibility of achieving comprehensive SRHR outcomes falls on all stakeholders. And although there are no magic bullets, meaningful reductions in HIV acquisition among adolescent girls and young women can be achieved through greater integration of HIV interventions with multisectoral interventions that empower young women to exercise their rights to optimised SRHR services. Linking promising approaches in SRHR and HIV requires long-term vision and investments that facilitate cross-sectoral programmes. Smart investments include comprehensive sexuality education programmes in schools and for out-of-school youth; eliminating unequal legal, economic, and social barriers to access information, services, and commodities; and enforcing zero tolerance for coercion, violence, and discrimination in any form.

Committing to achieving the 2030 targets of the UN Sustainable Development Goals and ending the AIDS epidemic will depend on scaling up evidence-based interventions to halt the HIV epidemic in adolescent girls and young women. This will involve linking the development and introduction of biomedical tools with behavioural and social support to ensure that these tools are used.