This article originally appeared in the Fall 2009 issue of the Guttmacher Policy Review, and is reprinted with permission from the author.  It article is part of a series on global AIDS issues to be published
by Rewire throughout December.   To find other articles in this series, search "global AIDS 2009."

In 1994, official delegations from more than
180 countries gathered in Cairo at the United
Nation’s International Conference on
Population and Development (ICPD) and
agreed to a dramatically different approach to
population issues.The Program of Action that
emerged from the conference was groundbreaking.
Under the rubric of improving global sexual
and reproductive health, it called for moving
beyond country-level macrodemographic targets
for population size to a primary focus on meeting
the rights, needs and aspirations of individual
women and men.The Program of Action was
striking in its insistence that enabling people to
decide freely the number, spacing and timing of
their children is fundamental to the strategic and
economic interests of all countries.Toward that
goal, it also called for a significant expansion of
services to acknowledge and address the sexual
and reproductive health needs of adolescents.

This year marked the 15th anniversary of ICPD, and in September,
civil society leaders from around the world convened in Berlin to take
stock of the progress—and what remains to be done. Although young
people themselves for the most part did not participate in Cairo, they
played a prominent role in Berlin. Youth aged 15–29 made up more than
25% of those in attendance at the Global Partners in Action
Nongovernmental Organization (NGO) Forum on Sexual and Reproductive
Health and Development. Moreover, the Youth Coalition—an international
organization of young people that was created at the five-year review
of ICPD and is committed to promoting sexual and reproductive
rights—organized a special youth symposium, which resulted in a
statement that boldly calls on policymakers and other stakeholders
around the globe to push for a more inclusive and progressive sexual
and reproductive health agenda.

One would think that for American sexual and reproductive health
advocates, the NGO Forum could not have come at a better time.
President Obama is strongly committed to women’s health and
international family planning assistance, as evidenced by the
rescission of the Bush-era "global gag rule" and his restoration of the
United States’ support for the United Nations Population Fund (UNFPA).
The president has publicly stated his support for age-appropriate,
comprehensive sex education for youth, and his blueprint budget for FY
2010 called for an end to abstinence-only programs in the United
States.

Despite these encouraging signals, however, the Obama administration
has not yet made any notable changes to U.S. policy targeting the
sexual and reproductive health of young people globally. Under the Bush
administration, the United States promoted premarital abstinence as the
single most important strategy for youth worldwide. Youth activists
argue that Obama needs to quicken his pace on the administration’s
promise to take a different approach. In preparation for that day, the
key questions are what progress has been made in meeting the sexual and
reproductive health of young people since 1994? What more needs to be
done to achieve adolescent sexual and reproductive health? And how
well-equipped is U.S. policy to get the job done?

Taking Stock

Two reports published earlier this year—Young People and Universal Access to Reproductive Health, published by the Youth Coalition, and Healthy Expectations: Celebrating Achievements of the Cairo Consensus and Highlighting the Urgency for Action,
published by UNFPA—take a look back at what has been achieved in the
first 15 years of the 20-year Cairo Program of Action and highlight
what is needed to fully achieve the Cairo goals, as well as other
global commitments. These reports draw attention to the fact that
today’s youth represent the largest generation in history. To prepare
for the future, they will need education, training and job
opportunities; they also must be free of widespread disease, unplanned
pregnancy, violence and discrimination. The good news is that
contraceptive use by married and unmarried adolescents is more common
than in the past, and as a result, rates of adolescent childbearing
have dropped significantly in most countries and regions over the last
few decades. Nonetheless, more than 16 million adolescents give birth
each year, and in some regions of the world, early childbearing is
common. As many as one in 10 women in Africa and South Asia have their
first child before the age of 16 (see chart). Having a baby always
carries potential risks, but for young adolescents, the risks are even
greater. Women under the age of 16 are more likely than those who are
older to experience premature labor, miscarriage and stillbirth, as
well as death from pregnancy-related causes.

Most births to teen mothers occur within
marriage and are planned, but millions are not, and in many such cases,
a young woman may seek to terminate her pregnancy. Adolescents aged
15–19 are estimated to have 2.5 million of the approximately 19 million
unsafe abortions that occur annually in the developing world. Unsafe
clandestine abortions endanger the health—or the very life—of young
women, and adolescents frequently make up a large proportion of
patients who are hospitalized for complications from such procedures.
Even in places where abortion is legally available, a young woman may
face obstacles: For example, she may not quickly recognize she is
pregnant, may not have the money readily available to pay for an
abortion or may be required to get a parent’s or her husband’s consent
before having an abortion.

Although mortality and morbidity related to pregnancy, delivery and
unsafe abortion remain the most significant risks to young women’s
health, in some parts of the world, young women also face a substantial
risk of AIDS. Worldwide, young people aged 15–24 account for nearly
half of all new cases of HIV infection, and young women are more
greatly affected than young men. In Sub-Saharan Africa—the region of
the world where the majority of people with HIV live—young women are
three times more likely than young men to be infected (see chart, page
9).

Despite widespread awareness of pregnancy and AIDS, adolescents’
knowledge of these subjects is not comprehensive, and myths are common.
According to a multiyear, multicountry study of adolescents in
Sub-Saharan Africa conducted by the Guttmacher Institute, many
adolescents think that a young woman cannot get pregnant the first time
she has sexual intercourse or if she has sex standing up, that they can
identify someone living with HIV by their outward physical appearance,
that HIV can be transmitted through a mosquito bite or that a man who
is HIV-positive can be cured by having sex with a virgin.

Importantly, adolescents recognize their need for better information
and want it to come from reliable sources they trust. In Uganda—one of
the study’s focus countries—about half of all young people said,
unprompted, that they would like to get information about contraceptive
methods, HIV and other STIs from teachers, health care providers or the
mass media, whereas just one-third would prefer to receive information
from family and one-fifth from friends. When asked why they preferred
the more formal sources, young people said those sources could be
trusted to provide reliable information.

A Bold Agenda

One day prior to the official start of the NGO Forum in Berlin, more
than 70 young delegates from 66 countries gathered for a youth
symposium to develop key messages to promote during the forum. The
resulting youth symposium statement strongly challenges policymakers
and other decision makers to strengthen their commitment to the Cairo
Program of Action "regardless of the political environment [or] donors’
and country donors’ agendas" and to move beyond Cairo by recognizing
young people’s rights. The statement outlines a number of key action
areas, including the promotion of comprehensive sex education, the
provision of sustainable sexual and reproductive health services, and
the involvement of young people in decisions about programs and
policies that affect them.

Sex education. The youth symposium
statement sets a goal of "accurate, timely and evidence-based"
comprehensive sex education and calls on policymakers to promote
programs both in and out of school. The statement emphasizes that young
people not only have the right to be safe and free from coercion,
discrimination and violence in intimate partner relationships, but that
they also have the right to "enjoy their sexuality in a…pleasurable
way." Toward this goal, all
sectors of society that are involved in sex education—from teachers to
community health workers to donors to ministries of health—need to be
"fully informed [and] sensitized on youth issues and empowered to act
in the best interests of young people."

Sexual and reproductive health services for youth. The
statement recognizes that for young people to achieve their sexual and
reproductive rights, they need access to a wide array of services. To
be effective, services must be provided by caregivers who have been
trained to work with young people, in an environment in which
adolescents feel comfortable. The statement calls for the elimination
of the legal barriers, such as parental and spousal consent laws and
restrictive abortion policies, that stand in the way of young people’s
accessing the health care they need. It also acknowledges that privacy
and confidentiality are important aspects of service provision for
adolescents, who may be uncomfortable discussing sexual matters or may
fear condemnation from their families or communities if they reveal
their sexual activity.

Meaningful youth involvement. The youth symposium statement
calls on policymakers, public health experts and national-level program
planners to involve young people themselves when considering the sexual
and reproductive health needs of youth. Youth-led organizations have a
key role to play at all stages in the process—from program and policy
design to the delivery and evaluation of sexual and reproductive health
services. Governments, donors and NGOs must invest in mentoring
programs and in the capacity of youth groups to participate fully in
program design and implementation.

The statement also celebrates the diversity of young people around
the world and does not shy away from recognizing young people on the
margins of society. "We are young people; women, men, lesbians, gays,
heterosexuals, transgender; in school, out of school, sex workers,
married, divorced, single or in a relationship; we live with HIV and
AIDS; we are disabled; we are migrants, refugees, displaced,
trafficked; we are working, jobless or seeking employment; we speak
different languages; we have different spiritual beliefs and practices;
we have different perceptions of the world around us; we use different
media and social networks to communicate globally." The statement
demands that policymakers and program managers "acknowledge and respect
our diversity…and eliminate the existing policies that discriminate
against us."

Beyond Cairo. Finally, the youth symposium statement calls on
policymakers to "think beyond Cairo," by pushing for a "more inclusive
and progressive agenda"—one that recognizes sexual rights and works
toward the elimination of gender bias and other social, economic and
legal barriers that prevent adolescents from accessing sexual and
reproductive health services and "fully enjoying their sexuality." The
statement’s support for young people’s rights is unflinching, even in
the face of cultural differences: "We recognize the value of cultural
differences and do not perceive it as a barrier for fully realizing
young people’s sexual and reproductive health and rights, and cultural
practices should not compromise young people’s rights."

The U.S. Response

The United States has been and remains the single largest
contributor of funds for programs around the world designed to prevent
teenage pregnancy and HIV, and U.S. policy is critical in shaping
health and development programs for youth worldwide. Two U.S.
government agencies in particular have assumed a significant role in
sexual and reproductive health programs for youth globally: the Office
of the U.S. Global AIDS Coordinator, which oversees the implementation
of the President’s Emergency Plan for AIDS Relief (PEPFAR), and the
U.S. Agency for International Development (USAID).

PEPFAR, originally enacted in 2003, is widely credited for providing
life-saving medicines to more than two million people living with HIV.
Last summer, the United States strongly recommitted itself to fighting
AIDS, by agreeing to renew PEPFAR for another five years. The new
PEPFAR statute is improved in many ways. For example, it bolsters its
previous treatment focus with an increased emphasis on care and support
services for people living with HIV, allows for a slight increase in
the proportion of funding that may go toward prevention and accounts
for some of the broader public health implications of HIV. Yet,
PEPFAR’s fundamental prevention policy remains fraught with
proscriptions and prescriptions that continue to hamper the program’s
ability to support the most effective interventions at the local level.

Regarding youth, the original PEPFAR mandated a rigid spending
requirement that one-third of all HIV prevention funds be reserved for
abstinence-only programs, whereas the new statute includes a more
flexible goal. It stipulates that in those countries with generalized
epidemics, the global AIDS coordinator must develop an HIV sexual
prevention strategy for which at least half of funding supports
"activities promoting abstinence, delay of sexual debut, monogamy,
fidelity and partner reduction." The coordinator must report back to
Congress on any country strategy that does not meet this goal and
provide a justification for this decision.

In short, PEPFAR still promotes abstinence and fidelity, but in a
more circumscribed way that leaves room for interpretation. It is now
up to the Obama administration to determine which programs and
interventions to fund to most effectively achieve these outcomes. So
far, however, the administration has not issued new guidance to the
field to address youth issues; as a result, global AIDS programs for
youth continue to be driven by guidance originally issued by the Bush
administration in 2005. According to the ABC Guidance ("ABC" is
short for abstain, be faithful and use condoms), PEFPAR’s primary
message for youth and other unmarried persons is abstinence until
marriage. In recognition of the fact that many young people engage in
sex before marriage, PEPFAR’s answer is "secondary abstinence." PEPFAR
funds may not be used to distribute condoms in schools or for
youth-targeting social marketing campaigns that encourage condom use,
because these interventions "give a conflicting message" and "appear to
encourage sexual activity or appear to present abstinence and condom
use as equally viable, alternative choices." Eric Goosby, the new
global AIDS coordinator, acknowledges that the guidance needs to be
revisited, but has moved tentatively and has not provided a specific
plan for doing so.

Meanwhile, USAID’s office of population and reproductive health has
traditionally focused on reproductive health interventions for youth.
Between 1994 and 2006, the office supported two major projects. The
first of these, FOCUS on Young Adults, built awareness and supported
research to identify appropriate strategies for promoting youth
reproductive health and preventing HIV. The second, YouthNet, shifted
the emphasis to program expansion, adaptation, institutionalization and
sustainability of successful strategies. When YouthNet came to an end
in 2006—well into the Bush administration’s second term—the agency
decided to no longer support sexual and reproductive health projects
focused solely on youth and, instead, to incorporate youth
interventions into larger projects. Staff within USAID acknowledge
that, although there may have been sound reasons for "mainstreaming"
youth activities into other projects, the U.S. government has lost
ground since 2006. In some cases, youth activities continued with
limited resources or became lower profile to avoid political
controversy; in other cases, interventions withered away altogether.

Since Obama’s election, there has been renewed interest within USAID
to reinvigorate reproductive health programs for youth. The agency is
considering partnering with other organizations to provide technical
assistance and strengthen existing youth education and service programs
in poor countries. USAID’s interagency youth working group, meanwhile,
continues to serve as a network where NGOs, donors and cooperating
agencies can share research and programmatic results. And yet, USAID
has been hampered in its efforts to reclaim global leadership in youth
reproductive health by its own lack of leadership. After a 10-month
search for a USAID director, President Obama in early November
nominated Rajiv Shah, a doctor and agriculture expert, to the post.
Shah’s nomination, which must be approved by the Senate, comes as the
White House and the State Department are studying how to redesign U.S.
foreign aid assistance for global health. "Shah has a difficult job
ahead of him, and there are many competing priorities," says Gwyn
Hainsworth, senior adolescent sexual and reproductive health advisor at
Pathfinder International. "In many countries, sexual activity among
young people prior to marriage remains stigmatized, and policymakers
may be reluctant to expand the capacity of teachers and health care
providers to effectively provide sexual health information and services
to young people. Additionally, the fact that many young people in
developing countries are already married and have reproductive health
needs is often overlooked. It will take strong leadership to break
through these political obstacles."

Young people themselves recognize these political obstacles, but say
the time for change is now. "We have strong allies in the
administration," says Katie Chau, a member of the Youth Coalition. "Now
is an important time to focus our advocacy efforts and make sure that
policies that affect youth are evidence-based. Many of our members live
in countries that receive U.S. funding for global AIDS or family
planning, and they feel the impact of U.S. policies on their own
health. Strengthening sexual and reproductive health and rights is a
pressing global need. It’s time we quicken the pace and move to a more
progressive agenda."