Centring adolescent girls and young women in the HIV and COVID-19 responses
Authors: Ameena Goga, Linda Gail Bekker, Philippe Van de Perre, Wafaa El-Sadr, Khatija Ahmed, Mookho Malahleha, Trisha Ramraj, Vundli Ramokolo, Vuyolwethu Magasana, Glenda Gray
Journal: The Lancet (2020)

Adolescent girls (10–19 years) and young women (20–24 years) are a key part of the 1·8 billion people who live in fragile contexts.1Tran N Tappis H Spilotros N Krause S Knaster S for the Inter-Agency Working Group on Reproductive Health in CrisesNot a luxury: a call to maintain sexual and reproductive health in humanitarian and fragile settings during the COVID-19 pandemic.Lancet Glob Health. 2020; 6: e760-e761Summary Full Text Full Text PDF Scopus (38) Google Scholar In 2019, adolescent girls and young women comprised an estimated 10% of the population in sub-Saharan Africa but accounted for 59% of new HIV infections.2UNAIDSUNAIDS data.https://www.aidsdatahub.org/sites/default/files/resource/unaids-2020-aids-data-book.pdfDate: 2020Date accessed: November 20, 2020Google Scholar, 3UNAIDSGlobal HIV & AIDS statistics—2020 fact sheet.https://www.unaids.org/en/resources/fact-sheetDate: 2020Date accessed: November 25, 2020Google Scholar Adolescent girls and young women are disproportionally affected by HIV. In eastern and southern Africa in 2017, 79% of new HIV infections among 10–19-year-olds were in females—each day about 460 adolescent girls became infected with HIV and an estimated 50 died from AIDS-related illnesses.3UNAIDSGlobal HIV & AIDS statistics—2020 fact sheet.https://www.unaids.org/en/resources/fact-sheetDate: 2020Date accessed: November 25, 2020Google Scholar Additionally, in 2017 HIV was the leading cause of death for women aged 15–49 years worldwide and among the top five causes of death for girls aged 10–14 years; more than 90% of deaths worldwide from AIDS-related illnesses among adolescents occurred in sub-Saharan Africa.4UNAIDSWomen and HIV: a spotlight on adolescent girls and young women.https://www.unaids.org/sites/default/files/media_asset/2019_women-and-hiv_en.pdfDate: 2019Date accessed: November 20, 2020Google Scholar In various contexts, adolescent girls are the unpaid care workers for younger siblings and ill or elderly family members.4UNAIDSWomen and HIV: a spotlight on adolescent girls and young women.https://www.unaids.org/sites/default/files/media_asset/2019_women-and-hiv_en.pdfDate: 2019Date accessed: November 20, 2020Google Scholar Gender inequality, gender-based violence (GBV), and poverty increase the vulnerability of adolescent girls and young women to HIV,4UNAIDSWomen and HIV: a spotlight on adolescent girls and young women.https://www.unaids.org/sites/default/files/media_asset/2019_women-and-hiv_en.pdfDate: 2019Date accessed: November 20, 2020Google Scholar and those living with HIV face heightened discrimination, stigma, and GBV.2UNAIDSUNAIDS data.https://www.aidsdatahub.org/sites/default/files/resource/unaids-2020-aids-data-book.pdfDate: 2020Date accessed: November 20, 2020Google Scholar Substantial efforts have been made to reduce the effect of HIV on adolescent girls and young women in high-burden countries through combination prevention approaches and initiatives, such as the DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe) partnership in sub-Saharan Africa, Sista2sita, SheConquers, and OneLove.5Hosek S Pettifor A HIV prevention interventions for adolescents.Curr HIV/AIDS Rep. 2019; 16: 120-128Crossref PubMed Scopus (54) Google Scholar, 6AvertHIV prevention programmes overview.https://www.avert.org/professionals/hiv-programming/prevention/overviewDate: 2019Date accessed: November 25, 2020Google Scholar Notwithstanding these efforts, globally in 2019 girls and women made up almost 50% of the 38 million people living with HIV;3UNAIDSGlobal HIV & AIDS statistics—2020 fact sheet.https://www.unaids.org/en/resources/fact-sheetDate: 2020Date accessed: November 25, 2020Google Scholar ending AIDS by 2030 requires that we address girls' and women's diverse roles by putting them at the centre of the HIV response.4UNAIDSWomen and HIV: a spotlight on adolescent girls and young women.https://www.unaids.org/sites/default/files/media_asset/2019_women-and-hiv_en.pdfDate: 2019Date accessed: November 20, 2020Google Scholar If the status quo remains, there will be an HIV resurgence among young women due to the failings of HIV prevention, as the largest population of adolescents move into adulthood.7Schaefer R Gregson S Fearon E Hensen B Hallett TB Hargreaves JR HIV prevention cascades: a unifying framework to replicate the successes of treatment cascades.Lancet HIV. 2019; 6: e60-e66Summary Full Text Full Text PDF PubMed Scopus (53) Google Scholar, 8UNAIDS2015 Progress report on the Global Plan towards the elimination of new HIV infections among children and keeping their mothers alive.http://www.unaids.org/sites/default/files/media_asset/JC2774_2015ProgressReport_GlobalPlan_en.pdfDate: 2015Date accessed: November 25, 2020Google Scholar Evidence from population-based surveys in eastern and southern Africa suggest that poorer or less educated adolescent girls and young women are still less able to negotiate male condom use than their more affluent or educated peers.2UNAIDSUNAIDS data.https://www.aidsdatahub.org/sites/default/files/resource/unaids-2020-aids-data-book.pdfDate: 2020Date accessed: November 20, 2020Google Scholar In fact, greater gains have been made in reducing new HIV infections among adolescent girls and young women in countries with higher completion rates of lower secondary school.2UNAIDSUNAIDS data.https://www.aidsdatahub.org/sites/default/files/resource/unaids-2020-aids-data-book.pdfDate: 2020Date accessed: November 20, 2020Google Scholar These gains may be the result of female empowerment as well as behavioural interventions, including sex education, counselling, cash transfers, and stigma and discrimination reduction programmes.6AvertHIV prevention programmes overview.https://www.avert.org/professionals/hiv-programming/prevention/overviewDate: 2019Date accessed: November 25, 2020Google Scholar Uptake and use of biomedical interventions, including sexual and reproductive health (SRH) services, male and female condoms, pre-exposure prophylaxis, treatment of sexually transmitted infections, and treatment as prevention among adolescent girls and young women are limited, with stagnating funding for condom procurement, suboptimal SRH services, limited access to HIV diagnosis, and low levels of viral suppression.7Schaefer R Gregson S Fearon E Hensen B Hallett TB Hargreaves JR HIV prevention cascades: a unifying framework to replicate the successes of treatment cascades.Lancet HIV. 2019; 6: e60-e66Summary Full Text Full Text PDF PubMed Scopus (53) Google Scholar, 9UNAIDSCondom use is declining.https://www.unaids.org/en/resources/presscentre/featurestories/2020/november/20201123_condom-use-decliningDate: Nov 23, 2020Date accessed: November 25, 2020Google Scholar Consequently, efforts to improve access to youth-friendly, accessible SRH services, including HIV testing and treatment, long-acting contraceptive options, and women-controlled HIV prevention options are imperative. Structural challenges to centring adolescent girls and young women in the HIV response include poverty, gender inequality, unavailability of safe centres for health care (including mental health) and safe spaces for recreational time, parental consent requirements that restrict adolescents' access to health care, social constructs of masculinity (patriarchy) and gender norms, laws that punish young women's sexuality, poor access to menstrual products limiting school attendance, and school systems that prevent access to or continuation of education for adolescents who are pregnant or mothers.2UNAIDSUNAIDS data.https://www.aidsdatahub.org/sites/default/files/resource/unaids-2020-aids-data-book.pdfDate: 2020Date accessed: November 20, 2020Google Scholar, 6AvertHIV prevention programmes overview.https://www.avert.org/professionals/hiv-programming/prevention/overviewDate: 2019Date accessed: November 25, 2020Google Scholar, 10UNAIDSAfrican UnionEmpower young women and adolescent girls: fast tracking the end of the AIDS epidemic in Africa.http://www.unaids.org/sites/default/files/media_asset/JC2746_en.pdfDate: 2015Date accessed: November 25, 2020Google Scholar, 11Goga AE Dinh T-H Essajee S et al.What will it take for the Global Plan priority countries in Sub-Saharan Africa to eliminate mother-to-child transmission of HIV?.BMC Infect Dis. 2019; 19: 783Crossref PubMed Scopus (20) Google Scholar COVID-19 has exacerbated these biopsychosocial challenges and eroded progress on improving the health and wellbeing of adolescent girls and young women. While younger children need and value adult involvement in their lives, adolescents, given their crucial stage of biological, cognitive, psychological, behavioural, and social development,12WHOAdolescent health.https://www.who.int/health-topics/adolescent-health/#tab=tab_1Date: 2020Date accessed: November 25, 2020Google Scholar value social interaction and face-to-face peer contact. COVID-19 mitigation strategies, including school closures, lockdowns, quarantine, or isolation, have been associated with poorer mental health among young people.13Human Rights WatchImpact of Covid-19 on children's education in Africa.https://www.hrw.org/news/2020/08/26/impact-covid-19-childrens-education-africaDate: 2020Date accessed: November 25, 2020Google Scholar, 14Xie X Xue Q Zhou Y et al.Mental health status amongst children in home confinement during the coronavirus 2019 disease outbreak in Hubei province, China.JAMA Pediatr. 2020; 174: 898-900Crossref PubMed Scopus (659) Google Scholar, 15Caffo E Scandroglio F Asta L Debate: COVID-19 and psychological well-being of children and adolescents in Italy.Child Adolesc Ment Health. 2020; 25: 167-168Crossref PubMed Scopus (53) Google Scholar, 16YoungMindsCoronavirus: impact on young people with mental health needs.https://youngminds.org.uk/about-us/reports/coronavirus-impact-on-young-people-with-mental-health-needs/Date: 2020Date accessed: November 25, 2020Google Scholar Although data on the impact of COVID-19 on adolescent girls and young women are still emerging, there are concerns that COVID-19-related school closures will exacerbate gender inequalities, increasing exposure to the risk of early marriage, pregnancy, child labour, and violence.17Save our FutureAverting an education catastrophe for the world's children.https://saveourfuture.world/white-paper/Date: 2020Date accessed: November 25, 2020Google Scholar Additionally, 7·6 million girls from pre-primary to secondary school are at risk of not returning to school as a result of COVID-19.17Save our FutureAverting an education catastrophe for the world's children.https://saveourfuture.world/white-paper/Date: 2020Date accessed: November 25, 2020Google Scholar This will further reverse gains made in female education. Despite calls to continue the provision of a minimum package of SRH care during the COVID-19 pandemic,1Tran N Tappis H Spilotros N Krause S Knaster S for the Inter-Agency Working Group on Reproductive Health in CrisesNot a luxury: a call to maintain sexual and reproductive health in humanitarian and fragile settings during the COVID-19 pandemic.Lancet Glob Health. 2020; 6: e760-e761Summary Full Text Full Text PDF Scopus (38) Google Scholar, 18Addae E COVID-19 pandemic and adolescent health and well-being in sub-Saharan Africa: who cares?.Int J Health Plann Manage. 2020; (published online Aug 27.)https://doi.org/10.1002/hpm.3059Crossref PubMed Scopus (21) Google Scholar, 19Inter-agency Working Group on Reproductive Health in CrisisProgrammatic guidance for sexual and reproductive health in humanitarian and fragile settings during COVID-19 pandemic.https://iawg.net/resources/programmatic-guidance-for-sexual-and-reproductive-health-in-humanitarian-and-fragile-settings-during-covid-19-pandemicDate: 2020Date accessed: November 25, 2020Google Scholar what happened during the 2014–16 outbreak of Ebola virus disease in west Africa is instructive.20Bandiera O Buehren N Goldstein M Rasul I Smurra A Lessons from Sierra Leone's Ebola pandemic on the impact of school closures on girls.The Conversation. May 20, 2020; https://theconversation.com/lessons-from-sierra-leones-ebola-pandemic-on-the-impact-of-school-closures-on-girls-137837Date accessed: November 25, 2020Google Scholar In Sierra Leone adolescents had reduced capability to access or use SRH services during the Ebola outbreak, and cash-strapped health services diverted resources away from essential SRH services to acute responses that facilitated Ebola containment.21UNFPARapid assessment of Ebola impact on reproductive health services and service seeking behaviour in Sierra Leone.https://reliefweb.int/sites/reliefweb.int/files/resources/UNFPA%20study%20_synthesis_March%2025_final.pdfDate: March, 2015Date accessed: November 25, 2020Google Scholar Consequently, it is likely that during the COVID-19 pandemic the compounding effects of limited access to SRH services, isolation, and loss of family members and income have disproportionately affected adolescent girls and young women, further exacerbating gender inequalities and GBV.1Tran N Tappis H Spilotros N Krause S Knaster S for the Inter-Agency Working Group on Reproductive Health in CrisesNot a luxury: a call to maintain sexual and reproductive health in humanitarian and fragile settings during the COVID-19 pandemic.Lancet Glob Health. 2020; 6: e760-e761Summary Full Text Full Text PDF Scopus (38) Google Scholar, 18Addae E COVID-19 pandemic and adolescent health and well-being in sub-Saharan Africa: who cares?.Int J Health Plann Manage. 2020; (published online Aug 27.)https://doi.org/10.1002/hpm.3059Crossref PubMed Scopus (21) Google Scholar It will be some months before the impacts of COVID-19 on adolescent girls and young women will be fully appreciated, including the social harms and inadvertent negative outcomes of the COVID-19 response. A risk–benefit assessment is needed to identify and mitigate the indirect effects of COVID-19 mitigation and containment strategies to address these impacts and also to prepare for the next epidemic. Furthermore, COVID-19 has had a disproportionate impact and burden on adolescent girls and women who are more likely to be first responders in health-care delivery; working women often bear the double burden of their formal or informal employment and of caring for families, often with limited safety protection.4UNAIDSWomen and HIV: a spotlight on adolescent girls and young women.https://www.unaids.org/sites/default/files/media_asset/2019_women-and-hiv_en.pdfDate: 2019Date accessed: November 20, 2020Google Scholar In terms of HIV services, data show a reduction in HIV testing at first antenatal visits in at least 17 countries between January and June, 2020, and a reduction in HIV treatment access among pregnant women in at least 15 countries.22UNAIDSCOVID-19's impact on HIV vertical transmission services reversed.https://www.unaids.org/en/resources/presscentre/featurestories/2020/october/20201027_covid19-impact-hiv-vertical-transmissionDate: Oct 27, 2020Date accessed: November 25, 2020Google Scholar Treatment access had still not recovered in five countries (Botswana, South Africa, Sierra Leone, Togo, and Guatemala) by October, 2020.22UNAIDSCOVID-19's impact on HIV vertical transmission services reversed.https://www.unaids.org/en/resources/presscentre/featurestories/2020/october/20201027_covid19-impact-hiv-vertical-transmissionDate: Oct 27, 2020Date accessed: November 25, 2020Google Scholar Given that pregnant adolescents have poorer access to HIV-related care to prevent vertical HIV transmission than adults,23Ramraj T Jackson D Dinh T et al.Adolescent access to care and risk of early mother-to-child HIV transmission.J Adolesc Health. 2018; 62: 434-443Summary Full Text Full Text PDF PubMed Scopus (23) Google Scholar these challenges have no doubt adversely affected the health of adolescent girls and young women. Strategies to ameliorate these impacts, especially in sub-Saharan Africa, are urgently needed.18Addae E COVID-19 pandemic and adolescent health and well-being in sub-Saharan Africa: who cares?.Int J Health Plann Manage. 2020; (published online Aug 27.)https://doi.org/10.1002/hpm.3059Crossref PubMed Scopus (21) Google Scholar The COVID-19 pandemic has been a setback for the health and wellbeing of adolescent girls and young women. Consequently, the needs of adolescent girls and young women must be a central consideration in HIV and COVID-19 responses going forwards. On World AIDS Day in 2020, we recommend ten actions to improve the health and wellbeing of adolescent girls and young women and mitigate the effects of HIV in the context of COVID-19 or similar pandemics (panel). These actions will empower adolescent girls and young women to reach their fullest potential and improve their opportunities for gainful employment, with its concomitant socioeconomic benefits, thus securing the lives and livelihoods of future generations.24World Health AssemblyGlobal Strategy for Women's, Children's and Adolescents' Health, 2016–2030: survive, thrive and transform.http://everywomaneverychildorg/images/2-pager_on_GS2_draft6pdfDate: 2015Date accessed: November 25, 2020Google Scholar Inaction or insufficient action will betray the next generation of women.PanelActions to put adolescent girls and young women at the centre of HIV and COVID-19 or similar pandemic responses•Keep schools open during the COVID-19 or similar pandemics with appropriate infection prevention and control measures•Continue unfettered access to quality education, including sexual and reproductive health education through schools and higher institutions of learning and other channels•Provide community-based safe environments for adolescent girls and young women•Establish or strengthen community-based mental health services for adolescent girls and young women•Provide user-friendly, accessible sexual and reproductive health services, including access to contraception, HIV testing, antiretroviral treatment, and pre-exposure prophylaxis•Provide access to women-controlled interventions to prevent HIV infection•Engage with adolescent girls and young women so that their voices guide policies and programmes aiming to enhance behaviours, biomedical, and structural interventions for adolescent girls and young women•Prioritise adolescent girls' and young women's rights to make autonomous decisions about their sexual and reproductive rights•Ensure that the social, mental, and physical health needs of adolescent girls and young women are a central consideration in future pandemic responses, including those relating to HIV and COVID-19•Invest in raising male children to be gender-aware, respectful members of society and encourage and support responsive caregiving by parents •Keep schools open during the COVID-19 or similar pandemics with appropriate infection prevention and control measures•Continue unfettered access to quality education, including sexual and reproductive health education through schools and higher institutions of learning and other channels•Provide community-based safe environments for adolescent girls and young women•Establish or strengthen community-based mental health services for adolescent girls and young women•Provide user-friendly, accessible sexual and reproductive health services, including access to contraception, HIV testing, antiretroviral treatment, and pre-exposure prophylaxis•Provide access to women-controlled interventions to prevent HIV infection•Engage with adolescent girls and young women so that their voices guide policies and programmes aiming to enhance behaviours, biomedical, and structural interventions for adolescent girls and young women•Prioritise adolescent girls' and young women's rights to make autonomous decisions about their sexual and reproductive rights•Ensure that the social, mental, and physical health needs of adolescent girls and young women are a central consideration in future pandemic responses, including those relating to HIV and COVID-19•Invest in raising male children to be gender-aware, respectful members of society and encourage and support responsive caregiving by parents We declare no competing interests.