South Africa 
Highest AIDS risk for young women

On a world-wide basis, women still account for under half of all cases of HIV/AIDS. Not so in Africa. In sub-Saharan Africa, 55 per cent of the 23.3 million people living with HIV were women in 1999, according to UNAIDS. Young girls are particularly vulnerable to the epidemic, and epidemiological studies show that 17 to 22 per cent of girls between 15 and 19 years old already are infected, compared to 3 to 7 per cent of boys their age.

Studies have shown that women (for biological reasons) are more vulnerable than men to sexually transmitted diseases and other opportunistic infections like HIV. This is especially marked in girls whose genital tracts are still not fully mature. Compounding biological vulnerability is the fact that women are far more likely to be coerced into sex, or raped - often by someone older, who has had greater exposure to the virus. The majority of young women cannot protect themselves against AIDS because they have to rely on their male partners who may decide whether or not to use a condom. 

Girls therefore are exposed to HIV earlier than boys. A preliminary analysis of multi-site studies sponsored by UNAIDS and its partners shows that in western Kenya, nearly 1 girl in 4 aged 15-19 is already living with HIV, compared with 1 boy in 25.

Generally speaking, the female reproductive tract is more susceptible than the male to infection with HIV and other sexually transmitted diseases. This biological vulnerability is greatest in young, still-maturing girls. The multi-site study mentioned above found that many girls become infected soon after their sexual debut, as a result of relatively few exposures to a partner with HIV. 

Coercion
Over half the young women in a study in Malawi reported having been coerced into having sex, as did over 20% in Nigeria. And in a sexual health study among adolescents in Zambia, girls indicated that around 20% of their sexual activity was forced (rising to around a half in some cases), with many of the coercive partners being people they knew. Rape and forced sex carries a higher HIV risk because condoms are rarely used and because forced intercourse can damage the delicate lining, making it easier for the virus or other microbes to enter the girl's body. 

Dependence on a male partner for economic support - whether on a sugar daddy or a husband - means less power to refuse sex or to insist on fidelity or condom use. This is especially true in cultures where females are expected to be unassertive and subservient to males.

Dr. Molefi Sefularo, MEC for Health in South Africa's North West Province, yesterday said that in South Africa, 23% of females had their first sexual experience with someone much older than themselves. The data suggests that much early sexual experience is conducted in contexts where there are such marked power and maturity differentials that manipulation must be considered an important determinant of early sexual experience. 

- In contexts where there are significant power differentials between partners, the less powerful partner is liable to be manipulated or coerced. Women have been shown in many societies not to be in a position to assert themselves in sex contexts, or to make choices about sexual participation, he went on.

Country by country
A recent study in Malawi measured yearly HIV incidence at nearly 6 percent in teenage women, as compared with less than one percent in women over 35.

In Zambia in the same age group 16%of girls versus just 1%of boys are HIV-infected. 

In Rwanda, rates for boys and girls are similar through the teens, but in their early 20s females are significantly more likely to be infected - 14% of women versus 9% of men.

Among 15-19 year olds, a UNAIDS multi-site study found an HIV prevalence of 15% among girls in Ndola (Zambia), compared with just under 4% among boys. In Kisumu (Kenya), 23% of girls aged 15-19 had already acquired the virus, as compared with just over 3% of the boys.

In major urban areas in Botswana, over 30% of all pregnant adolescents are infected, while in South Africa, Swaziland and Zimbabwe prevalence exceeds 20%.

In Cameroon and Benin a recent UNAIDS study shows that significantly more women started having sex before age 15 in the high-prevalence cities than in Cotonou and Yaoundé, where HIV prevalence is much lower. While some of these sexual experiences are between consenting partners, for many girls early sex (whether vaginal or anal) occurs under coercion or even outright force and violence. 

Education can help
A UNAIDS review of over 50 studies has shown that sexual health education programmes do not encourage sexual experimentation. When quality criteria are met, such programmes actually help to delay the age of first intercourse. They also reduce sexually transmitted diseases and unwanted pregnancy in adolescents who are sexually active.

Successful school AIDS education programmes that include family life and life skills education and sexual health education exist, for example in parts of Zimbabwe. Given a chance, young people have proven through their direct engagement that they have a great deal to contribute to a community response to the HIV/AIDS epidemic. They are a force for change.

Examples of progress in the work against AIDS among youths and girls in Africa include:
In Uganda, by 1995 over 50% of the men and 46% of the women in that age-group said they had never had sex, more than a three-quarters increase over the 1989 figures for either sex. HIV infections among pregnant teenagers aged 15-19 have substantially decreased in several urban clinics, in some cases falling to under 5% from over 20% at the start of the decade. 

Tanzania has seen similar decreases in HIV incidence among women under 25. In both rural and urban settings in one area of the country, HIV infection in young women has fallen by almost two-thirds.

In Senegal, sexual health and AIDS education was introduced in primary and secondary school curricula. Two out of five women under 25 and two-thirds of men used condoms with non-regular partners in 1997, compared with less than 5% at the start of the decade.

In Ethiopia, condom use has been promoted as a prevention strategy among young people. As a result, condoms have become more available and less costly, and their use has become a socially accepted norm among young people. Condom sales increased more than tenfold in the 1990s.

In Zimbabwe, all schools since 1993 have had compulsory weekly lessons on life-skills and AIDS from grade 4 (9-10 year olds) upwards. Topics discussed include the roles of men and women in society, rape, and coping with powerful sexual urges and desires. In the classroom, self-esteem and assertiveness are encouraged. Role plays suggest ways that children and young people can face up to pressure from their peers. 

Given the massive documentation, young girls must be made aware that they run an enormous risk of becoming infected during their first few exposures to sex, especially with an older man. Young women should be taught the necessary life-skills to withstand pressure to have early, unwanted or unsafe sex, while social pressure should be put on men to stop seeking out younger girls for sex, a UNAIDS study concludes. And all young Africans should be encouraged to have open conversations with their friends and partners about relationships and options for safe sexual activity.

Sources: UNAIDS and the Office of the MEC for Health, North West (South Africa)

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