SUPPLEMENT ARTICLE

Epidemiology of HIV and AIDS Among Adolescents:

Current Status, Inequities, and Data Gaps
Priscilla Idele, PhD,* Amaya Gillespie, PhD,* Tyler Porth, MSPH,* Chiho Suzuki, PhD,*
Mary Mahy, ScD, Susan Kasedde, DrPH,* and Chewe Luo, PhD*

Objectives: To examine levels and patterns of HIV prevalence,

knowledge, sexual behavior, and coverage of selected HIV services
among adolescents aged 1019 years and highlight data gaps and
challenges.

Methods: Data were reviewed from Joint United Nations Programme on HIV/AIDS HIV estimates, nationally representative
household surveys, behavioral surveillance surveys, and published
literature.
Results: A number of gaps exist for adolescent-specic HIVrelated data; however, important implications for programming can
be drawn. Eighty-two percent of the estimated 2.1 million adolescents aged 1019 years living with HIV in 2012 were in sub-Saharan
Africa, and the majority of these (58%) were females. Comprehensive accurate knowledge about HIV, condom use, HIV testing, and
antiretroviral treatment coverage remain low in most countries. Early
sexual debut (sex before 15 years of age) is more common among
adolescent girls than boys in low- and middle-income countries,
consistent with early marriage and early childbirth in these countries.
In low and concentrated epidemic countries, HIV prevalence is highest among key populations.
Conclusions: Although the available HIV-related data on adolescents are limited, increased HIV vulnerability in the second decade
of life is evident in the data. Improving data gathering, analysis, and
reporting systems specic to adolescents is essential to monitoring
progress and improving health outcomes for adolescents. More
systematic and better quality disaggregated data are needed to
understand differences by sex, age, geography, and socioeconomic
factors and to address equity and human rights obligations,
especially for key populations.
Key Words: HIV, AIDS, adolescents, prevention, care, treatment
(J Acquir Immune Dec Syndr 2014;66:S144S153)

From the *United Nations Childrens Fund, New York, NY; and Joint United
Nations Programme on HIV/AIDS, Geneva, Switzerland.
Initial results of this article were rst presented at a technical meeting
supported by United Nations Childrens Fund on HIV Prevention, Treatment, and Care in Adolescents at the London School of Hygiene and
Tropical Medicine, United Kingdom, 810 July, 2013.
The authors have no funding or conicts of interest to disclose.
Correspondence to: Priscilla Idele, PhD, United Nations Childrens Fund, 3
UN Plaza, New York, NY 10017 (e-mail: [email protected]).
Copyright 2014 by Lippincott Williams & Wilkins

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INTRODUCTION
This article focuses on adolescents, dened as aged
1019 years.1 Adolescence is the period when many people
begin to explore their sexuality; as a result, access to sexual and
reproductive health information and services becomes increasingly important. Despite the well-known need for protection
from HIV infections and other reproductive health risks, their
age and their social and economic status limit adolescent access
to information and services in many settings. Adolescence is
typically a period of experimentation, new experiences, and
vulnerability. Some adolescents may experiment with injecting
drugs, sexuality, and sexual orientation (men may begin to
have unprotected sex with other men), and some are exploited
sexually. Millions of adolescents who are becoming sexually
active live in countries with a high burden of HIV. Adolescence provides a window of opportunity in which to intervene
early. Comprehensive data are essential to shaping accurate
HIV-related messages and services before risky behaviors are
formed and become entrenched.
Since 2000, various global declarations and commitments, with specic goals and targets, have been made and set
by world leaders and governments to respond to the HIV and
AIDS epidemic. Most are general in nature; however, the
United Nations General Assembly Special Session on HIV and
AIDS (UNGASS) in 2001 specically included a target to
reduce the prevalence of HIV in young people aged 1524
years globally by 25% by the end of 2010 and to increase
young peoples access to essential HIV prevention information,
skills, and services so as to reach 95% of those in need by the
same date.2
More recently, for the countdown to 2015, the UN
Secretary Generals High-Level Advisory Panel on the Post
Millenium Development Goals Agenda released recommendations for post-2015.3 The report emphasizes equity, empowerment, and engagement of adolescents and youth and
strengthening of data as core drivers of transformation in the
next development agenda.
Although these global commitments, goals, and targets
are relevant for adolescents, the implications and accountabilities are rarely specic to this age group. In addition,
adolescent-specic data are limited, which present a serious
impediment to measuring and monitoring progress. Although
the international reporting process recommends reporting on
disaggregated data on adolescents and youth, little of these data
are collected or published in global or national progress
reports.4 As a result, compared with infants and adults, less
is known about the burden of HIV and AIDS among

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adolescents and progress to date in addressing their needs for

HIV prevention, care, and treatment services. To address this
gap, this article provides an overview of the global epidemiology of HIV and AIDS among adolescents and examines progress in their access to key selected, HIV-related high-impact
interventions that reduce HIV risk, morbidity, and mortality.
The article also highlights some of the remaining challenges in
data availability and monitoring of the HIV response among
adolescents and proposes some areas for further development.

METHODS
Epidemiological HIV and AIDS data on the burden of
disease and prevalence in adolescents at global and regional
levels were derived from the 2012 Joint United Nations
Programme on HIV/AIDS (UNAIDS) HIV and AIDS
estimates and reanalysis by United Nations Childrens
Fund.1,5 In addition, HIV prevalence data from national
population-based surveys in selected countries in which
HIV testing had been included610 were used to assess differentials by age and sex.
Data on adolescent HIV knowledge and sexual behavior for selected indicatorsknowledge about HIV, HIV testing uptake, sexual debut before 15 years of age, multiple
sexual partners, and condom use among those with multiple
partnerswere drawn from nationally representative
population-based surveys, such as the Multiple Indicator
Cluster Surveys11 and the Demographic and Health Surveys,6
or other nationally representative surveys. These surveys have
standardized methods and instruments to ensure that data are
comparable between survey rounds and across countries.
Data on adolescent key populations, such as young men
who have sex with men (MSM), sexually exploited children,
and adolescents who inject drugs, were mainly drawn from
the UNAIDS 2013 Global AIDS Report,5 supplemented with
various special targeted studies, including the published
literature.
Where applicable, knowledge and behavior indicators
were analyzed to assess levels of coverage and disparities by
selected characteristicsage, sex, rural and urban residence,

Epidemiology of HIV and AIDS Among Adolescents

education, and household economic status. Trend analysis is

described for relevant indicators in countries where repeat
surveys have been conducted in the last 510 years.

RESULTS
Burden of HIV and AIDS in Adolescents
Globally, an estimated 35.3 million people were living
with HIV at the end of 2012; of these, 2.1 million were
adolescents aged 1019 years, of which the majority was girls
(56%).12 The gender disparity has persisted over time, with
this number remaining largely unchanged over the past 5
years. These estimates include both adolescents who acquired
HIV through mother-to-child transmission (perinatal and
postnatal transmission through breast-feeding) and who
acquired HIV behaviorally through unprotected sex or by
sharing nonsterile injecting equipment.
The majority of HIV infections are in sub-Saharan
Africa, where 85% of all adolescents living with HIV were
located in 2012 (1.7 million) (Table 1). About 1.3 million
adolescents living with HIV in sub-Saharan Africa were in
Eastern and Southern Africa and 390,000 in the West and
Central Africa. Outside sub-Saharan Africa, South Asia had
the highest number of adolescents living with HIV
(130,000), accounting for 6% of the global burden of HIV
among adolescents, followed by East Asia and the Pacic
(110,000), Latin America and the Caribbean (81,000), Eastern
Europe and Central Asia (22,000), and the Middle East and
North Africa (17,000).

New HIV Infections Among Adolescents

About 300,000 new infections occurred among adolescents aged 1519 years in 2012, which accounted for about
13% of the 2.3 million new infections globally in 2012 (about
830 adolescents were infected with HIV everyday of 2012).12
However, global aggregate data on the epidemic in adolescents,
and youth in particular, mask signicant regional and population differences. In 2012, approximately two-thirds of all new
HIV infections in adolescents were among girls, mainly in

TABLE 1. Estimated Number of Adolescents Aged 1019 years Living With HIV by United Nations Childrens Fund
Regions, 2012
Estimated Number of Adolescents Living With HIV, 2012
Sub-Saharan Africa
Eastern and Southern Africa
West and Central Africa
Middle East and North Africa
South Asia
East Asia and the Pacic
Latin America and the Caribbean
Central and Eastern Europe and the Commonwealth of
the Independent States
Global

Total Aged 1019 yrs

Females Aged 1019 yrs

Males Aged 1019 yrs

Female, %

1,700,000
1,300,000
390,000
17,000
130,000
110,000
81,000
22,000

1,000,000
800,000
220,000
9100
62,000
55,000
35,000
11,000

720,000
550,000
170,000
8300
64,000
53,000
46,000
11,000

58
59
56
52
49
51
43
52

2,100,000

1,200,000

930,000

56

Source: United Nations Childrens Fund analysis of unpublished UNAIDS 2012 HIV and AIDS estimates.

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sub-Saharan Africa.1 In some countries in this region, more

than 80% of the adolescents newly infected with HIV in
2012 were adolescent girlsSouth Africa (82% female),
Sierra Leone (85% female), Gabon (89% female), etc.12

HIV Prevalence Among Adolescents in

Generalized Epidemics
In generalized epidemic countries with data, HIV
prevalence among adolescent females tends to be considerably higher than among adolescent males, suggesting that
context heightens adolescent girls sexual risks and vulnerabilities (Fig. 1). Most of the countries with the highest HIV
prevalence rates in the world are in Southern Africa. Agespecic prevalence data show a clear sex disparity in HIV
prevalence by the age of 15 years. For example, in Swaziland
where adult prevalence is estimated to be the highest in the
world at over 26% in 2012,5 a 20062007 survey found that
HIV prevalence in adolescents aged 1014 years is low and
similar to that of young children, but prevalence begins to
increase in adolescent girls aged 1519 years where it is 5
times as high as in boys of the same age. Nearly 40% of
young women are HIV positive by the age of 2024 years,
rising to nearly 50% by the age of 2529 years7 (Fig. 1).
In a range of relatively high HIV burden countries in
Africa, such as Botswana, South Africa, and Uganda, a similar
and worrying trend is evident, with low HIV prevalence in

early childhood for both sexes, which shifts with entry into
adolescence accompanied by increased prevalence among
females compared with males. The gap continues to widen
between the sexes during adolescence into young adulthood.8,9 HIV prevalence in Uganda is nearly double in adolescent girls aged 1519 years (3.0%) compared with boys of
the same age (1.7%)10 (Fig. 1).

HIV Prevalence Among Adolescents in Low

and Concentrated HIV Epidemic Settings
The limited studies available from low and concentrated
epidemic countries suggest that HIV prevalence is disproportionately high among adolescents belonging to key populations, especially adolescent MSM, adolescents who inject
drugs, and adolescents who are exploited sexually. These
adolescents also face high levels of stigma, which can prevent
their access to support and key services for prevention of HIV
infection.
In Ukraine where HIV prevalence was 0.9% among
people between 15 and 49 years old in 2012, and is among the
highest in the Eastern and Central Europe, the prevalence
among young people who inject drugs (PWID), younger than
25 years in Kiev, has been reported at 7.1%. Prevalence among
MSM and sex workers younger than 25 years in Kiev was
4.2% and 3.0%, respectively.5 Similarly, in the Russian Federation, although HIV prevalence in the general population was

FIGURE 1. HIV prevalence by age group in Swaziland (20062007), South African (2012), Botswana (2012), and Uganda
(2011).

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estimated at 1% in 2012, the prevalence among injecting drug

users (IDU) younger than 25 years in Moscow was estimated at
12%. HIV prevalence among MSM and sex workers younger
than 25 years in Moscow was reported at 10.8% and 4.1%,
respectively.5
Local studies in Asia show that HIV transmission
resulting from sexual exploitation and commercial sex has
been relatively contained, although pockets of concern
persist.13 Although these studies are not limited to adolescents, HIV transmission from unprotected sex between males
seems to be a key driver of the epidemics in several countries.
HIV prevalence exceeding 10% has been found in cities in
China,14 India,15 Thailand,16 and Vietnam.17
In most Latin American countries, the estimated HIV
prevalence in the general population is below 1%. However,
it is reported to be as high in major urban areas among MSM
younger than 25 years, eg, 13% in Paraguay, 12% in Mexico,
10.5% in Peru, 9.5% in Colombia, 9% in Argentina, and more
than 5% in several other countries in the region.5
Although IDU behaviors do not seem to be highly
prevalent among adolescents, the risks are extremely high for
those who do inject.18 There are also concerns about increasing
levels of use in some parts of the world. In a 2012 survey in
Myanmar, HIV prevalence was 7% among 15- to 19-year olds
who injected drugs and more than double that (15%) among
20- to 24-year olds.19 Studies suggest that injecting drug use

Epidemiology of HIV and AIDS Among Adolescents

accounts for more than two-thirds of all new infections in Iran,

40% of new infections in Eastern Europe, and more than onethird in Philippines.5 In Pakistan, where IDU is a key driver of
the epidemic, studies indicate that HIV prevalence among
PWID more than tripled, from 11% in 2005 to 38% in 2011.20

HIV Knowledge
The overwhelming majority of new HIV infections are
transmitted through sex. A basic understanding of HIV and
how it spreads is a necessary component of prevention,
although this is not sufcient to change behavior and reduce
risk. Despite consistent calls for improving knowledge, in
general, levels of knowledge of HIV among adolescents and
young adults are appallingly low, especially in the worstaffected countries.
Recent surveys in countries with generalized epidemics
show that, in most of these countries, less than half of
adolescent boys and girls, aged 1519 years, have a basic
understanding of HIV (Fig. 2). This falls far short of the
95% target agreed in 2001 at the UNGASS. Consistent with
the higher rates of HIV among girls in the most affected
regions, girls tend to have worse knowledge levels than boys
of the same age. In sub-Saharan Africa, only 26% of adolescent girls aged 1519 years and 36% of adolescent boys of
the same age have a comprehensive and correct knowledge of

FIGURE 2. Percentage of adolescents aged 1519 years and young women and men aged 2024 years with comprehensive
correct knowledge of HIV, by country, sex, and age in selected countries, 20072012.
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HIV.1 Disparities in knowledge about HIV prevention among

adolescent girls and boys are linked to gender, education,
household wealth, and place of residence.21 Adolescent girls
and boys in poor households and living in rural areas are less
likely to have comprehensive knowledge about HIV and
AIDS. These differences persist in nearly all countries with
available data.21 Global and regional averages can mask individual country progress. Several countries show evidence of
improved knowledge about HIV prevention. Between 2000
and 2012, Belarus, Guyana, Jamaica, Namibia, Rwanda,
Serbia, Swaziland, Trinidad and Tobago, Vietnam, and
Zimbabwe witnessed remarkable increases in knowledge
about HIV prevention to levels above 50% or more among
adolescent girls, and there were similar increases among adolescent boys in Rwanda and Namibia.21

Sexual Debut
Early sexual debut (before 15 years of age) provides
more opportunities over time for adolescents to be exposed to
HIV, especially where higher risk partners or multiple
partners are involved and condom use is less likely. The lack
of awareness and other social pressures and power imbalances
can also conspire to put the health of adolescents at risk.
Among adolescent girls, aged 1519 years, in subSaharan Africa, a higher percentage of girls (13%) than boys
(9%) had sex before the age of 15 years. This pattern was

observed in most regions with sufcient data. In West and

Central Africa, 16% of girls had sex before the age of 15
years compared with 7% of boys, and in South Asia, 8%
and 3% of girls and boys, respectively, had sex before the
age of 15 years.21
In most low- and middle-income countries, early sexual
debut is commonalmost 30% of adolescent girls aged
1519 years in Central African Republic and adolescent boys
in Malawi and Lesotho reported having rst sexual intercourse before they were 15 years old. Similarly, more than
10% of girls or boys in Madagascar, Cameroon, Uganda,
Kenya, Guyana, Sao Tome, Principe, Senegal, Rwanda,
Tanzania, and Kiribati had early sexual debut (Fig. 3).
In addition to HIV risk, early sexual activity is
associated with early marriage and early childbearing across
the world, which curtails education and other opportunities
for adolescent girls to reach their full potential. Indeed, in
low- and middle-income countries, 90% of births to adolescents are within marriage. Almost all adolescent births occur
within marriage in Asian and North African countries, as
do around 70%80% in sub-Saharan African and Latin
American countries and the Caribbean.22
The World Health Organization (WHO) reports an
estimated 16 million births in girls aged 1519 years and 2
million births in girls younger than 15 years each year. Worldwide, 20% of adolescent girls have given birth and entered into
parenting by the age of 18 years, whereas in the least

FIGURE 3. Percentage of adolescents aged 1519 years and young women and men aged 2024 years who had sex before 15
years of age, by country, sex, and age in selected countries, 20082012.

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developed countries, as many as 1 in every 3 adolescent girls is

a mother by the age of 18 years. More than 1 in 4 women aged
2024 years in sub-Saharan Africa has given birth before 18
years of age. And in 3 countries with the highest prevalence of
early childbearingGuinea, Mali, and Nigeraround 10% of
women gave birth before 15 years of age.22

Condom Use and Multiple Sexual Partners

Condoms are one of the most efcient means available
to reduce sexual transmission of HIV; yet, their use remains
abysmally low in several countries with high HIV prevalence.
Survey data from 2006 to 2012 show that condom use among
adolescents aged 1519 years who reported multiple sexual
partners in the last 12 months before the survey was at least
60% or more in only 2 countries among adolescent girls and
in 20 countries among adolescent boys.
Recent survey data show that having multiple sexual
partnerships among adolescent boys, 1519 years, is common
in both low and high HIV prevalence countries, up to 39% in
Jamaica and 18% in Mozambique (Fig. 4). However, a lower
proportion of adolescent girls than boys reported having had
multiple sexual partners across nearly all countries, which
ranged from 9% in Congo and Gabon to 16% in Jamaica
(Fig. 4). In interpreting these data, consideration should be
given to the possibility of individual response bias to sensitive
and personal questions.

Epidemiology of HIV and AIDS Among Adolescents

Even though most countries are still falling short of the

2001 UNGASS target of 95% condom use among those who
reported to have had multiple sexual partners, recent survey
data in some countries show substantial improvements in this
indicator. Between 2000 and 2012, increases of 10 or more
percentage points in condom use at last sexual activity among
adolescents aged 1519 years who reported multiple sexual
partners occurred in 9 of 22 low- and middle-income countries among adolescent girls and in 10 of 19 countries among
adolescent boys.21
In most countries, adolescent girls were less likely than
boys to use condoms in their most recent sexual experience
among those who reported multiple sexual partners. Condom
use is also much less common among adolescents in poorer
households and in rural areas.21

HIV Testing
Most adolescents do not know their HIV status.
Although most adolescents know of a place where they can
get tested for HIV, the proportion who reported ever having
had an HIV test remains low across most countries; yet, this is
a critical step toward access to HIV care and treatment (Fig. 5).
Although access and coverage vary greatly by country, survey
data from 2008 to 2012 in most sub-Saharan African countries
indicate that less than 1 in 3 adolescent girls aged 1519 years
reported having ever been tested for HIV and having received

FIGURE 4. Percentage of adolescents aged 1519 and young women and men aged 2024 reporting multiple partners in the last
12 months who used a condom at last sex, by country, age and sex in selected countries, 20072012.
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FIGURE 5. Percentage of adolescents aged 1519 years and young women and men aged 2024 years who have ever been
tested for HIV and received results, by country, sex, and age in selected sub-Saharan African countries, 20072012.

the results. Tragically, this is not only a missed opportunity for

a well-known entry point to access care and treatment but also
a means of preventing HIV infection.23
In Eastern and Southern Africa, 29% of adolescent girls
aged 1519 years reported having ever had an HIV test and
having received the results, which is higher than adolescent
boys (20%),1 perhaps because of early pregnancies that led
them to seek maternal health services and HIV testing linked
to antenatal care. In some countries in Asia, the limited data
available suggest that over 60% of young key populations
initiate sexual activity early in life (by 1519 years) and yet
HIV testing is low.24

HIV Care and Treatment

Age-disaggregated data on coverage of antiretroviral
treatment (ART) among adolescents are lacking. Nearly half
(1 million) of adolescents living with HIV in low- and middleincome countries were in need of ART at the end of 2012
according to 2010 WHO ART eligibility guidelines.12 The
increased CD4 threshold to 500 for initiation of ART recommended in the 2013 guidelines raises even further the number
of adolescents in need of treatment. Given the fact that there
continue to be large numbers of perinatally infected children
growing into adolescence (long-term survivors), the number of
adolescents living with HIV in need of treatment is likely to
continue to grow for some time.

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Although global data on ART coverage for adolescents

are not available, low ART coverage among children aged
014 years provides an indication of the inequities in the
global response. In 2012, ART coverage among children aged
014 years in need of HIV treatment was only 34% compared
with 64% of all eligible adults 15 years and older.5
Both the increasing AIDS-related deaths among adolescents and the limited studies that exist suggest that
adolescents do not have adequate access to ART. Retention
and adherence rates also seem to be poor even when enrolled
in care and treatment.2529 Retaining adolescents in care is
particularly challenging. Dealing with the prospect of lifelong
treatment is daunting at any time in life, but for adolescents,
this comes on top of navigating the usual challenges of their
developing maturityemotionally, psychologically, physically, and sexually.

Comparing Adolescents and Young People

Across countries in Southern Africa with generalized
epidemics, adolescence marks the beginning of an increase in
prevalence of HIV, which accelerates through the reproductive years (Fig. 1). Before adolescence, little difference is
evident between males and females, whereas females begin
to experience much greater levels of HIV than their male
counterparts after adolescence. Although the magnitude
varies, the trend is the same across countries.
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Perhaps most alarming of all, during the period 2005

2012, AIDS-related deaths among adolescents increased by
about 50% (from 71,000 in 2005 to 110,000 in 2012), in
contrast with a 32% decrease among all other age groups
during the same period.
Knowledge about HIV prevention among adolescents and
young people is very low, and there is a trend toward adolescent
males and females (1519 years) having less knowledge than
young adult males and females (2024 years) (Fig. 2). Young
adult males and females (2024 years) tend to be more likely
than adolescent males and females (1519 years) to have ever
had a test and received their results (Fig. 5).
Adolescent males and females (1519 years) who had
multiple partners in the last 12 months tend to be more likely
to report having used a condom than young adult males and
females (2024 years). Although the pattern does not hold for
all countries, there is a tendency for young adult females (20
24 years) to be more likely than adolescent females (1519
years) to have had early sexual debut; but the reverse tends to
be true for males (Fig. 3).

DISCUSSION AND CONCLUSIONS

The remarkable progress made in decreasing new infections from mother-to-child transmission indicates that a concerted
global effort, strong political commitment and leadership at the
country level, and resource allocation can lead to signicant
results. The same kind of dedicated attention over time is long
overdue for adolescents. The launch of the global plan toward
the elimination of new HIV infections among children by 2015
and keeping their mothers alive30 in 2009 has led to rapid
reductions in new HIV infections among children in low- and
middle-income countries overall and in the 22 priority countries.
Globally, 52% fewer children were infected with HIV in 2012
(260,000) than in 2001 (550,000), with an accelerated pace of
reduction between 2009 and 2012 compared to the preceding
decade.1 Although declines in new infections have been marked
among young children largely because of progress in preventing
mother-to-child HIV transmission, the 36% decline in adolescent
new infections has been much more modest.12
The increase in HIV prevalence during the transition
from childhood to adolescence provides clear evidence of the
increasing HIV vulnerability in the second decade of life. The
package of high-impact interventions that reduce HIV
infections, morbidity, and mortality has been clearly laid
out in the UNAIDS investment approach.31 However, without
improved data gathering, analysis, and reporting systems specic to adolescents, the international community currently can
neither measure the progress in a standardized way nor use
the knowledge that comes from such systems to implement
the most efcacious programs that can improve health outcomes for adolescents.

Importance of Prevention
HIV prevention among adolescents is particularly
important given their evolving needssocially, physiologically, and psychologicallyas they transition from childhood
through adolescence to adulthood. Lack of attention to their
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Epidemiology of HIV and AIDS Among Adolescents

reproductive and sexual health rights and related services at

this age can have irreparable consequences in the trajectory of
the HIV and AIDS epidemic globally.
Epidemiological, knowledge, and behavioral data from
UNAIDS and surveys show modest progress in global prevention efforts and conrm that we are still far from ensuring
universal access to critical prevention services and support for
adolescents, including provision of age-appropriate information, access to condoms, HIV testing and counseling, and
essential sexual and reproductive health and treatment services.
The comparison of adolescents (1519 years) with young
people (2024 years) on HIV indicators where data are available suggests an important window of opportunity for intervening to reduce HIV risk and vulnerability and reverse the pattern
of increasing HIV infection as children mature into adolescence
and young adulthood. Before adolescence, little difference is
evident between males and females, whereas females begin to
experience much greater levels of HIV than their male counterparts after adolescence and throughout the early reproductive
years in generalized epidemics. Knowledge of HIV is very low
across the board but again tends to be even lower among females. Although the magnitude varies, the trend is the same
across countries.
The good news is that positive behavior change among
adolescents around some of the key risk indicators is moving in
the right direction, eg, regarding age at sexual debut, multiple
sexual partners, and condom use. However, the bad news is that
it has not been enough. The reduction in risky behaviors has
been too slow and has not been sufcient to result in substantial
declines in new HIV infections among adolescents, especially
girls. This reiterates the need to sustain messaging over time
and with successive generations of adolescents.

More to Learn About Why AIDS-Related

Deaths Are Increasing
Estimates of adolescent HIV prevalence include both
those who acquired HIV through mother-to-child transmission (perinatal and postnatal transmission through breastfeeding), also known as vertical transmission, and those
who acquired HIV behaviorally through unprotected sex or
sharing of nonsterile injecting equipment. It is not clear what
proportion of adolescents living with HIV were infected vertically compared with behavioral transmission. Empirical data
are needed to better understand the main modes of HIV transmission among adolescents. Also, globally, there is very limited understanding of the disease progression of children who
acquired HIV vertically.
The reported increase in adolescent deaths is based on
UNAIDS estimates. There is very little empirical evidence on
this phenomenon. The models reect the increase in the
number of women living with HIV giving birth during the late
1990s and early 2000s. The children of those women are
recently entering into adolescence. The models assume that
untreated children infected from their mothers during pregnancy or delivery average 1 year of survival, whereas children
infected during breast-feeding and who receive no ART live
for an average of 14 years.32 Thus, the models estimate that
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many children infected during breast-feeding (about half of

all vertical transmissions) will die during their adolescence.
Generally, the low level of testing among adolescents
could partly be the reason for increased AIDS-related
mortality among them. Adolescents who do not know that
they are infected with HIV are unlikely to seek ART, and
their diagnosis may be substantially delayed until they
experience symptoms of advanced HIV disease, in many
cases it will be too late for treatment. The very low coverage
of pediatric ART in these settings exacerbates this effect.
Limited studies indicate that adolescents have poor retention
and adherence outcomes even when enrolled in HIV care and
treatment. Better data on the survival time of HIV-infected
adolescents and uptake of ART and other services are needed
to enhance understanding of AIDS-related deaths and other
health outcomes among adolescents.30

Data Gaps and Disaggregation

Even where data exist, disaggregation, sample size, and
interpretation of those data are often inadequate. For example,
basic disaggregation by sex can help to understand factors such
as social and economic inequalities and age-disparate sex, which
are key factors in the epidemic affecting young women and girls.
Disaggregation of HIV care and treatment data for adolescents is
not currently possible because of the way they are collected. The
disaggregation levels for ART coverage of groups younger than
15 years and 15 years and older do not provide enough
information about the developmentally distinct and important
subgroups that are hidden in these large age brackets.
In the case of key populationsMSM, sex workers, and
PWIDmost behavioral surveillance surveys are not nationally
representative as they are collected from capital cities or only
a few geographic locations. In addition, the indicators, data
collection methodologies, and age disaggregation levels are
not standardized across countries, making comparative analysis
within and between countries even more difcult. There is
a need for age-disaggregated data to monitor results with a focus
on assessing and responding to disparities in access, coverage,
and quality of high-impact HIV interventions and to track progress on implementation of important guidelines, such as the
2013 WHO HIV treatment guidelines33 and the adolescent
HIV testing and counseling and treatment guidelines.34
In addition to the factors that increase vulnerability for all
adolescents, the vulnerability of adolescents from key populations is profoundly compounded by severe social stigma and
harsh, poorly informed, legal, and policy regulations and law
enforcement practices that criminalize their behaviors and foster
discrimination and violence. These factors hinder access to
critically needed health services and other HIV prevention,
treatment, protection, care, and support interventions. Age of
consent policies and laws are intended to protect youth minors
but often have the unintended effect of limiting not only access
to services but also the collection of data related to adolescents.
Data are not generally available for younger adolescents
aged 1014 years, even though many engage in sex or other
higher risk behaviors much earlier. Current surveys are not
designed to collect data on adolescents aged 1014 years
because of the challenges in getting parental approval for their

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involvement in surveys and a lack of age-appropriate questions

for them. There is a need to develop age-appropriate questions
during surveys, which ensure reliability of responses, are
acceptable to parents, and conform to sound ethical foundations
related to research on minors. Special consideration needs to be
given to key populations and other situations where illegal
behavior may be involved and where the value of understanding
the context needs to be balanced against legal and ethical considerations and foremost ensuring their safety.

Taking Action
Despite the need for better data related to adolescents,
important implications can be drawn from the emerging
global, regional, and national data sets. Adolescents constitute
about 1.2 billion of the worlds population. These adolescents
are becoming sexually active and need to understand the risks
of HIV and other sexually transmitted infections, especially
adolescents living in high HIV burden countries. Demographic projections suggest that the absolute number of adolescents is expected to increase slightly through 2050, leading
to a youth bulge in developing countries. The adolescent
population in sub-Saharan Africa is expected to double in
2050, a region where HIV infections are also highest, and
adolescents already account for 23% of the current population. Although data improvements are needed, the current
evidence makes clear that adolescents are more vulnerable
to HIV than persons in older age groups and that effective
interventions are known, invoking an obligation to take
action. Given these demographic shifts, it is vital that the
post-2015 agenda takes into account age-appropriate HIVrelated interventions aimed at reducing risk, vulnerability,
morbidity, and mortality among them.

Limitations
This article provides a snapshot of the HIV epidemic
among adolescents and progress made toward addressing the
prevention, care, and treatment needs to mitigate risk,
infection, and mortality among them. It does neither assess
the programmatic effectiveness and scientic evidence of
different high-impact interventions nor deal with interventions designed to mitigate the impact of HIV, eg, interventions with orphans and other children infected or affected by
HIV and AIDS, that are beyond the scope of this article.
Various development sectors and their program interventions, beyond those that are HIV specic, play a critical
role in reducing vulnerability to HIV infection among
adolescents. Just as critical are the political commitments
and policy and legal environments that address the issues of
poverty, low levels of education, marginalization of particular
population groups, stigma, and discrimination attached to
particular groups or behaviors, among others. Policy and
program efforts across the development sectors along with the
enabling environment are factors that have signicant inuence on the effectiveness and success of HIV-specic
interventions that enhance HIV knowledge and improve
access to testing, care, and treatment services. However,
analysis of these factors is beyond the scope of this article.
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J Acquir Immune Defic Syndr  Volume 66, Supplement 2, July 1, 2014

The data presented in this article show simple aggregate

or percent differences in selected outcomes by age and sex
and do not control for the interactive effects of various
variables, such as education level of respondent, household
wealth, rural or urban residence, ethnicity, and other factors.
A multivariate (regression) analysis would be more useful in
determining the factors most associated with desired outcomes across adolescent subgroups. The ndings, however,
suggest areas for further research and analysis.
ACKNOWLEDGMENTS
The authors thank Bill G. Kapogiannis, MD, of
National Institutes of Health for the review of this article
and Ken Legins of United Nations Childrens Fund for coordinating the drafting of the various article series.
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