Just in time for World AIDS Day, Secretary of State Hillary Clinton unveiled a Blueprint for Achieving an AIDS-Free Generation. The Blueprint lays out four “road maps” that will guide the President’s Emergency Plan for AIDS Relief (PEPFAR)—the U.S. government’s global AIDS program—as it continues to provide life-saving HIV and AIDS prevention, treatment, care, and support programs around the world.
The four road maps—saving lives, smart investments, shared responsibility, and driving results with science—are based on the following five principles:
- Make strategic, scientifically sound investments to rapidly scale-up core HIV prevention, treatment and care interventions and maximize impact;
- Work with partner countries, donor nations, civil society, people living with HIV (PLHIV), faith-based organizations, the private sector, foundations and multilateral institutions to effectively mobilize, coordinate and efficiently utilize resources to expand high-impact strategies, saving more lives sooner;
- Focus on women and girls to increase gender equality in HIV services;
- End stigma and discrimination against PLHIV and key populations, improving their access to, and uptake of, comprehensive HIV services; and
- Set benchmarks for outcomes and programmatic efficiencies through regularly assessed planning and reporting processes to ensure goals are being met.
Overall, the Blueprint is surprisingly strong, especially in light of the fact that over the past few years, the Office of the Global AIDS Coordinator (OGAC)—the office responsible for administering PEPFAR—has done a lackluster job on young people and focused its rhetoric almost exclusively on biomedical approaches such as voluntary male circumcision, prevention of mother to child transmission (PMTCT), and treatment as prevention. While vitally important, these three strategies alone are not, and never will be, nearly enough to address all drivers of the epidemic, particularly as they relate to young people who continue to account for over 40 percent of all new HIV infections around the globe.
Among the many positive attributes of the Blueprint are its intentional focus on women and girls and key affected populations including men who have sex with men (MSM), sex workers, and people who inject drugs (PWID). No plan would be complete without recognizing the critical importance of addressing the structural drivers of the epidemic, including gender inequality, violence, poverty, stigma, discrimination, and other legal barriers to services, all of which disproportionately impact women, girls, and key affected populations. To address those barriers, the Blueprint specifically calls for improving girls’ access to education, increasing economic opportunities for women, preventing and addressing gender-based violence and exploitation, engaging men and boys in addressing norms and behaviors, repealing laws that criminalize people for who they are or who they love, and supporting the human rights of women, girls and LGBT populations.
In addition, supporting women—both HIV-positive and negative—to plan their families is a key pillar of the Blueprint, recommending increased access to voluntary and comprehensive family planning and reproductive health (FP/RH) services with a range of contraceptive options including male and female condoms, counseling and referrals, and integration of and linkages between FP/RH and maternal, newborn and child health as well as HIV/AIDS and programs serving orphans and vulnerable children (OVC).
Integration is vital for helping women and young people receive information and services in one location, and it’s great to see it interwoven throughout various sections of the Blueprint. However, continuing to rely solely on USAID to supply contraceptives places severe limits on the ability of women and young people to protect themselves and plan their families. If a young woman lives in a PEPFAR-funded country where USAID has no presence, what then? How does she access other forms of contraceptives, particularly if her partner refuses to use condoms, the only form of contraception supported by PEPFAR?
What about the other needs of young people? How do they fit within the Blueprint? For starters, there is a section, albeit somewhat short compared to other sections, that specifically focuses on strengthening programmatic commitment to and emphasis on reaching and supporting young people with HIV services. The fact that the youth section appears in the road map on “smart investments” should not be overlooked. Perhaps PEPFAR is now seeing what we’ve long known—that investing in young people is not just the right thing to do, it’s the smart thing to do.
So what does this youth section say? First, it says that PEPFAR will work with partner governments to develop age-appropriate, evidence-based curricula for use in schools, while working with parents, communities, and implementing agencies to reach out-of-school youth. Secondly, it recognizes that education, alone, is not enough and that a comprehensive package of programs needs to be specifically tailored and targeted for sexually-active and at-risk youth. Third, it calls for special attention to be given to young people living with HIV (YPLHIV) as they transition to adulthood, seek youth-friendly HIV care and treatment programs, develop sexual relationships, and plan their own families. Fourth, the Blueprint prioritizes better monitoring to track services utilized by YPLHIV and evaluation of PEPFAR-funded youth programs to identify the most effective interventions for young people. And lastly, PEPFAR for the first time ever, explicitly recognizes that the key affected populations of MSM, sex workers, and PWID also include young MSM, young sex workers, and young PWID, thereby requiring programs to be designed that specifically address their needs in an accessible and acceptable manner.
In addition to a specific section on youth, adolescent girls and young women are also prominently highlighted in the section on women, girls, and gender equality. Given the fact that this population is often invisible in larger gender programs, the Blueprint rightfully acknowledges the need for stronger surveillance efforts to ensure that adolescent girls and young women are adequately represented. Going one step further, the Blueprint finally requests “to the extent feasible” that data be disaggregated by sex and age in all health service programs, including those serving adolescent girls and young women—something Advocates for Youth has been requesting for years.
Furthermore, PEPFAR is tasked with adopting evidence-based best practices in youth-friendly health care and services, including supporting positive youth development approaches for in-school and out-of-school youth, developing specific programs for adolescents and pre-adolescents including boys and married adolescent girls, working with communities to change attitudes around child marriage, preventing and responding to sexual abuse and coercion, and increasing access to economic strengthening and educational resources.
While the Blueprint makes great strides in the U.S. response to HIV and AIDS, it is not without its shortcomings. Evidence- and rights-based comprehensive sexual health education is critical for young people, but the Blueprint fails to state whether the education it calls for is comprehensive, rights-based, or LGBT-inclusive. Furthermore, while a comprehensive and tailored package of services and programs for youth is needed, the Blueprint makes no mention of what that package might look like or why it seems to be restricted to those young people who are already sexually active or considered at-risk, rather than to ALL young people. The same can be said for access to male and female condoms, which also is limited to those who are already sexually active.
And despite very strong language in other sections requiring the active engagement of PLHIV, key affected populations, and civil society in the design, implementation and evaluation of HIV programs, there is a complete and utter lack of attention to meaningfully engaging young people and YPLHIV in youth programs. Engaging parents, guardians, and influential adults, yes, but young people themselves, astonishingly not one mention whatsoever!
In her remarks, Secretary Clinton stated, “Now, make no mistake about it: HIV may well be with us into the future. But the disease that it causes need not be.” In order for that to be absolutely true, we can and must do better by our young people. We must ensure that programs for young people are comprehensive, evidence- and rights-based, and inclusive of the diversity of youth. We must move away from segmenting youth into artificial categories based on real or perceived notions of sexual activity or level of risk and provide ALL young people with the information and services they deserve and need. We must allocate sufficient resources—financial, technical, and human—to best address youth within the HIV pandemic. And we absolutely must ensure that young people themselves are meaningfully engaged in all program and policy decisions impacting them.
Young people have the right to accurate and complete sexual and reproductive health and HIV information and services. And the U.S. government has a responsibility to respect young people and provide them with the tools they need to safeguard their sexual health.