Introduction

Africa’s young people aged 15-24 years are disproportionately infected and affected by HIV/AIDS as evidenced by the nearly 4 million of sub Saharan African youth who currently live with the virus and the fact that twenty countries in the region  Africa accounted for about 69% of all new HIV infections globally in young people in 2009¹.  

These figures reveal the disproportionate impact of HIV/AIDS on Africa’s youth; yet they do not provide a comprehensive picture of the varied HIV prevalence and their effects among different subgroups of young Africans since they are a highly heterogeneous population.  Policymakers and program managers need sound and timely evidence to better target interventions that are rapidly needed to effectively address the HIV prevention and impact mitigation needs (including stigma and discrimination) of the various categories of youth across the region. This is more so because the wellbeing of youth, who make up about one-fifth of the total African population, is intricately tied to the continent’s development prospects². However, there is a dearth of robust data on youth that are sufficiently disaggregated to adequately reveal the specific HIV-related vulnerabilities, including stigma and discrimination faced by African’s youth.  

With an aim to fill this pertinent gap, the

Population Council in collaboration with the Ford Foundation implemented a mixed method crosssectional comparative study with an analytical focus on the commonalities and differences across six focal African countries - Egypt, Kenya,

Nigeria, Senegal, South Africa and Uganda. The study aimed to provide a comprehensive evidencebased picture of the HIV related issues facing young people in the six study countries and the prevailing legal, policy, and programmatic responses. It comprised of extensive countryspecific literature reviews, legal and policy assessments, statistical analyses of recent national sexual and reproductive health (SRH)/HIV-related behavioural survey datasets and focused

qualitative inquiries (focus group discussions, indepth interviews and key informant interviews). 

On July 22 2012, the Ford Foundation and Population Council co-sponsored a satellite session at the XIX International AIDS Society Conference (AIDS 2012) in Washington D.C.

“Getting Real with Youth-Friendly Services in Africa.” The objective of the session was to stimulate young people to engage with and react to the study findings and in the light of these findings, discuss and share their perspectives, experiences and concerns about how responsive existing policies, programs and services are to the HIV prevention and impact mitigation needs of young Africans. The session consisted of a presentation of the research findings, panelists’ reactions to the study findings and a discussion with the audience about the issues that were raised.

The session was moderated by Humphrey Nabimanya of Reach a Hand Uganda (RAHU) and the panelists included Babatunde Ahonsi (Population Council), Chris Castle (UNESCO –

United Nations Educational, Scientific and Cultural Organization), Phindile Sithole-Spong

(AIDS Consortium; Rebranding HIV), Kikelomo

Taiwo (Youth Advocate Group, Education as a Vaccine) and Eka Esu Williams (Ford

Foundation).

The research findings, presented by Babatunde Ahonsi, revealed high risk sexual behaviours and relatively poor health seeking behaviours among youth aged 15-24 across the study countries making them highly vulnerable to HIV and SRH morbidity. These risks are exacerbated by a cultural context of hostility towards or silence on youth sexuality and limited access to information and confidential, youth-friendly SRH services. It was also highlighted that the existence of few youth specific policies and law provisions, pluralistic and contradictory legal regimes that disempowered youth in terms of age of consent/marriage and marginalize young most at risk populations, and minimal youth participation in policy development and implementation, all help to worsen youth vulnerabilities to HIV. 

Policy Angle

Chris Castle stated that in most cultures and contexts there remains a discomfort and sensitivity to the fact that young people in these age ranges are sexually active. He noted that youth continuously raise the same issues when asked about their primary needs but they continue to be ignored. He encouraged the meaningful engagement of youth and the need to continue to listen to youth voices. 

UNESCO is particularly concerned about sexuality education for young people and unsurprisingly the study also highlighted the impact of education as a key factor in mitigating HIV risk.  Young people need to be in school and to have access to quality education. They also need education about sex and relationships and sexuality education broadly as well as access to youth friendly services. He also emphasized the need to ensure that youth are comfortable accessing these services. 

In terms of policy actions, UNESCO is currently embarking on a project that aims to enable a stronger policy and political commitment by East and Southern African leaders to young people as regards their SRH, education and their service access needs similar to what was done with the Latin American/Caribbean Declaration of 2008. UNESCO will utilize research findings and the voices of young people to encourage leaders in these countries to make commitments to young peoples’ SRH education and services. He ended his commentary stressing that young people should be at the core of all HIV preventative and care efforts. 

Youth Voices

Phindile Sithole-Spong was taken aback and intrigued by the study findings. Speaking from her experience living with HIV in South Africa, which had led her to work in the sector and to seek to “rebrand” HIV, she re-emphasized the importance of listening to youth. Youth voices are often not heard because they are supposedly too young, naïve and lacking in the years of life experience required to know enough about the issues. But listening to youth voices is paramount to eradicating HIV/AIDS and stigma. Young people have valuable knowledge to share especially as they are personally experiencing these circumstances and situations and are exposed to the discourse on these issues.  

She spoke of the “one size fits all” approach of youth-focused policies and strategies in her country stating that such interventions do not cater to the youth and take into account their heterogeneity. Campaigns and programs need to listen to youth and to understand their different needs, wants, backgrounds, and stories to be effective. She pointed out the contradiction in a currently running campaign that states “imagine an HIV free generation” when policies and programs are not dealing appropriately or adequately with the current HIV positive generation.  

Kikelomo Taiwo, who works for a youth focused non-governmental organization, Education as a Vaccine (EVA) that manages youth-friendly services in Nigeria, reflected on the challenges in Nigeria. She reported a high negative perception of sexuality education which makes it difficult for young people to obtain information and to ask questions about their sexuality and their bodies. At the level of policy implementation and service delivery, there are issues with accountability and transparency. Despite budgetary provisions for youth-friendly public facilities, these facilities remain non-functional and therefore unavailable to youth. The attitudes of providers at existing facilities are poor and youth experience high levels of stigma. The climate in these facilities prevent youth from making informed decisions and being confident accessing services they need.   

She highlighted the need to educate youth in innovative ways. For example, EVA uses mobile phones to ensure that young people get access to SRH information confidentially without incurring costs. Young people are able to call into a hotline where they can obtain information anonymously and for free. Knowledge is insufficient; it is also important to teach youth how to use the information they receive. For instance, some youth know that they should use condoms during sex to protect themselves but they do not know how to negotiate safer sex. 

On improving youth participation in HIV policy development and programming, she mentioned mentoring as a way to build the capacity of youth. She encouraged older people to invest in youth and appropriately functioning systems as a continually living testament of their legacy. 

Donor’s Perspective

Eka Esu Williams spoke from her experience supporting programs around adolescents and young people in her role working at the South African office of the Ford Foundation. The key concern for donor institutions is how to balance the work done on the ground at the local, national and regional levels. The problems are interconnected at all these levels which is why it is important that this study focuses on the commonalities across the countries  and the divergences and complexities around work with young people adding value to current understanding.  

On youth participation, she urged youth not to sit passively awaiting involvement but to be active in getting involved. Youth participatory efforts need to go beyond consultation and basic involvement to developing the leadership and expertise of youth. There are instruments like the African Union’s Youth Charter and the Decade for the Empowerment and Development of Youth that have been inaugurated and adopted. Little is being done with these instruments but there is some action at the level of the African Union (AU). The Ford Foundation is supporting the AU on a project with its Youth Division that aims to develop youth expertise while trying to transform the AU into a more youth friendly organization.  

Unfortunately the Country Coordinating Mechanisms (CCMs) of the Global Fund, a major source of funding for HIV prevention programs in most African countries, have poor youth participation although such provisions have been made. In terms of participation of marginalized young people (men who have sex with men and sex workers), the defense often given by the CCMs is that the activities of these young people are illegal hence, their involvement is closed for discussion. Despite this, she was heartened by the statements made by the Malawian President with regard to her willingness to repeal archaic laws and embrace more progressive policies. 

In terms of youth-specific policies, she was most concerned that those who should be aware of such policies are not or are confused about them because they are often contradictory. For example, in South Africa, sexual intercourse below age 16 is illegal even if consensual but youth are legally able to access HIV and SRH services at age 12 or 13. There is also the fact that civil society organizations and governments spend a significant amount of time and funds on advocacy and developing guidelines and frameworks leaving no time for actual implementation. Policy implementation is also plagued by the lack of available resources and an aligned roadmap to make these programs available. Stakeholders need to focus on how to hold all actors accountable for policy and program implementation.

She was wary about the nature of current youth-friendly services that are often stand-alone, dedicated, and separate within health facilities, which has implications for sustainability in terms of available resources. She also pointed out that although the other important cause of death for young people in the region aside from HIV, is maternal mortality, and contraception is often the first entry point of young people for accessing health services and a possible gateway for testing and sexuality education, there remains limited integration between reproductive health and HIV services. She stressed the need for fresh ideas about how currently available resources can be utilized to obtain greater results and impacts. 

Upon completion of the panel discussion, the audience was given the opportunity to interact with the panelists, react to the study findings and to share their experiences and opinions on improving access to youth-friendly HIV and SRH services in Africa. The following is a summary of the insights gained from this exchange of ideas:

• Youth participatory efforts in Africa need to go beyond consultation and basic involvement to providing opportunities for building their expertise and leadership abilities. Young Africans need to be empowered to advocate for their issues actively and to hold policymakers accountable to their commitments to youth development. Youth should be innovatively engaged utilizing mediums that are accessible to them. 
• Education of youth, providers, and policymakers remains paramount along the following lines. 

^-          Youth need access to comprehensive sexuality education and need to be armed with evidence as revealed in this study as tools for advocacy to begin to mount pressure on policy processes and actors. 

^-          Sensitization of service providers to the unique needs of youth and values clarification around youth sexuality is essential to curbing the issues around confidentiality and stigma that hinder youth from adequately accessing SRH services.  

^-          The findings of this study and others like it should be drawn to the attention of the region's policymakers and opportunities for consensus building around the implications of such findings should be created. It is from such consensus building that authentic actions and commitments to change will emanate.

• The gendered aspects of youth HIV vulnerability and the heightened risks of female youth to HIV infection need to be highlighted and brought to the fore of youthfocused HIV programming and policies in the region. 
• Youth focused policies and programs must be tailored to the heterogeneity of youth and their varied contexts to be effective.

Overall, the session gave rise to a number of important policy recommendations. First, improving sexual health-seeking behaviors especially uptake of HIV counseling and  testing by male youth and condom use by female youth through a combination of youth-empowering communication and poverty reduction

interventions is imperative. Second, evidencebased advocacy needs to be targeted at policymakers and donors to generate more commitment to paying greater attention to the youth dimensions of the HIV epidemic and national responses to it especially in relation to neglected but disadvantaged categories of youth. In addition, efforts to promote the mainstreaming of youth-friendly SRH and HIV services are required given the challenges of scaling up and sustaining the few model stand-alone services provided largely by non-governmental organizations. Finally, innovative operational research is called for to better understand how to increase the meaningful involvement of young people in the conception, planning and implementation of SRH and HIV/AIDS policies and programs.

I wish to thank the satellite session audience and panelists for giving their time and so openly sharing their expertise, insights, and experiences. Special thanks to the youth and key informants who actively participated in the study. I am  grateful to my Population Council colleagues who worked on the study and whose efforts made the satellite session possible. 

UNICEF. Opportunity in Crisis: Preventing HIV from early adolescence to young adulthood. New York: UNICEF, 2011.

AU and UNFPA. State of the African Youth Report. Addis Ababa: AU, 2011.