UNAIDS estimated that 40 million people were living with HIV at the end of 2004 (UNAIDS, 2005
). Approximately one quarter of infections occur among young people 15-24 years of age and that more than half of all new HIV infections are to people younger than 25 years (UNAIDS, 2004
). HIV prevalence and incidence rates among young people are hard to come by, but those available for women attending antenatal clinics indicate that sexually active young women in sub-Saharan Africa are often at particularly high risk. In some areas more than 10% of girls ages 15-19 years and one-quarter to one-third of young women ages 20-24 years are infected with HIV (UNAIDS, 2005
The rural community of Vulindlela, 150km west of Durban, South Africa is a stark example of this crisis. Vulindlela is in KwaZulu-Natal, the province at the epicenter of one of the worst HIV epidemics in the world with HIV prevalence among pregnant women utilizing antenatal services estimated at 47.1% and morbidity and mortality are rising rapidly (Kharsany, Carrara, Frohlich, Abdool Karim, Abdool Karim, 2005
). Faced with such devastation, the local chief in Vulindlela sought out researchers at the Centre for the AIDS Programme of Research in South Africa (CAPRISA) in Durban to help find a solution. Otherwise, he told them, he will soon be a leader with no people to lead.
The global UNAIDS HIV data and the Vulindlela prevalence data make a compelling case for the need to implement effective HIV prevention strategies among at-risk teens as well as adults. Existing HIV prevention options encompass a wide spectrum and the most successful programs combine a range of options that are tailored to both personal needs and the social context. Among the most common are behavioral interventions often described as the ABC approach: (A) abstain from sex and other risky behaviors such as drug use; (B) be faithful to one sexual partner (or, more accurately, practice mutual monogamy); and (C) use condoms with all sexual partners (Shelton et al., 2004
). Behavioral interventions such as these can be highly effective but effectiveness is constrained by contextual factors including social, legal, ethical and economic.
Attention to social and structural issues has emerged relatively recently (Parker, Easton, Klein, 2000
). For example, in an attempt to integrate gender concerns some interventions include improved education opportunities for girls and creating economic opportunities for women. Others focus on strengthening women’s reproductive and sexual autonomy in ways that improve their overall health, as do measures to reduce violence against women, including rape. Development of local economic opportunities for men may reduce community-wide susceptibility by reducing the need for men to engage in migrant labor or long-distance trucking, both of which foster a flourishing sex industry with rapid turnover of sexual partners. However, such structural changes are difficult to design, implement, evaluate, and replicate.
In the short term, while solutions to the more challenging structural and behavioral issues related to HIV transmission are being sought, some of the most effective options for slowing the epidemic are biomedical. Examples include treatment of sexually transmitted infections that accelerate HIV transmission, prevention of mother-to-child-transmission with antiretrovirals, post-exposure prophylaxis (PEP) for targeted exposure events such as needle sticks and rape, and, most recently, male circumcision (UNAIDS, 2005
More exciting still are several methods currently in development: microbicides that can be used vaginally or anally in addition to or instead of condoms; vaccines to either prevent infection or limit disease progression; and pre-exposure prophylaxis (PREP) or the daily use of antiretrovirals to prevent the acquisition of HIV. Importantly, all of these methods have the potential to be female-controlled and while they do not change the behavioral or structural dimensions of HIV risk for girls and women, they may safeguard women’s health while those challenges are addressed by global, national, and community leaders. If proven safe and effective, these methods could help save the next generation from devastation by HIV---provided the necessary evidence is generated to support programs targeting youth.