Worldwide, more than half of all people who become infected with the human immunodeficiency virus—HIV—acquire the virus when they are under 25 years old.

It is tragic that HIV should single out a youthful and otherwise relatively healthy population group. But it is hardly a coincidence, given the daily circumstances of many young people’s lives. As we have learnt from two decades of experience with this epidemic, the path of HIV is eased by poverty, lack of skills, violence, and harmful social norms such as machismo and early sexual debut.

This briefing paper takes a look at the young people of Latin America and the Caribbean in the era of AIDS. How exposed are they to HIV? In the context of their everyday lives, what factors tend to make them more vulnerable to the virus? Finally, how can communication build up the protective factors in their environment and break down the harmful ones?

• listen to children and young people, hear what they feel is important in their lives, engage in conversation with them about issues that concern them including sex, sexuality and HIV/AIDS

   

• learn from one another—children from children, children from adults, adults from children, adults from other adults, HIV-negative from HIV-positive—about respect, participation, support, and protection from HIV infection and AIDS stigma

• live in a world where fewer people become infected with HIV, and where children and young people with HIV or AIDS can live free from discrimination.

   

In Latin America and the Caribbean, an estimated 1.3 million adults (aged 15–49) and children
(0–14) were living with HIV at the end of 1998. Men who have sex with other men, and those—often men as well—who inject drugs are disproportionately affected in many countries of the region. However, rising infection rates in women show that heterosexual transmission is gaining in importance. Systematic surveillance is limited, but HIV prevalence in pregnant women attending antenatal clinics reportedly reaches 1% in Honduras and exceeds 3% in Porto Alegre, Brazil. HIV rates in pregnant women are significantly higher in the Caribbean—by 1993 a rate of 8% was seen in Haiti and in 1996 a similar rate was reported from one surveillance site in the Dominican Republic.

Altogether, from the limited surveillance data available, UNAIDS estimates that more than 65 000 15–24 year olds became infected during 1998 alone in this region. In addition, 8000 children ranging from infants up to 14–year-olds became infected in 1998. Most of these infections were in children who acquired the virus from their HIV-positive mother during pregnancy or birth or through breastfeeding.

Because HIV surveillance systems generally take age 14 as the cut-off point for child infections, and because the overwhelming majority of these occur through mother-to-child transmission, relatively little is known about the magnitude of sexual transmission among youngsters aged 10–14.

Data from Brazil suggest that some early spread of this kind does occur. For example, in 1998 almost 10% of AIDS cases in youngsters aged 12 or younger were not the result of mother-to-child transmission. In addition, 13% of Brazil’s cumulative total of AIDS cases since the start of the epidemic were in 15–24 year olds, and fully 82% were in people under 44. It is important to bear in mind that AIDS is the severe end-stage of infection with the human immunodeficiency virus.
In developing countries, people typically develop AIDS 8–10 years on average after initial infection with HIV. This means that a 30–year-old with AIDS might well have become infected in his or her early twenties.

It would be a mistake to judge the potential seriousness of the HIV threat to the youth of Latin America and the Caribbean from the current numbers of infections and AIDS cases. To see where the real dangers lie and understand how the epidemic could grow, one needs to look at the magnitude of unsafe behaviour taking place, both sexual and drug-related, and at the risk factors that fill the lives of children and young people.

Sex can start very early. The 1998 Caribbean Adolescent Health Survey conducted by the Pan American Health Organization (PAHO) in 100 schools in Antigua, Dominican Republic, Grenada and Jamaica and with out-of-school youth showed that, among those who reported being sexually active, more than 40% said their sexual debut had started before age 10 and another 20% said it had started at age 11 or 12. In some places, young people in rural areas become sexually experienced earlier than city-dwellers—in Dominican Republic, 67.7% as against 47.1%, in Guatemala 71.4% as against 48.8%.

Early sex is generally unprotected sex, as demonstrated by the consequences—unwanted pregnancy, HIV infection and other sexually transmitted diseases (STDs). The Caribbean survey found that half of all sexually active adolescents said that they did not use contraception at last intercourse. According to a Lima study of adolescents and young adults (aged 19–30), only 11% of those heterosexually active used condoms consistently, and 22% reported an unplanned pregnancy. Among self-identified homosexual young men in Peru, 2 out of 5 reported having unprotected anal intercourse in the past four months.

A report by The Alan Guttmacher Institute estimates that, in the region as a whole, between a quarter and a half of all young mothers say that their pregnancy was unplanned. And a community-based study in Nicaragua discovered that over half of pregnant adolescents had begun having intercourse between the ages of 12 and 14; around half the pregnant girls were 16 or younger. Many involuntarily pregnant girls in the region do not carry their pregnancy to term: of the 20 million annual unsafe abortions in the world, the World Health Organization (WHO) estimates that 23% are in Latin America where 8.5% of the world population lives. In Peru and Nicaragua, 15% of all pregnancy-related deaths are in adolescents, and most of this mortality is due to illegal abortion.

Early sex is often forced sex—and dangerous sex. In Santiago, Chile, nearly 3% of young women report that rape was their first experience of intercourse. Sexual abuse and rape are most often perpetrated not by strangers but by a young woman’s intimates—friends, relatives and partners, including boyfriends and husbands (although rape in marriage is seldom punishable by law). Forced sex can injure the genital tract and make it easier for HIV or the microbes that cause other sexually transmitted diseases to penetrate the body and cause infection. According to a Panos report, surveys in the USA indicate that between 4% and 30% of women who have been raped acquire an STD as a result.

Sexual abuse and sexual exploitation of children, often associated with poverty and dysfunctional families, open the door to major HIV risks in Latin America and the Caribbean. Girls subjected to sexual abuse in childhood are typically robbed of self-esteem and a feeling of control over their lives, which increases their risks of drug-taking and commercial sex later on. In one country, 80% of children entering the sex trade had been sexually abused, often by a relative. Economic pressures in Latin America and the Caribbean have forced an ever-increasing number of people into absolute poverty. Even in Costa Rica, often called the Switzerland of Central America, 10%
of the inhabitants live in absolute poverty, 40% of female adolescents do not attend school, and more than a quarter of young people aged 12–19 work for below-subsistence wages in domestic service. Domestic labourers are open to sexual exploitation and assault by the males in the employer’s family. Sex tourism, often perceived as an Asian problem, is another growing AIDS-related problem in the region. Preferred destinations for sex tourism with minors are Costa Rica and the Dominican Republic, but increasingly Brazil, Guatemala, Haiti, Honduras, Nicaragua and other countries are being cited.

Drug use increases the HIV risk. Drug use is seen in many countries throughout the region, and can start very early—for example, glue-sniffing by youngsters living or working on the streets. The danger of becoming infected with HIV by sharing injecting equipment is well known, and real. For example, a study in Rio de Janeiro among people who injected cocaine (around one-third of whom were under 25) showed that 15% were HIV-positive. However, even among the cocaine users who did not inject the drug, HIV prevalence was 7%—a high figure explained by the frequency
of unsafe sex among drug users. A study of drug-dependent people in an outpatient health facility in Sao Paulo found that about 60% systematically engaged in unsafe sexual practices including having unprotected sex, having multiple partners, and trading sex for drugs.

There is no single or simple answer to these interlinked problems and their links with HIV/AIDS. Fortunately, a great deal is known about how to create a comprehensive response—a response that helps reduce vulnerability to HIV (a vulnerable person is someone who has little or no control over his or her exposure to the virus), discourage risk behaviour, and build understanding between those who are HIV-positive and those who are as yet uninfected.

Whether in the Netherlands, Thailand or Uganda, communities that have adopted a comprehensive approach have been rewarded by a lower rate of infection and less stigma and discrimination directed at those living with HIV or AIDS. On the basis of this experience, UNAIDS and its cosponsors have put forward a global strategy featuring seven major sets of action (see box).

1. Establish or review national policies to reduce the vulnerability of young people to HIV/AIDS and ensure that their rights are respected, protected and fulfilled.

    

2. Promote young people’s genuine participation in expanding national responses to HIV/AIDS.

    

3. Support peer and youth groups in the community to contribute to local and national responses to HIV/AIDS.

    

4. Mobilize parents, policy-makers, media, and religious organizations to influence public opinions and policies with regard to HIV/AIDS and young people.

    

5. Improve the quality and coverage of school programmes that include HIV/AIDS and related issues.

    

6. Expand access to youth-friendly health services including HIV/STD prevention, testing and counselling, care and support services.

    

7. Ensure care and support of orphans and young people living with HIV/AIDS.

None of these actions is conceivable without communication—among young people, between children and adults, and within communities as a whole. This is what prompted the choice of LISTEN, LEARN, LIVE! as the theme for the 1999 World AIDS Campaign with Children and Young People.

Communication can spark people’s courage in overcoming harmful traditions and attitudes. Communication can help create awareness of HIV/AIDS, get across the facts, and build survival skills. And communication can create bonds between generations—bonds that have been proven to help children and young people survive and thrive in a world with AIDS.

HIV risk does not occur in a vacuum. In Latin America and the Caribbean, as everywhere else in the world, young people’s lives are filled with circumstances and expectations that encourage risk behaviour, amplify vulnerability, or both.

It is hard to overstate the HIV risk from machismo, a Spanish-language word that has come into widespread use in other languages too because it so neatly sums up the constellation of risk-taking and often predatory behaviours with which young men are expected to prove their masculinity in many parts of the world.

Machismo puts lives in danger—not least, the lives of the young men themselves, as a recent Panos report makes clear. Young men are expected to demonstrate their virility with early and frequent sex, and multiple partners. Thus, in Mexico City 15% of boys as against 4.5% of girls have first intercourse before age 15; in Guatemala City the figures are 31.6% as against 13.9%. Young men are expected to know about sex. Yet many probably know little. Among unmarried 15–24 year olds, premarital sex is commoner among males, according to a series of Young Adult Reproductive Health Surveys in several Latin American cities and countries showing that 24–73% of the men, as compared with 12–59% of the women, had had intercourse. Those who are not knowledgeable about sex cannot afford to let on—and wind up running the consequent risks. Finally, the tension between machismo and homosexuality complicates the task of informing men who engage in male-male sex about HIV prevention. As a result of all these factors, in Latin America and the Caribbean as a whole HIV infections among men outnumber those among women.

The risks, however, are not confined to men. The other side of the machismo coin is vulnerability for young women, who are expected to be ignorant about their bodies and sexual matters, are expected to defer to male sexual demands and decision-making even when they know their partner may be infected through outside relationships, and are often emotionally and economically dependent on him. While for young men the major HIV threats arise from drug use and male-male sex, the threat to young women is mainly from heterosexual transmission. Among Brazilian 15–17-year olds, for example, heterosexual intercourse was the route for 7% of male AIDS cases but close to 48% of females. And infections among young women are growing. Among 15–24-year-olds, men outnumbered women by 12:1 in 1982; by 1996–98 the ratio was 1:1.

Macho attitudes can also help sow the seeds of violence. While the prime victims of male violence are other men, these acts rarely amplify the HIV risk directly (exceptions include rape in all-male settings such as detention centres and prisons). However, women who are targets of male violence—often, at the hands of their husband or partner—are put at risk of HIV. Forced sex transmits the virus more readily, both because of genital injury and because condoms are rarely used in such circumstances. Even when the violence is not sexual, however, the mere threat of it makes women wary of challenging their partner’s extramarital relationships or afraid to demand condom use. And when sexual abuse occurs early in life, evidence is accumulating that this translates later on into greater sexual risk behaviour.

The scale of male-female violence is horrifying. In Mexico, 7 out of 10 child victims of violence are girls, and 60% of women dying a violent death were younger than 13. According to the Caribbean Adolescent Health Survey, by age 16–18 one out of five young people reported being physically abused and one in eight report sexual abuse. Females were twice as likely to be sexually abused as males.

While it is crucial for women to stand up to violence and challenge it through legal and other means, it is equally crucial to target young men—not by tarring them all with the same brush as perpetrators or tacit supporters of violence, but by enlisting them as allies in preventing violence against young women.

Without communication, there is little hope of enabling children and young people to take the measures they need to protect themselves and others from HIV. HIV prevention cannot be done to people—it can only be done by and with people, and only when they have the understanding, motivation, skills, tools and freedom to avoid unsafe sex and drug use.

Schools are prime settings for such discussions to take place—between teachers and students, and among the students themselves. Sexual health programmes can impart the facts about sexuality, HIV/STD transmission, pregnancy and drug use, and help youngsters learn and practise the skills they need in today’s world. Among the skills are how to understand their own options about sex and risk, how to avoid unwanted and unsafe sex and drug use, how to negotiate safer behaviour, and how to make and stand up for their own decisions in the face of pressures by peers or older adults.

Talking with children about HIV and sexuality must start early, in view of the early onset of intercourse and the early risk of sexual abuse in the family and community. While more children are attending school for longer these days, many—particularly girls—have relatively few years of education, and this precious but brief opportunity must be seized to ensure that they leave school with the facts and skills needed for survival.

Health-care staff can also serve as trusted adults with whom young people can communicate.
In a US study, adolescents were found to be more willing to disclose sensitive information about their sexuality and substance abuse, for example, to doctors when these provide assurances
of confidentiality.

Communication with young people must take place not only in schools, sports clubs, clinics, workplaces, and wherever they congregate. It must also take place in the home. Children and young people want communication and connection with trusted adults. In Latin America and the Caribbean, as elsewhere around the world, youngsters report wanting more discussion about AIDS, sex and sexuality—and wanting that information to be provided by their parents. According to studies by the International Center for Research on Women, young people need and want communication with parents, aunts and uncles, grandparents, godparents, community leaders.

Children and young people report feeling distressed by the lack of contact. In the Caribbean Adolescent Health Survey, between one-third and two-thirds of all respondents said they were unable to discuss their concerns with either their mother or their father. Around one-fifth of the youngsters worry about their parents leaving them. Those with such worries were up to twice
as apt to have expressed extreme anger.

In the Caribbean survey, the absence of a caring adult was linked to devastating consequences. In the absence of a mother’s caring some 25–29% of 10–18-year-olds reported a suicide attempt, as compared with 8–11% of those who enjoyed care from a mother. When a father’s caring was absent, the risk of suicide doubled.

Listening to a child’s concerns, speaking with him or her, are hallmarks of a caring relationship. These are the processes that weave the connection between adult and child. Having a caring adult has been shown to be protective. For example, in the Caribbean survey, those benefiting from a father’s care enjoyed more protection from early sexual debut, extreme anger and poor health. In a study in Alabama, New York and Puerto Rico, adolescents were three times more likely to use a condom at first intercourse when they had a mother who talked to them about sex before they became sexually active. And in a large-scale study in Minnesota, the mere fact of having a caring adult available—not necessarily a parent—was again shown to be an important protective factor for young people. When health outcome was measured (e.g. in terms of smoking, age of sexual debut and pregnancy), feeling connected to a caring adult was associated with better health. Somewhat surprisingly, other often-cited factors—among them, race, socio-economic class, parent’s educational level, and living in a single-parent household—were not found to be linked to health outcome.

All young parents need to understand how important their caring is to their children. Young men need special help to overcome centuries-old traditions which appeared to relegate them to a less important role vis-à-vis their children. As one father remarked, "It is not my duty to talk to children, that is the job of the mother. They know the rules. If they want something from me, they tell their mother and she would inform me."

Communication is also vital for breaking down the walls that sometimes separate those living with HIV or AIDS from others in their communities. Children and young people who are HIV-positive have important things to teach those who have so far escaped infection. They also have important needs that deserve respect and attention. Listening and learning can help all not just to survive but to live positively.