REVIEW AND ANALYSIS OF THE SECONDARY DATA ON INTERNATIONAL AND NATIONAL GOALS AND TARGETS ON HIV AND YOUNG PEOPLE FOR

REVIEW AND ANALYSIS OF THE SECONDARY DATA ON INTERNATIONAL AND NATIONAL GOALS AND TARGETS ON HIV AND YOUNG PEOPLE FOR THE INTER-AGENCY TASK TEAM FROM THE UNGASS COUNTRY AND SHADOW REPORTS, 2008 Global Interagency Task Team on HIV and young people March 2010 1

TABLE OF CONTENTS PART ONE GLOBAL REPORT ON UNGASS INDICATORS 1. INTRODUCTION..... pg.3 2. THE 2001 COMMITMENT AND THE MILLENNIUM DEVELOPMENT GOALS pg. 3 3. RATIONALE FOR THE SYNTHESIS OF THE STRATEGIC INFORMATION FROM UNGASS COUNTRY REPORTS AND METHODOLOGY USED.pg. 4 4. HIV - THE GLOBAL PICTURE AND ITS IMPACT ON YOUNG PEOPLE. pg. 6 5. THE UNGASS INDICATORS ON HIV AND YOUNG PEOPLE AN OVERVIEW... pg. 7 6. EMERGING ISSUES AND GAPS.. pg.13 7. SUMMARY.. pg.17 APPENDIX ONE COUNTRIES REPORTING YOUTH UNGASS INDICATORS APPENDIX TWO - 35 COUNTRIES FROM SUB-SAHRAN AFRICA REPROTING UNGASS INDICATOR #22 - HIV PREVALENCE IN PREGNANT WOMEN AGED 15-24 APPENDIX THREE SPECIFIC UNGASS YOUTH INDICATORS AND ITS REPORTING APPENDIX FOUR SURVEY OF UNGASS INDICATORS BY COUNTRY REPORTING IN 2008 PART TWO - COUNTRY SPECIFIC information including Country Case Studies: Kenya, Zimbabwe, Nigeria, Viet Nam pg. 1. Southern Africa 2. East Africa 3. West Africa 4. Asia Pacific 5. Caribbean 6. Latin America 7. Eastern Europe and Central Asia 8. North America and Western Europe 9. Middle East and North Africa 10. Oceania Review and Analysis of the secondary data on international and national goals and targets for the Inter- Agency Task Team on HIV and young people 2

PART ONE 2008 UNGASS INDICATORS AND REPROTING ON HIV AND YOUNG PEOPLE 1. INTRODUCTION In 2001, heads of State and government representatives convened for the United Nations General Assembly Special Session on HIV/AIDS (UNGASS). In 2001 UNGASS, 189 countries signed a Declaration of Commitments (DoC) as a pledge to halt and begin to reverse the spread of the AIDS epidemic through international, regional and country-level partnerships and with the support of civil society. The countries also agreed to report regularly on their progress in responding to HIV, and the DoC lists twenty-five indicators to be used in reporting their progress. Five of these indicators are measurements to monitor the AIDS response among youth, aged 15-24. These commitments to focus on HIV and young people were reinforced in the UN General Assembly Special Session on Children (2002) and the General Assembly Political Declaration on HIV/AIDS (2006). The global Interagency Task Team (IATT) on HIV and Young People, convened by UNFPA, was established in 2001 to enhance the effectiveness of the global response and to support country responses to AIDS in the context of young people. In order to have an understanding of the AIDS response among young people from the existing epidemiology and the programme monitoring data, the IATT commissioned a review and analysis of existing data from 2008 UNGASS reporting on HIV and young people. As a first step, a PowerPoint presentation including the strategic information on HIV and young people was produced and presented in the satellite session facilitated by the global Interagency Task Team on HIV and young people at the International AIDS Conference in Mexico City titled: Achieving Universal Access for Young People. As a second step, a draft synthesis report on HIV and young people was produced with the compilation and analysis on the data/strategic information from the 141 available 2008 UNGASS country and ten shadow reports, UNAIDS report on the global AIDS epidemic 2008 and UN Secretary General s report on HIV and shared with the members of the strategic information working group for their review. In 2008 and in 2009, inputs and suggestions were made by the working group members (strategic information) of the global IATT in order to improve and finalize the synthesis report on HIV and young people. 2. The 2001 UNGASS commitments and the Millennium Development Goals The eight Millennium Development Goals (MDGs) have become well-known since they were first promulgated. In terms of this report, MDG #6 to combat HIV/AIDS and malaria is the obvious area under which HIV and Youth is placed. However, there are also issues in HIV and AIDS that have a bearing on young people that also need to be addressed under MDG #3 promote gender equality and empower women issues regarding the vulnerability and risk that girls and young women face in trying to protect themselves, their partners and their children from HIV infection (MDG #5 to improve maternal health also applies to young women as unprotected sex can result in potentially unsafe and/or unwanted pregnancy). As of 10 March 2008, 147 Member States that had signed the UNGASS Declaration had reported against the twenty-five core indicators that were developed to track implementation of the 2001 Declaration of Commitment. Fifty-one countries that had signed the Declaration did not submit the UNGASS country reports (see APPENDIX ONE). Review and Analysis of the secondary data on international and national goals and targets for the Inter- Agency Task Team on HIV and young people 3

For this report, the following eight UNGASS indicators were analysed because of their relevance and applicability to the AIDS response for Young People: UNG4: UNG7: UNG 11: UNG 13: UNG 15: UNG 16: UNG 17: UNG 22: Percentage of adults and children with advanced HIV infection receiving antiretroviral therapy Percentage of women and men aged 15-49 who received an HIV test in the last 12 months and who know the results Percentage of schools that provided life-skills based HIV/AIDS education within the last academic year Percentage of young women and men aged 15 24 who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission Percentage of young women and men ages 15-24 who have had sexual intercourse before the age of 15 Percent of adults aged 15-24 (or 15-49) who had sex with a non-regular the past 12 months Percentage of adults aged 15 24 (or 15-49) who had more sexual the past 12 months who report the use of a condom during their last intercourse Percentage of young women and men aged 15 24 who are HIV infected Citing HIV prevention as the mainstay of our response, the General Assembly, in its Declaration of Commitment on HIV/AIDS, called for a 25 per cent reduction in HIV prevalence among young people (aged 15-24) in selected countries by 2005 (to be measured by UNG22). As well, by 2005 ninety percent of all young people (aged 15-24) were to have access to vital HIV prevention information, services and commodities, including life skills education, rising to 95% by 2010 (measured by UNG13). Progress against the above indicators will be discussed in this report, and a listing of the countries which reported on these indicators is in APPENDIX THREE with details in APPENDIX FOUR. 3. Rationale for the synthesis of the strategic information from 2008 UNGASS country reports and methodology used This synthesis was undertaken in order to capture and inform efforts on HIV prevention, treatment, care and support among young people. There are plans to compile and analyze strategic information on young people from the UNGASS country reports in 2010, and this report will serve as a baseline. Reports reviewed for the synthesis This report is based on the review of 2008 UNGASS country reports, supplemented by a review of the Reports of the Secretary General to the General Assembly (2006, 2008), the UNAIDS Global AIDS Epidemic Report (2008), and UNAIDS and WHO global and regional epidemic update reports (2007, 2008). As well, the Global Youth Coalition on HIV/AIDS (GYCA) has produced ten 1 shadow country reports in addition to the UNGASS country reports. These shadow reports were prepared by young people who are actively participating in the tracking and reporting of UNGASS commitments; young researchers tracked and monitored progress in their own countries and made recommendations for moving forward. These ten reports were also reviewed for this 1 Egypt, India, Jamaica, Kenya, Nepal, Nigeria, Senegal, USA, Viet Nam, Zimbabwe Review and Analysis of the secondary data on international and national goals and targets for the Inter- Agency Task Team on HIV and young people 4

document, along with six other shadow reports 2 that were produced in response to the 2006 UNGASS reports. Although it was reported (above) that 147 UNGASS country reports had been submitted, only 141 were made available for this review. Of those 141, two reports (Kazakhstan, Qatar) were not analysed because the reports were in Cyrillic or Arabic script. Of the remaining 139, 106 reported on UNGASS youth indicators and 35 did not. Countries like South Africa submitted an UNGASS report, but did not report on indicators relating to young people. A list of countries reported on youth indicators are enclosed in APPENDIX ONE. APPENDIX TWO is the list of countries from sub-saharan Africa reporting UNGASS indicator # 22 and APPENDIX THREE consists of specific UNGASS youth indicators and its reporting by countries. It should be noted that among the 51 that did not submit an UNGASS report or whose report was not made available for this review are several sub-saharan African countries known to have high HIV prevalence rates, such as Burundi, Congo (Brazzaville), Equatorial Guinea and Sudan. From the other regions, notable countries that did not submit an UNGASS country report include Myanmar, Egypt and the United States.. Challenges faced while reviewing and analysing the reports The actual process of accessing the data on HIV and young people from the various UNGASS country reports was not an easy task.these reports range from three to over two hundred pages in length, and the data is not necessarily arranged in the same order in each report. Whereas some countries compiled summary tables at the beginning of their reports, other countries buried the data in the text there was no standardisation in the format of the reports. Further, there were some instances where the data in the introductory summary section did not match the data reported later in the report. It needs also to be noted that there were some cases where data in the 2008 UNAIDS Global Report on AIDS and the UNGASS country report did not coincide, and it was beyond the scope of this report to try to reconcile the data. In most cases, the data from UNGASS country reports are cited here, or the source is footnoted. Defining young people and reviewing the data Globally, approximately one billion young people aged 15-24 make up almost one fifth of the world s population. 3 Young people aged 15-24 account for 45% of all new HIV infections worldwide. 4 However, the foregoing two sentences begin to capture part of the initial problem, and that is what do we mean when we speak of young people? Is it the 10-24 age group, the 15-24 year olds, or some other somewhat arbitrary grouping that separates these people from children and from adults? The UNGASS data has been collected from youth aged 15 to 24 years. The United Nations defines young people as those persons between the ages of 15 and 24 years. By that definition, children are those persons under the age of 14. However, it is worth noting that Article 1 of the United Nations Convention on the Rights of the Child defines children as persons up to the age of 18. 5 WHO considers adolescence as the period between 10 and 19 years. 6 UNICEF often refers to children up to the age of 14, and fifteen is usually the upper limit when people are talking about orphans and vulnerable children (OVCs), although UNICEF programmes for OVCs often go up to the age of 18. Meanwhile, the UN 2 Democratic Republic of the Congo, Ghana, India, Japan, Kenya, Pakistan 3 Youth and the United Nations, Available at www.un.org/youth 4 2008 Report on the Global AIDS Epidemic, UNAIDS, 2008, p. 33. 5 Youth and the United Nations, Available at www.un.org/youth 6 WHO Programming for Adolescent Health and Development. WHO Technical Report Series 886, 1999. Review and Analysis of the secondary data on international and national goals and targets for the Inter- 5 Agency Task Team on HIV and young people

agencies working on HIV follow the broad definition of UNFPA, which is: adolescents: 10-19; youth: 15-24 and therefore young people: 10-24 years. Keeping the upper limit of youth as age 25 is not always feasible. There are countries that classify people as legally adult by the time they are 20 or 21. On the other hand, in many countries, someone is considered a young person until one is in one s thirties. The social and biological differences between a fifteen and a twenty-five year old person are immense: the former may still be barely entered into puberty, still living at home and very much as a child, while the latter could be married, working, parenting several children, and functioning in society with full adult responsibilities. Trying to discuss this group as a homogeneous unit, even within one country or community, or trying to develop a single HIV programming strategy for young people and including both ends of this spectrum is quite challenging. In this report a synthesis of the data from the UNGASS country reports unless otherwise noted, data from adults means data from the indicators specifying people aged 15-49 and data from young people/youth refers to the 15-24 age group. 4. HIV The global picture and its impact on young people 33.2 million people worldwide were living with HIV as of December 2007. 7 The annual rate of new HIV infections appears to have decreased over the last decade, with an estimated 2.7 million people newly infected with HIV in 2007 8 down from 3.2 million in 1998. The annual number of AIDS deaths has declined from 3.9 million in 2001 to 2.0 million [1.8 million 2.3 million] in 2007 9, in part as a result of the substantial increase in access to HIV treatment in recent years. Worldwide, women represent half of all HIV infections among adults, but nearly 60 per cent of those infected in sub-saharan Africa. 10 An estimated 45% of all new HIV infections are in young people aged 15 to 24. 11 In parts of Africa and the Caribbean, young women (15-24) are up to six times more likely to be HIV-infected than young men. Sub-Saharan Africa accounted for 67 per cent of all adults living with HIV, 90 per cent of AIDS deaths of children under the age of fifteen and 75 per cent of all AIDS deaths in 2007. 12 Although different countries have diverse epidemic scenarios, AIDS remains the leading cause of death in the region. According to national estimates that incorporate sentinel surveillance and population-based sero-prevalence surveys, the percentage of adults in sub-saharan Africa aged 15-49 and living with HIV ranges from 0.7 per cent in Senegal to 25.9 per cent in Swaziland. 13 From the other regions, low levels of HIV infection in the general adult population, but the epidemic is concentrated among populations of most -at -risk, such as sex workers, injecting drug users and men who have sex with men. In Asia and Pacific region, the UN Secretary General s Report (2008) indicated that AIDS remains the leading cause of death from disease among people aged 15-44. 14 7 Global AIDS Epidemic, Report, 2008, UNAIDS, p. 16 8 2008 UNAIDS Report, p. 16 9 2008 UNAIDS Report, p. 15 10 2008 UNAIDS Report, p. 33 11 2008 UNAIDS Report, p. 33 12 2008 UNAIDS Report, p. 30, 37 13 UN Secretary General s Report, 2008, p. 8 14 UN Secretary General s Report, 2008, p. 8 Review and Analysis of the secondary data on international and national goals and targets for the Inter- Agency Task Team on HIV and young people 6

The 2008 Secretary General s Report further goes on to state that expanded sets of data and new methods of analysis indicate that although the rate of new infections has fallen globally, the number of people getting newly infected has increased in a number of countries. These include China, Indonesia, the Russian Federation and Ukraine, while HIV infections also seem to be increasing in European Union countries and North America (reflecting a return to high-risk behaviour in vulnerable populations). The number of new infections has yet to fall in some of the countries with the highest HIV prevalence rates, such as Lesotho, Swaziland and South Africa. 15 In nineteen out of the thirty-five countries with hyper-endemic, generalized, or concentrated epidemic scenarios, national surveys conducted between 1990 and 2007 have provided enough comparative data to assess sexual behaviour trends among young people. In some of them the trend data indicate significant reductions risky sexual behaviour that will expose them to HIV. The proportion of young people who reported having had sex with non-regular partners in the previous year decreased for both men and women in Kenya, Malawi and Zimbabwe, and for women only in Haiti and Zambia. However, the proportion of young men and women having sex with non-regular partners increased in Cameroon, Rwanda and Uganda. There have been striking shifts in condom use during sex with non-regular partners. The proportion of young people who said they used condoms the last time they had sex with a nonregular creased for both men and women in Cameroon, Haiti, Malawi and United Republic of Tanzania, and for women only in Côte d'ivoire, Kenya, Togo, Rwanda and Uganda. On the other hand, that proportion decreased for men only in Cote d'ivoire and Rwanda. 16 In Uruguay, unprotected sex (mostly heterosexual) is believed to account for approximately two thirds of newly reported HIV cases. 17 5. UNGASS indicators on HIV and young people An overview As of 10 March 2008, 141 Member States had reported national information against 25 core indicators that were developed to track implementation of the 2001 Declaration of Commitment on HIV/AIDS 18. Five of these are specific indicators that measure prevalence or behavioural details in the 15-24 age range the youth. Another refers specifically to interventions designed for young people - life skills. In reviewing the UNGASS country reports, it was revealed that some countries were not reporting on the indicators on young people. Therefore, data reported on young people is extremely scanty from some countries. As well, any data reported on the most-at-risk populations by countries includes young people within that population, with no age disaggregated data. Countries that submitted UNGASS country reports in 2008 147 Number of UNGASS reports, 2008 reviewed for this analysis 141 Countries that reported on youth indicators through UNGASS reporting 106 Countries that did not report on youth indicators through UNGASS reporting 35 Countries that did not submit UNGASS country reports in 2008 51 APPENDIX THREE is a list of the countries that reported on specific UNGASS youth indicators, and APPENDIX FOUR is a detailed list of eight UNGASS indicators for countries that submitted UNGASS reports. Highlights of that list are presented in this section. The listing follows the numerical order of the UNGASS indicators: 15 Ibid, p. 15 16 2008 UNAIDS Report, p. 36 17 2008 UNAIDS Report p.57 18 As also noted earlier, only 141 UNGASS reports reviewed Review and Analysis of the secondary data on international and national goals and targets for the Inter- Agency Task Team on HIV and young people 7

UNG4: Percentage of adults and children with advanced HIV infection receiving antiretroviral therapy This indicator is most obviously an indicator of people receiving HIV treatment, but the reporting in the country UNGASS reports is by and large at the national level, with no disaggregation by age or region. Therefore, the missing data is the percentage of people on ARVs who are in the 15-24 age range. The 2008 UNAIDS Global AIDS Report notes that by the end of 2007, an estimated 3 million people in low- and middle-income countries were receiving antiretrovirals a 42 per cent increase over December 2006 and a tenfold rise over the last five years. Globally, almost 30 per cent of those who were estimated to need antiretrovirals in 2007 were receiving these drugs. In Namibia, where HIV treatment coverage was negligible in 2003, 88 per cent of individuals in need were on antiretrovirals in 2007. The figure was almost as high in Botswana, which has focused its AIDS response on HIV treatment and care. In Rwanda, antiretroviral coverage increased from 1 per cent in 2003 to almost 60 per cent in 2007. In Thailand and Viet Nam, treatment coverage increased more than tenfold between 2003 and 2007. 19 In total, 102 countries reported on antiretroviral coverage, with a number of countries reporting 100% coverage 20. UNG7: Percentage of women and men aged 15-49 who received an HIV test in the last 12 months and who know their results This is an indicator that can also be viewed as a proxy indicator to understand the extent and effect of HIV information campaigns as well as the availability of HIV counselling and testing services. However, this indicator has substantial variation in the ways that countries are reporting. Seventy-four countries reported on this indicator, with a range from almost zero (Chad 0.5%, Sri Lanka 0.24%) to others reporting almost universal coverage (Seychelles 100%, Barbados 98.5%, Finland 95%). A country like Uganda, which has a well-developed testing system, reported that approximately 4% of the population received an HIV test, whereas neighbouring Tanzania reports that 36% of adults had an HIV test in the past year. A better indicator, on which many countries report, is the percentage of people in the country who do not know their status. This would be a more accurate measure of the information gap and the need for improved quality counselling and testing uptake. In any case, specific information on the uptake of testing and counselling by young people is not reported by countries with age and sex disaggregation. UNG 11: Percentage of schools that provided life-skills based HIV education within the last academic year This is an indicator measures the extent of mainstreaming of HIV in education sector. By 2005, forty-seven of fifty-eight countries reported included HIV education in the secondary school curriculum, while forty-three provided HIV education as part of the primary school curriculum. Sixty-seven countries reported on this indicator through UNGASS reporting in 2008. The percentage of schools where trained teachers actually delivered HIV educational sessions in the past year varies widely among reporting countries (from 3 per cent to 100 per cent). Spain reported a massive range in schools that provide HIV education (the range given was 6.7-93%). Among the 21 countries having comprehensive coverage data, only 9 countries reported having delivered HIV education to more than 50 per cent of young people in 2005. 19 Unless otherwise noted, individual country data is from that country s UNGASS report or the UNAIDS 2008 report 20 Comoros, Sierra Leone, Tunisia, Qatar, Bosnia and Herzegovina, Romania, Cuba, El Salvador, St. Kitts Nevis, Mexico, New Zealand, Tuvalu, Review and Analysis of the secondary data on international and national goals and targets for the Inter- Agency Task Team on HIV and young people 8

By 2007, in countries with generalized epidemics, fewer than 70 per cent had implemented school-based HIV education in most or all districts, and 61 per cent have put in place HIV prevention programmes for out-of-school youth. Where HIV programmes exist, either for inschool or out-of-school youth, their quality has often not been evaluated. 21 It is worth noting that countries such as Botswana, South Africa and Zimbabwe have reported 100% implementation of school HIV programmes. Whether this is a recording of the actual numbers of schools where the programmes are currently being implemented or the target that has been set by the country for HIV education programmes in schools needs to be further explored. UNG 13: Percentage of young women and men aged 15 24 who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission Young peoples knowledge of HIV remains inadequate. The 2008 UN Secretary General s Report states that in 18 countries (14 in sub-saharan Africa and 1 each from Asia and Pacific, Eastern Europe, Latin America and North Africa) in which young people (aged 15-24) were surveyed between 2001 and 2005, fewer than 50 per cent had accurate information/facts on HIV, with young men having a higher level of knowledge than young women in seventeen of the eighteen countries. 22 In 2007, it was reported globally that the national surveys revealed that 40 per cent of young males (ages 15-24) and 36 per cent of young females had accurate knowledge regarding HIV still well below the 95 per cent goal for young people s HIV knowledge unanimously endorsed by Member States in the Declaration of Commitment on HIV/AIDS. Both in sub- Saharan Africa and globally, young women had low knowledge level on basic facts on HIV than males. Most young people know that condoms can prevent sexual transmission of HIV, and 80 per cent of young men and women are aware that being in a monogamous relationship with a person of the same sero-status is an effective HIV prevention strategy. % youth who correctly identify ways of preventing HIV transmission 23,24 2005 2007 2010 global target 90% coverage Males 33% (7-50)* 40% Females 20% (8-44)* 36% * Percentages in parentheses indicate the global range Among the 84 countries that reported through UNGASS reporting on this indicator 25, there was a great range of results revealing not only ignorance, but also misconceptions coexisting with correct knowledge. For example in Trinidad and Tobago, 56% of young women and men aged 15-24 were able to correctly identify ways of preventing the sexual transmission of HIV, but at the same time 36.4% and 25.8% respectively identified praying and avoiding people with AIDS as means of preventing HIV transmission. 21 The above percentages were reported in the 2008 UNAIDS Global AIDS Report which did not specify which countries were being referred to. 22 UN Secretary General s Report, 2008, p. 11 23 UN Secretary General s Report, 2008, p. 5 24 It will be noted that in some cases the data between the 2008 UNGASS Reports, the 2008 UN Secretary General s Report, the 2008 Shadow Reports, and the 2008 UNAIDS Global Epidemic Report do not coincide. Reconciling this data was beyond the scope of the current report. 25 See APPENDIX FOUR Review and Analysis of the secondary data on international and national goals and targets for the Inter- Agency Task Team on HIV and young people 9

UNG 15: Percentage of young women and men age 15-24 who have had sexual intercourse before the age of 15 In low- and middle-income countries, the percentage of young people having sex before age 15 is decreasing in all regions a continuation of trends detected earlier this decade. Over the past ten years, data from selected countries, such as Kenya and Zimbabwe, indicate that significant, population-wide changes in sexual behaviour can be achieved and that such behavioural shifts have the potential to reverse national epidemics. Between 1998 and 2007, the share of young people globally reporting sexual intercourse before age 15 fell from 14 per cent to 12 per cent. Worldwide, boys are significantly more likely to report sex prior to age 15 except in sub-saharan Africa, where adolescent girls under 15 are almost 50 per cent more likely than boys to be sexually active. 26 While global trends towards delayed sexual debut are clear, surveys reveal substantial variations between countries, including a trend towards earlier sexual debut in some countries. 95 countries reported on this indicator, and while most of the higher level results are from Africa and Latin America (Sao Tome 60%, Chad 35%, Brazil 45.3%), the Netherlands also reports that by age 17, 50% of the population is sexually active. The 2008 UNAIDS Global AIDS Report confirms this, noting that age of first sexual activity in sub-saharan Africa is comparable to high-income countries, ie US where 47% of young people have initiated sex by the time they finish high school. 27 In Swaziland, sexual debut is delayed only 4.8% of males and 6.9% of females aged 15-24 said that they had sex prior to age 15. 28 However, once they become sexually active, they are at risk given the extremely high HIV prevalence rates amongst adults in Swaziland. On the other hand, in Brazil, where the overall HIV prevalence is 0.41% (and 0.26% in the 15-24 year old category), 45.3% of males and 25.5% of females age 15-24 reported sex before the age of 15. 29 UNG 16: Percent of adults aged 15-49 who had sex with a non-regular the past 12 months Globally, 15 per cent of adult men aged 15-49 reported having sex with more partner in the previous 12 months, compared to 6 per cent of women. 69 countries reported on this indicator in the 15-49 year age group, with only 40 specifically reporting on the 15-24 year age group, but as can be seen from APPENDIX FOUR, there is great variation on how this was reported, ranging from a single figure, or reporting on women only, to disaggregating by sex, to reporting separately on ages 15-19 and 20-24, with a few countries disaggregating between males and females as well as between the two age groups. The percentage of young women and men reporting sex with a casual partner over the past year varies tremendously by country, region and sex. For example, in Namibia, preliminary data from a 2006 population-based survey show that, among young people (15 24 years), 90% of sexually active men and 75% of women reported having had sex with a non-marital, noncohabiting the previous 12 months. 30 In Moldova, the percentage of men reporting a casual partner was 20.2% for the 15-19 years group and 31.9% for the 20-24 years group, but only 2.2% and 4.5% for the females in the same groups. Brazil reported a differential of 29.5% for men and 7.3% for women. And other results raise questions about data reliability, such as 26 2008 UNAIDS Global Aids Report 27 2008 UNAIDS Global AIDS Report pg. 105 28 Swaziland Country Progress Report, 2008 29 Brazil Country Progress Report, 2008 30 Namibia Country Progress Report, 2008, p. 21 Review and Analysis of the secondary data on international and national goals and targets for the Inter- Agency Task Team on HIV and young people 10

Guatemala, where it is reported that 34.2% of men aged 15-19 have had a casual partner, but only 19.1% of those aged 20-24. UNG 17: Percentage of adults aged 15 49 who had more sexual the past 12 months who report the use of a condom during their last intercourse This indicator is a measure to assess practising safe behaviour. Condom use among sexually active 15- to 24-year-olds appears to have increased as reported by 11 countries in sub- Saharan Africa. Notable exceptions were Rwanda and Uganda, where condom use by young men actually decreased. As in other aspects of young people s sexual behaviour, there is tremendous variation in rates of condom use by country, region and sex. While condom use increased among young people in most of the sub-saharan African countries surveyed, the overall frequency of condom use remains below 50 per cent, with fewer females than males reporting condom use during intercourse with a non-regular partner. In Namibia, for example, half of the women (48%) and a third of the men (33%) surveyed did not use a condom consistently with those partners. 31 62 countries reported on this indicator for the 15-49 year age group, with 41 specifically reporting for the 15-24 year group. As can be seen in APPENDIX FOUR, as with other indicators, there is great variability that is not necessarily related to HIV prevalence. For example, in Canada, 23% of 15-49 year olds reported using a condom 32 with only 12.8% reporting in Costa Rica. 33 In Cambodia, 40.4% of males but only 12.3% of females aged 15-49 reported condom use, but 75% of the 15-24 year olds reported using a condom during last intercourse. 34 However, this data was not disaggregated by sex. UNG 22: Percentage of young women and men aged 15 24 who are HIV infected UNGASS indicator 22 has been adopted as a proxy measurement for incidence, and thirty-five countries (listed in APPENDIX TWO) had reported on trends in HIV prevalence among 15 24- year-old pregnant women, in whom HIV infections are likely to be relatively recently acquired, are influenced less by mortality and antiretroviral treatment than are trends in adult or all-age HIV prevalence. The countries were to report data from sero-prevalence surveys of young women in antenatal clinics. However, 23 out of the 35 countries had insufficient or no data on HIV prevalence and/or sexual behaviour trends among young people including several countries with high HIV prevalence. In the remaining twelve high-prevalence countries 35 with sufficient data to identify trends, HIV prevalence among young women has declined since 2000-2001, in some cases by more than 25 per cent, with more modest reductions elsewhere. As can be seen from APPENDICES THREE and FOUR, 74 UNGASS reports provide data on this indicator, and the vast majority give a single figure, which is presumably prevalence among antenatal mothers. Eleven countries disaggregate between the 15-19 and the 20-24 age groups, and a handful (four) actually provide separate data for males and females. In Kenya, HIV prevalence among young pregnant women declined significantly by more than 25% in both urban and rural areas, while similar declines were observed in urban areas of Côte d Ivoire, Malawi and Zimbabwe, and in rural parts of Botswana. Less striking (i.e. statistically non-significant) declines in prevalence in young pregnant women have occurred in both urban and rural areas of Burkina Faso, Namibia and Swaziland, urban parts of the Bahamas, Botswana, Burundi and Rwanda, and rural parts of the United Republic of Tanzania. There 31 Namibia Country Progress Report, 2008, p. 23 32 Canada Country Progress Report, 2008 33 Costa Rica Country Progress Report, 2008 34 Cambodia Country Progress Report, 2008 35 the Bahamas, Botswana, Burkina Faso, Burundi, Côte d Ivoire, Kenya, Malawi, Namibia, Rwanda, Swaziland, the United Republic of Tanzania and Zimbabwe Review and Analysis of the secondary data on international and national goals and targets for the Inter- Agency Task Team on HIV and young people 11

was no evidence of a decrease in HIV infection levels among young people in Mozambique, South Africa or in Zambia. Some of these results are seen in Table 1. Table 1: percentage of young women 15-24 who are HIV-infected (in order of % change) 36 Country Prevalence 2001 (%) Prevalence 2006-2007 (%) % change Notes Burkina Faso 3.9 1.3-66 Zimbabwe* 19.9 (2002) 13.1-34.1 Kenya* 29 (1999) -> 9 5.9-34.4 (2002) Thailand 0.95 (2004) 0.64-32.6 Cote d Ivoire* 6.2 (2004) 4.5-29.7 Ghana 3.5 (2002) 2.5-28.6 1.9% in 2005 -> 2.5% in 2006 Botswana* 15-19 yrs 25 20-24 yrs - 39 15-19 yrs 18 20-24 yrs - 29-28 - 25.6 Cambodia 1.2 (2003) 0.9-25 Namibia* 18 (2003) 14-22.2 Rwanda* 4.6 (2002) 3.6-21.7 Malawi* 14.4 (2003) 12-16.7 South Africa <20 yrs 15.9 20-24 yrs 30.6 <20 yrs 13.7 20-24 yrs - 28-13.8-6.7 Swaziland* 39.4 34.6-12.2 Lesotho 14.9 Jamaica 1.1 (2003) 1.3 +18.1 Mozambique 12.5 16.2 +29.6 * 35 countries reported on prevalence in young antenatal women An interesting comparison can be made in APPENDIX FOUR by comparing the data for UNG 22 with the national prevalence (column 1). Where the data exists, one would expect the prevalence in the youngest age group (15-19) to be less than the national average, and then closer to the national average in the 20-24 group, and in many countries this seems to be the case. But in some countries, this pattern is not followed. To give the example of two high prevalence countries: in Swaziland the prevalence in the 15-24 group (34.6%) is more than eight percentage points above the national average 37, while in Botswana the prevalence in the 15-24 year group is one-third the national average. 38 This may be an example of markedly different epidemiology of HIV transmission between the two countries (reflecting the diversity and heterogeneity of the HIV epidemic even within the same sub-region), but it may also reflect more variable qualities of data collection and reporting. In lower risk countries, similar variations are seen. In the Philippines the overall prevalence in the 15-49 population is 0.1%, while in the 15-24 population the female prevalence is 4% and the male prevalence is 3.7%. 39 In India, the overall prevalence in the 15-49 age group is 0.36% while in the 15-24 year old group it is 0.57%, a possibly significant difference 40. Conversely, in Cuba, the overall 15-49 prevalence is 0.1% while it is only 0.03% in the 15-24 year old group. 41 36 The countries listed in Table 1 are examples of cases that demonstrated significant changes in the percentage of young women who are HIV-infected from 2001 and 2007. Source: respective Country UNGASS Progress Reports, 2008 37 Swaziland Country Progress Report, 2008, p. 2 38 Botswana Country Progress Report, 2008 39 Philippines Country Progress Report, 2008 40 India Country Progress Report, 2008 41 Cuba Country Progress Report, 2008 Review and Analysis of the secondary data on international and national goals and targets for the Inter- Agency Task Team on HIV and young people 12

There are other countries, such as Malawi, Kenya, Ghana and Cote d Ivoire, where the two figures are practically identical, which may be a reminder that antenatal prevalence is still being used as a proxy for the national prevalence in many countries, despite the many reasons why young pregnant women may not be representative of the entire sexually-active population. 6. Emerging issues and gaps In the process of reviewing progress against the UNGASS indicators, a number of common themes and issues repeatedly emerged that have relevance whether a country has high or low national seroprevalence, or whether the epidemic is localised, generalised, emerging or mature. The following are some of the main issues that have emerged from the review of the 141 UNGASS reports received: Many countries have well-developed HIV policies for women, children, orphans, and an assortment of most-at-risk groups, but lack a coherent policy for young people and involvement of young people in the decision-making process: A review of those UNGASS country reports that address policy issues reveals that many countries do not have a specific policy with regard to HIV and youth. There are policies for orphans and vulnerable children (OVCs), and numerous countries have policies regarding gender, most-at-risk groups, and other vulnerable populations. Globally, more than 80 per cent of countries, including 85 per cent in sub-saharan Africa, have policies in place to ensure women s equal access to HIV prevention, treatment, care and support. Many of these policies are for women and girls, i.e. Programmes must be grounded in a commitment to the protection of the human rights of girls and women. Young people are either considered part of the adult population, or when mention is made of them it is usually in the HIV Prevention sections of the policy documents, where they are identified either as a vulnerable group or a segment of the population out-of-school youth, for example, are identified as a group. In the Declaration of Commitment 2001, young people are specifically mentioned only in the section on Prevention. And while prevention in young people is undoubtedly the most important issue, it is also true that HIV care, and mitigation is also important to young people. Young people are, of course, also the primary recipients of some of the most widespread HIV prevention programmes, delivered to both in-school and out-of-school, many of which promote abstinence and delaying the early initiation of sexual activities, youth clubs, newsletters and various Behaviour Change Communication materials etc. And it is obvious that the societal, behavioural and attitudinal changes that need to occur in order to revert the epidemic need to come through changes in the population that is just beginning their sexual lives the young. By 2005, eighty-five per cent of the seventy-eight countries reporting through UNGASS had a policy or national HIV strategy in place to promote HIV-related sexual health education for young people. The UN Secretary General s Report 2006 noted that the remaining challenge is to ensure effective implementation of educational programmes that are tailored to the needs of young people and offered in a manner that motivates young people to reduce their risk of infection. 42 That being said, a common theme running through most of the UNGASS shadow reports is that while there may be policies in place that mention young people or issues of concern to young people, there may be little implementation of those policies taking place at the community level 42 UN Secretary General s Report, 2006. Review and Analysis of the secondary data on international and national goals and targets for the Inter- Agency Task Team on HIV and young people 13

to address the issues of young people and strategies cited in the policy document. As well, despite some token efforts in some countries to include them, young people do not feel part of the process, in that they are not being consulted when HIV national strategic plans are being made with strategies and programmes that concern them. In a number of UNGASS shadow reports, reference was made to HIV prevention messages that were not appropriate or specifically tailored to the target audience, or abstinence campaigns that targeted inappropriately, at older youth populations who were already sexually active, and for whom a safe sex rather than no sex message would have made for better results. It is not only the lack of policy that has been mentioned repeatedly in the country UNGASS reports, but the lack of implementation in those countries that do have a policy on young people. The lack of involvement of youth is another issue that was mentioned repeatedly, especially in the ten Shadow Reports that were reviewed. The Shadow Reports repeatedly noted that government, policy makers and often the leaders of youth friendly NGOs do not involve and consult with the young people for whom they are supposedly working. The UNAIDS Global Report on AIDS, 2008 notes that a central weakness of many HIV prevention initiatives for young people is that they do not speak frankly or provide the accurate, comprehensive information that young people need. Many countries that require HIV education in schools have curricula that prioritise abstinence focused programming, discouraging forthright discussions about condoms and safe sex. However, no study in low- and middleincome countries has found this approach to be effective, and studies in the United States indicate that youth-oriented prevention programmes that exclusively promote abstinence do not reduce the risk of HIV infection. 43. HIV prevention needs to begin before the age of 15: The UNGASS data from many countries from all regions reveal that by the age of fifteen, a significant proportion of the population, especially the male population, may have already become sexually active (greater than 30% in the DRC and Cuba and greater than 40% in Haiti, Jamaica, and Brazil). 44 Whether that activity is consensual or the result of rape, violence or other coercion, or whether the fifteen year olds are having sex with their own cohort or with older adults is immaterial to the point that whatever the behaviour and attitude change interventions to be delivered, the message has to begin well before the age of fifteen if there is to be any hope of influencing behaviour in the later teenage years when sexual activity increases. Age and sex disaggregation is not done when compiling data on most-at-risk populations (sex workers, men having sex with men (MSM), and injecting drug users (IDUs): Even though young people are part of most-at-risk populations, countries were not reporting data with age and sex disaggregation, even though it is requested through UNGASS reporting. Young people do make up a significant proportion of the MSM, IDU, and sex worker (SW) communities, and may very well have risks different from their older colleagues (e.g. Teenage sex workers who may not have the negotiating skills of more experienced SWs to demand condoms or who may accede to riskier practices for financial rewards under coercion). Special issues that might be of concern to young IDUs, SWs, MSMs are not reported on, and their data is subsumed in the broad category of most-at-risk populations, without having disaggregation by age within the UNGASS country reports. These issues are highlighted in some of the UNGASS reports, such as Macedonia, where it states that (among) men who have unprotected sex with men, people selling sex, and injecting drug users, young people co-exist with older community members and both share many of the same experiences and vulnerabilities, as well as exhibit some specificities to their age group. 43 2008 Global Report on UNAIDS pg. 103 44 Respective Country UNGASS Progress Reports, 2008 Review and Analysis of the secondary data on international and national goals and targets for the Inter- Agency Task Team on HIV and young people 14

However, there do seem to be particular barriers to accessing appropriate preventive and treatment services that are related to both legislative restrictions on service provision to adolescents, and the caution with which harm reduction non governmental organization working with most-at-risk groups operate in order to avoid being accused of exploitation or abuse of young people. These barriers are further aggravated by prevailing social attitudes that stigmatize most-at risk adolescents and marginalize them. 45 In many countries there are legal constraints against providing necessary HIV and reproductive health services as well as health education to young people: Part of the problem in developing programmes for young people are legal issues regarding age of majority, which has an effect on young people s rights to access condoms, testing, counselling, and access to family planning services, HIV treatment, etc. The age of consent and marriage varies widely from country to country, between males and females and even within a country. With such variation across the world and with most of the laws not being explicit, it is difficult to realise a norm in terms of child rights and the relationship of a child to the state. These legal barriers affect HIV programming globally.whether it is in North America, Asia or Africa, there are many communities where even the public teaching of safe sex messages to young people under the age of majority is not tolerated. And in these communities, the ability to actually implement needed interventions to young people, whether it is provision of condoms, family planning or other reproductive health services, is severely compromised. This issue is not limited to any one region and involves the teaching of health education messages in the schools, the legal age for young people to receive reproductive health interventions or contraceptives, or religious and cultural strictures that mitigate against public discussion of HIVrelated issues. On a broader scale, a number of countries report on stigma and discrimination affecting women as well as a number of high-risk communities such as MSMs. But hardly any reports discuss stigma and discrimination regarding young people aged 15-24, who may be denied access to services, treatment and care because of their age. As noted in some of the Shadow Reports, the Declaration of Commitment (DoC) in 2001 stated that young people were not to be denied access to HIV prevention and treatment services, and one might argue that in those countries where reproductive health services are not available to them, that constitutes a violation of their human rights. The prevalence of HIV in young people does not seem to be linked to any particular variable: There continues to be debate as to why the prevalence has been falling in some countries, because there do not appear to be temporal or other linkages to the initiation of certain initiatives, and a cursory review of APPENDIX FOUR reveals this continued lack of association. While there is evidence that changes in HIV prevalence in some countries is linked to measurable behaviour change, the difference in prevalence in other countries is not necessarily linked to any of the UNGASS indicators that have been reviewed. For example: Age at first sex Swaziland has an HIV prevalence of 26%, with 4.8% of males and 6.9% of females having sex before age 15. In Lesotho, six times as many men and twice as many women have sex before age fifteen as Swaziland, and yet the two country s prevalence rates are almost the same More the past year many more young people in Ghana admit to more the previous year, and yet the prevalence in Swaziland is ten fold greater 45 Macedonia UNGASS Report page 24 Review and Analysis of the secondary data on international and national goals and targets for the Inter- Agency Task Team on HIV and young people 15

Condom use Namibia and Guyana both report high rates of condom use (greater than 60%) yet the prevalence in Namibia is nine times higher. The HIV prevalence often differs substantially between young men and women: The UNGASS indicators in many African countries, some of which are listed in APPENDIX FOUR, showed that young women are frequently two to three times more likely to contract HIV than their male counterparts. This is not widely reflected in other regions. For example, fourfifths of infected individuals in Croatia are male 46, and that proportion is reflected in Hungary (85% male) 47 and Georgia (77.6% male) 48. However, in Estonia in 2004, for the first time, in the 15-19 year old age group, the number of women infected was bigger than men. 49 A number of factors may account for this, including differences in biological susceptibility, the effects of inter-generational mixing, and other local socio cultural factors. However, the relationship between these factors is not well-understood with evidence, making it difficult to design specific age- or sex-targeted interventions. The paradigm guiding most HIV intervention policy is that increased knowledge influences behaviour and practices, but this is not necessarily the case: There are several examples in APPENDIX FOUR where a high rate of knowledge about HIV (UNG13) is linked to less risky behaviour (UNG 16), but there are also several examples that do not demonstrate any correlation. Not all of the UNGASS indicators are being well-reported, and not all of the countries who should be reporting data on young people are indeed doing so: APPENDIX ONE notes the 35 countries that submitted an UNGASS report but did not report on indicators relating to young people (or were incomplete). (Notable examples include the Bahamas, China, Indonesia, Kazakhstan, Pakistan, Philippines, and South Africa.) Furthermore, 51 UN member countries did not submit any reports. Response rates and data quality issues: A number of the UNGASS indicators for young people are behavioural questions that are not surveyed annually, but only for the country s Demographic and Health Surveys (DHS), which are often conducted every five years. Therefore, while the UNGASS Reports are supposedly reporting 2007-2008 data, some of the information in APPENDIX FOUR is from DHS s that were conducted in 2003 and 2004, so trying to assess progress since 2001 in 2008, using data from 2003-4, has its own share of caveats. There also seems to be variance in reporting several UNGASS indicators. For example: UNG 7 - Percentage of women and men aged 15-49 who received an HIV test in the last 12 months and who know the results the results of this vary enormously, and it seems that different countries are reporting different measurements: the number of people tested against the total population of the country, the number of people who received results against the total number tested, etc. UNG 16 and 17 these two indicators measure sexual intercourse with more the previous year, and whether a condom was used - the majority of countries interpret this to mean people in the 15-24 age range, however, other countries, such as Benin, report data in the 15-49 range and a few countries (such as Antigua and Bermuda) report both. Many countries, such as Algeria, did not publish results. 50 46 Croatia Country Progress Report 47 Hungary Country Progress Report pg 1 48 Georgia Country Progress Report pg.3 49 Estonia Country Progress Report pg. 5 50 UNGASS 2008 Reports Review and Analysis of the secondary data on international and national goals and targets for the Inter- Agency Task Team on HIV and young people 16