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.
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.