]
South African National AIDS Council (SANAC)
PREVENTING HIV AMONG
GIRLS AND YOUNG WOMEN
IMPLEMENTATION STRATEGY
2015-2019
[12 September 2014]
South African National AIDS Council (SANAC)
PREVENTING HIV AMONG GIRLS AND YOUNG WOMEN
IMPLEMENTATION STRATEGY
© SANAC 2014
Acknowledgements
•
South Africa National AIDS Council
•
•
•
USAID South Africa
Sexual HIV Prevention Programme (SHIPP)
•
National Department of Health
•
Department of Basic Education
Department of Higher Education and Training
•
Reviewers
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FOREWORD
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ACRONYMS
AIDS
Acquired Immune Deficiency Syndrome
ART
Antiretroviral treatment
FET
Further education and training
HEAIDS
Higher Education and Training HIV/AIDS Programme
HEI
Higher Education Institutions
HCT
HIV counselling and testing
HIV
Human Immunodeficiency Virus
HSRC
Human Sciences Research Council
LGBTI
Lesbian, Gay, Bisexual, Transgender and Intersex
NDoH
National Department of Health
NSP
National Strategic Plan
PEP
Post-exposure prophylaxis
PLHIV
People living with HIV
PMTCT
Prevention of Mother-to-Child HIV transmission
PrEP
Pre-exposure prophylaxis
SANAC
South Africa National AIDS Council
SANC
South African Nursing Council
SRH
Sexual and reproductive health
STI
Sexual transmitted Infections
UNAIDS
United Nations Joint Program on HIV & AIDS
VCT
Voluntarily counselling and testing
VMMC
Voluntary Male Medical Circumcision
WHO
World Health Organisation
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CONTENTS
1.
INTRODUCTION .........................................................................................................................7
2.
VULNERABILITY TO HIV INFECTION AMONG GIRLS AND YOUNG WOMEN ..............................8
2.1.
Physiological and biological factors ..........................................................................................9
Transmission dynamics and viral load ......................................................................................9
Sexually transmitted infections (STIs) .......................................................................................9
Other physiological factors .................................................................................................... 10
2.2
Sexual relationships and sexual risks ..................................................................................... 11
Sexual debut........................................................................................................................... 11
Teenage pregnancy ................................................................................................................ 11
Condom use ........................................................................................................................... 13
Knowledge of HIV status ........................................................................................................ 14
Transactional sex, multiple, concurrent and older sexual partners ...................................... 14
Sexual violence....................................................................................................................... 15
Substance abuse .................................................................................................................... 15
2.3.
Social and structural factors .................................................................................................. 16
Legal and policy environment ................................................................................................ 16
Health and social services ...................................................................................................... 17
Schools and tertiary institutions ............................................................................................ 18
Gender and relationships....................................................................................................... 19
Economic support .................................................................................................................. 20
Social and community mobilisation ....................................................................................... 20
Engaging through communication ......................................................................................... 21
3.
ACCELERATING HIV PREVENTION AMONG GIRLS AND YOUNG WOMEN ............................. 23
3.1
A multilevel, combination HIV prevention approach ............................................................ 26
3.2
Heterogeneity of HIV prevalence and prioritizing response.................................................. 27
3.3
Segmentation of youth sub-populations ............................................................................... 27
Youth in school aged 15 and older......................................................................................... 28
Youth attending clinics and hospitals .................................................................................... 28
Unemployed youth out-of-school .......................................................................................... 29
Pregnant teens (and partners) ............................................................................................... 29
Youth in tertiary institutions .................................................................................................. 31
Orphaned youth ..................................................................................................................... 31
Youth with disabilities ............................................................................................................ 31
Youth who have experienced physical and sexual violence .................................................. 32
Youth sex workers and clients ............................................................................................... 32
LGBTI youth ............................................................................................................................ 32
Youth PLHIV............................................................................................................................ 33
3.4
Implementation through six key programme areas .............................................................. 33
3.5
Affirmation of values.............................................................................................................. 35
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3.6
Community mobilization and engaging youth ....................................................................... 35
4.
SCALE-UP AND RESOURCE ALLOCATION ............................................................................... 38
5.
RESEARCH, MONITORING AND EVALUATION ........................................................................ 40
5.1
Targets and indicators............................................................................................................ 41
6.
ENDNOTES AND REFERENCES ................................................................................................ 45
FIGURES
Figure 1: Factors influencing sexual transmission of HIV ....................................................................8
Figure 2: Teenage pregnancy in South Africa, 2010-2013 ............................................................... 12
Figure 3: Logic model for incidence reduction among girls and young women in South Africa...... 25
young women aged 15-24 in South Africa ....................................................................................... 25
Figure 4: Distribution of HIV prevalence in South Africa by district, 2012 ...................................... 27
Figure 5: Categories of vulnerable youth to be engaged ................................................................. 28
Figure 6: Community mobilization process ...................................................................................... 37
Figure 7: Implementation framework and logic model ................................................................... 38
Figure 8: Steps for accelerated programming .................................................................................. 39
TABLES
Table 1: Estimates of teenage pregnancy among sexually active teens, 2013 ................................ 12
Table 2. Priority strategies and outcome goals for accelerating HIV prevention among girls and
Table 3. Functions in six key programme areas for accelerating HIV prevention among girls
and young women aged 15-24 in South Africa ...................................................................... 34
Table 4: Sexual rights and relationship values to support priority strategies.................................. 35
Table 5: Key programme areas and indicators for HIV prevention among girls and young
women aged 15-24 in South Africa ........................................................................................ 41
Table 6. Priority strategies, outcome goals and indicators for HIV prevention among
girls and young women aged 15-24 in South Africa .............................................................. 43
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1.
INTRODUCTION
The South African National AIDS Council (SANAC) fosters consensus between government, civil
society and all other stakeholders towards enhanced country response to HIV, tuberculosis (TB)
and sexually transmitted infections (STIs). This includes offering strategic guidance on all spheres
of response.
The purpose of this implementation strategy is to address and accelerate the prevention of HIV
among girls and young women aged 15-24 in South Africa. Disproportionally high HIV prevalence
in this sub-population has been evident since the 1990s, when the first antenatal surveys of HIV
were implemented. This pattern has continued over the past decade and has been further
clarified through more recent analyses of HIV incidence.
In 2002, 14.8% of girls and young women under 20 years of age attending antenatal clinics in
South Africa were HIV positive (95% CI: 13.4-16.1).1 Just over a decade later, in the 15-19 year
age group, HIV prevalence was 12.4% (95% CI: 11.6-13.3).2 At population level in 2002, HIV
prevalence among girls and young women aged 15-24 was 12% (95% CI: 9.2-14.7). In 2012, the
prevalence level was 11.4% (11.4 9.8–13.2).3
Analyses of data from the national survey conducted by the HSRC in 20124 found that among
young people aged 15-19, HIV prevalence among females was eight times higher than that of
males – 5.6% vs 0.7%. In the 20-24 year age range, the difference in prevalence was three times
higher among females than males – 17.4% vs 5.1%. When analysis of new infections was
conducted, it was found that HIV incidence was nearly five times higher among females aged 1524 in comparison to males in the same age group (2.54% 0.55% vs 0.55%).5
The UNAIDS agenda for accelerated country action for women, girls, gender equality and HIV6
recommends that evidence informed policies and programmes be developed. This includes
drawing on quantitative and qualitative evidence to better inform programmes that promote and
protect the rights of girls and women. Emphasis is placed on universal access to sexual and
reproductive health (SRH) services including protection and promotion of rights and gender
equality – including engaging boys and men. Key to response is championing leadership and
supporting enabling environments that overcome disempowerment and that focus on
transformation.
The development of this strategy included a review of a wide body of research on HIV in South
Africa and globally with a focus on understanding drivers of HIV incidence and guiding response
to reduce new infections. More than 700 peer-reviewed articles, as well as academic theses and
dissertations, research reports and surveys were analysed. Emerging guidance was presented at a
high level meeting of researchers and key stakeholders, and this was followed by a multi-stage
review and follow-up meetings that led to the draft implementation strategy. Further
refinements were implemented to achieve clear and practical guidance focused on bringing
about the greatest impacts on new infections among girls and young women within the shortest
timeframe.
The key principles of this implementation strategy for South Africa are relevant to government
departments, donors, international bodies, implementing organisations and sectoral entities and
guidance on implementation, monitoring and evaluation is provided.
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2.
VULNERABILITY TO HIV INFECTION AMONG GIRLS AND YOUNG WOMEN
Vulnerability to HIV infection refers to the potential to be exposed to the as a product of a range
of individual and contextual factors. Vulnerability to HIV infection in generalised HIV epidemics is
continuous for the population as a whole and and variations in vulnerability are strongly
influenced by economic, social and geographic factors. HIV prevalence in South Africa is notably
higher in poorer contexts such as informal urban and rural areas, and HIV is also distributed
unevenly between provinces and districts in South Africa.7
Direct risk of HIV infection through sexual intercourse is determined by the extent of exposure to
HIV in combination with factors influencing the likelihood of transmission at any given sex act.
Preventing HIV infection through sexual intercourse among girls and young women can be
understood as a continuous process of averting HIV infection at every sexual encounter. By
implication, all sexual encounters among girls and young women represent an important ‘unit of
intervention’ for HIV prevention. This includes exposure to HIV in the context of consensual
sexual relationships and casual partnerships as well as situations where sex is unwanted, coerced
or violent. Addressing responsibilities and accountabilities between sexual partners to address
HIV prevention is crucial, as is actively addressing sexual violence.
HIV incidence and prevalence among boys and men has a bearing on the vulnerability to HIV
among girls and young women, and it is relevant to address HIV incidence and prevalence
holistically.
Vulnerability to HIV infection is multifaceted, and determined by an extensive range of
interlinked factors. These include physiological and biological factors, sexual risks and sexual
risks, and social and structural factors. Physiological and biological factors comprise individual
characteristics including physical make up and health. Sexual relationships represent the context
of most potential exposures to HIV, but risks of sexual exposure extend beyond relationships.
Social and structural factors relate to the context of economic life, social practices, health
systems, and factors related to geographic locale that influence HIV vulnerability.
Interaction between these factors influences the risk of HIV acquisition and the likelihood of
exposure to HIV. Whether or not an HIV infection occurs is further determined by the efficiency
of HIV transmission during or after sex. Together, these factors determine whether or not an
incident HIV infection occurs. This framework serves as the basis for this implementation strategy
and is outlined in Figure 1.
Figure 1: Factors influencing sexual transmission of HIV
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2.1.
Physiological and biological factors
Transmission dynamics and viral load
The risk of acquiring HIV during heterosexual intercourse ranges from 0.8% to 0.19% per sex act
for females, and 0.05% to 0.1% per sex act for males.8 The likelihood that HIV will be transmitted
by an HIV positive sexual partner is influenced by viral load, stage of HIV infection and presence
of sexually transmitted infections (STIs).9
Viral load relates to the amount of HIV in body fluids, and higher viral load of HIV increases the
likelihood of transmission. 10 Viral load varies over the course of HIV infection. Initial HIV
infection, referred to as the primary stage, lasts for approximately three months. This period is a
time where there is rapid increase in HIV viral load. This is followed by the latent stage where the
immune system has suppressed the initial infection, and there are no obvious symptoms of HIV.
The latent stage, which can last many years, is followed by the late stage, which is a period where
viral load increases and symptoms are present.
While HIV can be transmitted during all stages of infection, the likelihood of HIV transmission
during the primary stage of HIV infection may be as much as 26 times higher in comparison to
the latent stage.11 HIV is also more likely to be transmitted in the late stage, as viral load is
increased.
Antiretroviral treatment (ART) considerably lowers the risk of transmission through effectively
suppressing viral load.12 Since point of first HIV infection is not easily established, managing and
reducing viral load primary infection through ART is not feasible. Furthermore, while HIV can be
transmitted during the latent stage, current guidelines recommend that ART is initiated during
the late stage of HIV infection when CD4 counts have reached a threshold level.
Reducing higher viral loads that occur during late stage infection have been found to be effective
for reducing new infections at population level, and intensive ART programmes in high HIV
prevalence settings have the effect of reducing ‘community level viral load’.13 Studies have also
shown that sexual risk taking does not increase when in the context of scaled up ART
programmes.14
Considerable progress on implementing ART has been made in South Africa to date, and
according to the 2010 World Health Organisation (WHO) guidelines, based on a CD4 count of
≤350 cells/mm3, more than 80% of eligible people living with HIV (PLHIV) were accessing
treatment.15
The revised WHO guidelines recommend earlier initiation of ART, at a CD4 count of ≤500
cells/mm3, while also initiating ART for serodiscordant couples, pregnant women living with HIV,
people with TB and HIV, people with HIV and hepatitis B, and children living with HIV who are
under five years of age, irrespective of CD4 levels.16 The WHO guidelines suggest that 50% of all
PLHIV should be accessing ART by 2015. The 2012 HSRC survey found that ART coverage was 31%
among all HIV positive samples.17
Sexually transmitted infections (STIs)
Bacterial and viral sexually transmitted infections (STIs) increase the likelihood of transmitting
and acquiring HIV. Infection with Herpes Simplex Virus 2 (HSV-2) is incurable, and results in
sporadic outbreaks of genital ulcers. HSV-2 increases susceptibility to HIV infection, with risk
Page 9
being 3.4 times higher for women and 2.8 times higher for men, in comparison to persons not
infected with HSV-2. Co-infection with HSV-2 also increases the likelihood of HIV transmission.18
While HSV-2 is most strongly associated with HIV transmission and acquisition, co-infections with
other STIs such gonorrhea, 19 chlamydia, and Trichomonas Vaginalis,20 also increase risks for both
sexes.21 Significant associations have been found between Human Papillomavirus (HPV) and
incident HIV infection, although it remains necessary to determine the potential impacts of
increasing coverage of HPV vaccines.22 Symptoms of STIs may not be apparent or may be
unnoticed, and this hampers clinical management and treatment.
Other physiological factors
Girls and young women have a heightened physiological vulnerability to HIV in comparison to
adult women, and as a result, HIV infection may occur as a result of comparatively fewer sex
acts.23 Factors influencing the increased likelihood of HIV infection among women in comparison
to men include the following:
 The vagina has a greater surface area that may be exposed to HIV. 24
 Vaginal epithelial cells of girls and young women in their teens are more easily penetrated by
HIV.25
 Genital secretions that are more typical among girls and young women in their teens may
contribute to an ‘inflammatory genital milieu’ that is more conducive to HIV acquisition.
Factors related to the phase between menses may also play a role in suppressing immunity.26
 Bacterial infections such as Bacterial Vaginosis occur only in women, 27 and symptoms are not
always apparent.
 The use of injectable contraception by women – notably depot-medroxyprogesterone acetate
(DMPA) – has been found to increase the risk of HIV infection nearly twofold,28 although oral
contraceptive pills are not associated with higher susceptibility to HIV.29
The risk of male to female HIV transmission through anal intercourse is estimated to be 4-20
times higher than for vaginal intercourse.30
There are some factors where there is uncertainty as to the extent of association with HIV
infection. For example, some studies have shown that dry sex and vaginal douching do not
increase the likelihood of HIV infection, whereas other studies indicate associated effects.31
Factors related to reduced likelihood of transmission are as follows:
 The risks of HIV transmission through oral sex are extremely low.32
 When used consistently and correctly, male condoms provide very high levels of protection
from HIV, and other STIs 33 including HSV-2, 34 . Female condoms are effective for HIV
prevention, but are not widely distributed in South Africa.35
 Medical male circumcision (MMC) reduces the likelihood of female to male HIV transmission,
but does not reduce the likelihood of male to female transmission.36 The benefits of male
circumcision programmes are longer-term, as a product of the overall HIV prevalence among
men being reduced over time – provided that male circumcision targets are reached. 37
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 Post-exposure prophylaxis (PEP) reduces the likelihood of transmission following unprotected
sex including when administered to prevent infection after rape.38
A number of biomedical technologies continue to be studied. These include pre-exposure
prophylaxis (PrEP) which involves administering a daily dose of ART to reduce the risk of HIV
infection,39 vaginal microbicides which target infection during and after sexual intercourse,40 and
HIV vaccines.
2.2
Sexual relationships and sexual risks
While physiological and biological factors influence potential for HIV transmission, sexual
relationships and sexual risk factors further determine the likelihood of exposure to HIV and
pregnancy. Although biomedical interventions such as condoms, contraceptives, STI treatment,
PEP and ART provision play a vital role in prevention, it is also necessary to bring about key
changes in sexual risks and relationship factors that are not directly addressed by biomedical
approaches.
Sexual debut
Exposure to HIV through sex among girls and young women arises from sexual debut. Estimates
for sexual initiation in South Africa by single age among girls are 15% for girls aged 15, 38% for
girls aged 16, 59% for girls aged 17, 72% for girls aged 18, and 81% for young women aged 19. By
the age of 20, 91% of young women have had sex, and levels of having had sex increase to 96%
by the age 25.41
Although girls and young women aged 15-19 are less likely to be sexually active than young
women aged 20-24, those who do have sex are more susceptible to HIV as a product of
physiological and biological factors related to being younger.42
Early sexual debut establishes the onset of risk of HIV infection as well as to the biological cofactors that increase HIV risk including incurable STIs such as HSV-2. Early sexual debut among
girls and young women is associated with being more likely to have multiple sexual partners,43 to
have older sexual partners, to have experienced forced sex,44 and to being more likely to use
alcohol or drugs.45 Early sexual debut also introduces risk of pregnancy, which includes potential
for unwanted pregnancy or abortion. 46
Teenage pregnancy
Teenage pregnancy is a marker of unprotected sex. Data from Statistics South Africa’s general
household survey – which identifies pregnancy among teenage household members in the past
year – shows that between 2010 and 2013, teenage pregnancy increased among 15-18 year old
girls, while declining slightly among 19 year olds (Figure 2). The data does not provide
information on whether pregnancies were carried to term, whether young women were already
young mothers or had previously been pregnant.
Although teenage pregnancy appears to be low among younger teens, it needs to be taken into
account that only a small proportion of girls in their early teens have ever had sex. When
assessing the likelihood of pregnancy among teens who have ever had sex (using modeling
estimates), 47 it is evident that more than one in eight girls and young women in their teens have
been pregnant in the past year, irrespective of age.
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Figure 2: Teenage pregnancy in South Africa, 2010-201348
Table 1 shows past year pregnancy among teenage girls in 2013, indicating the estimated high
proportions of those who were sexually active who were also pregnant in the past year.
Table 1: Estimates of teenage pregnancy among sexually active teens, 2013
Age
Pregnancy
prevalence in past
year49
Estimated
proportion females
sexually active50
15
1.9%
15.2%
Estimated proportion
sexually active who
were pregnant in past
year
12.5%
16
4.5%
38.1%
11.8%
17
18
19
6.8%
9.9%
10.2%
58.9%
72.2%
81.2%
11.5%
13.7%
12.6%
Factors underpinning teenage pregnancy are similar to those underpinning vulnerability to HIV.
For example, a study in a community near Cape Town identified age-disparate sex was a main
factor leading to teenage pregnancy,51 with a similar finding being made in Limpopo, with links
also being made to early sexual debut.52 A study in the Eastern Cape found that pregnancy at age
15 or younger was significantly associated with higher HIV incidence.53
An audit report on teenage pregnancy in South African schools found an average of 58 teenage
pregnancies per 1,000 female learners between 2004 and 2008. The highest proportions were in
the Eastern Cape and KwaZulu Natal, and the lowest in Gauteng and the Western Cape.54Most
teenage pregnancies are unplanned, and an analysis of the 2003 Demographic and Health Survey
(DHS) found that only one in five pregnancies were ‘wanted’ at the time of pregnancy in a South
African study. 55
Use of hormonal contraception among girls and young women is low. A study of youth aged 1524 found that among those using a method, most were using condoms (57%), while around a
third were using hormonal contraceptives – 9% oral and 26% injectable. Mentions of rhythm
method, withdrawal and emergency contraception ranged from 6%-12%, and 11% were not
using any method.56 A study of teens in the Eastern Cape found that condoms were not
protective for unplanned teen pregnancy, while hormonal contraception was protective.57
Antenatal care for women under 20 has been found to be less adequate compared to services for
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older women,58 while children born to teen mothers in South Africa are more likely to be
underweight and stunted.59 While PMTCT coverage in South Africa is high, a study in KwaZuluNatal found that pregnant adolescents were underserviced in comparison to adult women.60
Absentee fatherhood is increasing in South Africa, and there has been minimal focus on support
to younger fathers.61 The role of absentee fathers is also impeded by emphasis on financial
provision to the exception of other aspects of paternal involvement.62 Early and unsupported
parenting among girls and young women entrenches long-term vulnerability to HIV.63
Responsibilities of fatherhood may be avoided through denying paternity, or confirming paternity
and ‘paying damages’, or refusing compensation in spite of acknowledged paternity. All of these
responses increase the extent of economic stress on young women.64 Unresolved paternity is
stressful for young women, and lack of access to means of proving paternity undermines access
to legal obligations for child support.65 Studies do however show that some young fathers
embrace paternity and employ adaptive strategies towards committing to fatherhood, including
linking fatherhood to masculine identity and caregiving.66
While unsafe abortion contributes to maternal mortality globally, South Africa’s Choice of
Termination of Pregnancy Act (CTOPA) – introduced in 1996 – has contributed to declines in
termination-related mortality.67 A study of youth aged 18-24 in four provinces found that one in
six young women (16%) reported that they had ever terminated a pregnancy.68 Department of
Health data on termination of pregnancy over the period 1997-2006 showed that 12% of
terminations of pregnancy were among girls under the age of 18.69 A study in KwaZulu-Natal
indicated that most terminations were requested on the basis of socio-economic reasons.70
Condom use
Male condoms are widely available in South Africa in the public sector, and through social and
commercial distribution, although public sector distribution has declined from a peak of 492million condoms in 2010.71 According to the HSRC surveys, male condom use at last sex has
varied over past decade among 15-24 year olds, peaking at 85% among males and 66% among
females in 2008, and declining to 68% and 50% among males and females in 2012.72 Male
condom use is higher among persons in younger age groups and is also equally distributed. For
example, the 2012 National Communication Survey (NCS),73 found that 65% of females and 64%
of males aged 15-19 used a condom at last sex. There were also high levels and equitable levels
of confidence a in condom use with 65% of women and 58% of men agreeing that they could
refuse sex if a person they liked refused to use a condom.
Reporting condom use at last sex is consistent with higher risk groups in South Africa – for
example being higher among persons never married, unemployed, those living in urban formal,
urban informal and rural informal areas, those having two or more partners in the past year and
those having a relationship of less than a year in duration.74 A study of young women in a rural
area in South Africa found the 44% of girls and young women aged 15-26 used condoms
inconsistently, while consistent use was associated with having one sexual partner and a more
gender equitable relationship.75 Inconsistent and incorrect condom use, as well as cessation of
use in longer-term relationships are challenges.76 Higher levels of gender equity positively
influence condom use, while lower levels of gender equity limit use.77
A high proportion of youth reported condom use at first sex – 78% among 16-19 year olds and
70% of 20-24 year olds. A study in Uganda found that condom use at first sex was strongly
Page 13
associated with condom use at most recent sexual intercourse.78 Associations between lower HIV
status and condom use at first sex have also been found in South Africa.79
Female condoms are available on a limited basis in South Africa, with around 300 public sector
sites being complemented by distribution through social marketing.80 While higher cost limits
wider distribution in comparison to male condoms, distribution of the female condom alongside
male condoms increases the likelihood of protected sex.81
Knowledge of HIV status
HIV counseling and testing (HCT) services are widely available through public health facilities in
South Africa, and through social marketing and private sector health services. In 2012, more than
50% of youth aged 15-24 had ever been tested for HIV, and levels are higher among females. 82
Recent HIV testing has also increased over time.
Although knowledge of HIV status through HIV testing does not significantly contribute to safer
sexual behaviours among people who test HIV negative, it has been found to decrease the
likelihood of having multiple sexual partnerships among people who test HIV positive.83 Condom
use is higher following HIV testing among people who test HIV positive,84 and testing provides an
entry point to other HIV-related services and support.
Knowledge of HIV status between sexual partners is improves condom use, particularly if HIV
discordancy is known.85 HIV testing is routinized in the delivery of antenatal services in South
Africa, providing an entrée into provision of mother to child transmission (PMTCT), and
contributing to higher levels of ever having had an HIV test among young women. Offering
routine HIV testing usefully complements voluntary counseling and testing (VCT) programmes,
and improves HIV case detection.86
Transactional sex, multiple, concurrent and older sexual partners
Transactional sex refers to sexual relationships motivated by expectations for receiving food,
cosmetics, clothing, transportation, cash or other material benefits. 87 Transactional sexual
relationships include those with older sexual partners,88 with casual sexual partners, and with
multiple and concurrent sexual partners.89 HIV incidence has been found to be higher among
young women in South Africa who have transactional relationships with casual partners or
concurrent partners.90 A South African study of girls and young women aged 16-24, found that
35% were in sexual partnerships with men who had other concurrent partners.91 A study in
Botswana observed that for every year’s increase in age difference between sexual partners,
there was a 28% increase in the likelihood of unprotected sex. Having unprotected sex with a
symptomatic STI was also observed to be higher among men with multiple partners in the past
year.92
Low levels of marriage and cohabitation among girls and young women in South Africa contribute
to shorter-term relationships, with frequent sexual partner turnover. 93 Having multiple sexual
partners –defined as having more than one sexual partner in the past year in surveys – is strongly
associated with higher HIV incidence.94 Among women, economic vulnerability, younger age at
sexual debut and living in formal urban areas is associated with having had multiple partners.95
While transactional and age-disparate sexual relationships, may be seen as empowering for some
young women,96 they may also be characterized by disempowerment, sexual coercion and
Page 14
violence.97 Having older partners carries a higher risk for HIV transmission,98 and younger women
are linked to wider sexual networks when they have relationships with men who are five or more
years older.99 In some high prevalence settings in South Africa, sex with older men may not be
specifically risky,100 although the reasons for such findings are not fully established. The wide
variations in HIV prevalence between males and females aged 15-19 in South Africa as found in
multiple surveys by the HSRC, suggest exposure to older men who are more likely to be HIV
positive. The 2012 National HIV Communication Survey (NCS),101 found that in the past year, 39%
of sexually active girls aged 16-19 had sexual partners five or more years older than themselves.
Sexual violence
Coerced sex violates individual rights and undermines agency to determine whether, when or
how sex occurs. Physical and sexual violence is criminalized in South Africa falling within the
ambit of either the Domestic Violence Act or the Sexual Offences Act. Physical and sexual
violence directed towards women in South Africa is high.102 Girls under 20 are more likely to have
experienced recent physical violence by a partner in comparison to women who are older.103
Experiences of coerced sex, physical and sexual violence increase the likelihood of future risktaking, early and unwanted pregnancy, and HIV infection.104 A study in South African found that
men who perpetrate partner violence have a predisposition towards higher risk sexual
behaviours and other factors that increase the likelihood that they will be HIV positive.105
A study on the reporting of rape in Eastern Cape, found that payment of compensation for rape
or for forcing victims into marriage had occurred in a number of cases where victims were young
girls.106 Abduction of girls with a view to enforcing marriage through ukuthwala falls within the
definition of coerced sex and sexual violence.107 Young lesbian women in South Africa have been
subjected to rape by men due to their sexual orientation.108
Statutory rape is defined in South Africa as sex with a person below the age of 16 where there is
a more than two-year age gap between perpetrator and victim, irrespective of whether consent
is given by the younger partner.109 While there is no information on the extent of prosecution of
statutory rape in South Africa, a study of under-age sex among adolescents aged 12-15 in Cape
Town found that 9.3% of girls reported having had vaginal sex and 1.4% reported having had anal
sex.110
Substance abuse
Alcohol consumption is associated with higher HIV prevalence,111 and is also linked to higher
exposure to sexual violence. 112 Risks occurring as a result of alcohol consumption include
increased likelihood of casual sex, unprotected sex, and having concurrent sexual partners. At
South African alcohol venues it has been noted that some men who buy women alcohol expect
sex in return. This leads to unsafe sex, and may result in physical or sexual violence when
expectations for sex are not met. 113 Minors who frequent venues where alcohol is consumed are
also at risk.114 A South African study found that 12% of adolescents initiated alcohol use prior to
age 13, while binge drinking among female youth had increased by about a third from 1998 to
2008.115
Recreational drug use is on the increase in South Africa, including use of variants of psychoactive
drugs other than marijuana – for example, methamphetamine116 (also called ‘tik’) as well as
mixed drugs such as ‘whoonga’ or ‘nyaope’ which may include highly addictive ingredients such
Page 15
as heroin.117 Methamphetamine use has been associated with having unprotected sex and having
multiple partners among men,118 low condom use among young women,119 and has been linked
to increased prevalence of physical and sexual violence and crime in South Africa.120
2.3.
Social and structural factors
Legal and policy environment
South Africa’s Bill of Rights focuses on inequality and freedom related to gender, sex, pregnancy,
marital status and sexual orientation. The Commission for Gender Equality promotes and
supports gender equality within public and private sectors and includes addressing legislation,
investigating complaints and monitoring progress towards gender equality goals. Government
departments include a strong focus on gender mainstreaming which flows into various strategies
and programmes.121 The recently enacted Women Empowerment and Gender Equality Bill reemphasises gender equality obligations and emphasises the need for collective societal
involvement.122 A number of South African laws also directly address domestic and sexual
violence.
South Africa is committed to the Millennium Development Goals (MDGs),123 and aligns HIV and
AIDS goals such as the UNAIDS ‘Getting to Zero’ strategy, among others.124 There are also
commitments to regional protocols such as the Southern African Development Community
(SADC) Programme of Action on Gender Equality and Development,125 and alignment with donor
priorities and gender strategies.126 This includes a commitment to the Joint United Nations
Programme on HIV/AIDS (UNAIDS) Agenda for Accelerated Country Action for Women, Girls,
Gender Equality and HIV.127
South Africa’s National Development Plan (NDP) Vision 2030,128 targets an HIV free generation of
people under 20, placing emphasis on universal access to ART, consistent condom use, and
access to pre-exposure prophylaxis and microbicides. A four-fold decrease in HIV incidence is
targeted as are declines in maternal and infant mortality, interpersonal violence and substance
abuse. Primary health care through community health workers and health education through
schools is also emphasized. In a review of health systems, it is observed in the NDP that “the
fundamental importance of full community participation and the role of civil society has been
underplayed, and the focus on ‘people-first – Batho Pele’ has diminished”, that integration of
community perspectives and needs has been replaced by a top down approach, that health is
undermined by inequality, and that such imbalances should be systematically addressed. The
NYP 2009-2014129 emphasizes addressing youth vulnerability and marginalization, with a focus on
youth development.
The National Department of Health’s Strategic Plan 2014/15-2018/19130 includes emphasis on
increasing access to SRH services and expanding coverage of contraception and providing first
dose coverage of Human Papillomavirus (HPV), and scaling up combination approaches for HIV
prevention.
SANAC plays a leadership role in fostering consensus between government, civil society and
other stakeholders, towards a co-ordinated multisectoral response on HIV and AIDS. The South
African National Strategic Plan (NSP) on HIV, STIs and TB, 2012-2016131 includes a commitment to
addressing gender, emphasizing the need to foster equitable gender norms and address genderbased violence. Girls and young women, girls who drop out of school, persons affected by
Page 16
poverty, persons with disabilities, and persons who abuse alcohol are identified as key
populations in the Plan. Attention is also given to youth who are orphans. Although sex work is
illegal in South Africa, SANAC has a national plan for addressing HIV in relation to sex work.132
The work of SANAC is guided by representatives from various sectors including a Women’s
Sector; Men’s Sector; Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI) Sector; Youth
Sector and Sex Worker Sector; Children’s Sector; Sport, Arts and Culture Sector; and, Non
Governmental Organisation Sector.
The Department of Social Development (DSD) Strategic Plan 2010-2015,133includes integration of
HIV and AIDS into DSD activities, implementation of a national plan on orphans and vulnerable
children, promotion of Youth Pioneers, improving opportunities for poor and marginalized youth,
and providing grants including child support grants.
The integrated HIV and AIDS strategy of the Department of Basic Education (DBE) 2012-2016134
highlights mandatory sexual and reproductive health (SRH) education as an assessed subject,
supported by co-curricular SRH and HIV-related life skills education. Emphasis is placed on
training of educators, increased access to SRH and HIV services, and a safety plan that includes
‘zero tolerance’ of discrimination, stigma and GBV.
The Higher Education HIV/AIDS (HEAIDS) programme’s policy and strategic framework on HIV
and AIDS,135 commits to promoting knowledge generation, while also promoting health and
wellbeing to address the epidemic within institutions, placing emphasis on a unified sector
response and institutional leadership.
Health and social services
A wide range of SRH and HIV services, are offered at public health clinics and hospitals in South
Africa and adolescent friendly standards and services are operational in many settings. Primary
HIV prevention is supported by widespread distribution of condoms through public health
services as well as other distribution points. Setting and implementing criteria for adolescent
friendly services, including a rights emphasis and non-judgmental service provision, are noted to
improve service quality.136 The extent of adequate implementation is however uneven. 137 An
analysis of strategies for scaling up and improving adolescent friendly contraceptive services
highlights the importance of training curricula, support tools and checklists in combination with
empowering adolescents as agents of change.138
SRH services are typically oriented towards women clients, and this contributes to less adequate
levels of care and support for men in relation to HIV, including influencing the extent of
untreated HIV and increases in mortality.139
Although safe legal abortion is available in South Africa, guided by the Choice of Termination of
Pregnancy Act (CTOPA), second trimester requests for abortion pose an ongoing challenge and
limited knowledge of correct gestational age for termination of pregnancy has been noted.140 A
study in South Africa found that reasons for delaying termination seeking were related to
changes in personal circumstances, delays in confirming pregnancy and health service barriers.141
Health care providers highlight preferences for stand-alone clinics that have the potential to
provide services that were more supportive, and higher quality of pre- and post-termination
counseling.142 A study on the implementation of the CTOPA noted that strong commitment by a
small cadre of nurses has been central to effective implementation,143 although it remains that
even after more than a decade of implementation, some nurses are reluctant to participate in
Page 17
various aspects of implementation.144 Rights to conscientious objection to conduct terminations
of pregnancy are recognized.
Schools and tertiary institutions
School-based life orientation is mandatory in secondary schools in South Africa, and includes
content on reproductive health and HIV. While a broad set of core modules are included, these
can be adapted to various settings. Positive outcomes of the programme have been observed in
relation to knowledge and attitudes, 145 as well as reducing sexual frequency and increasing
condom use.146
A review of youth-focused HIV prevention interventions in South Africa, including school-based
programmes, found limited impact on risk behaviors and biological outcomes. It was however
noted that using group-based approaches and delivering interventions in schools with outside
assistance, and focusing on school-level change. 147 A systematic review of approaches for HIV
prevention among youth found consistent evidence for knowledge and attitudinal outcomes for
in-school HIV prevention education. Such programmes involve adult facilitators, multi-session
programmes, skills and knowledge-building activities, and design appropriate to context.
Abstinence only and peer-led interventions were not effective.148
School attendance in South Africa is very high,149and attendance increased between 2002 and
2012. Of 11.2 million children aged 7-17 years in 2012, 290,000 (2.5%) were not attending school.
School attendance is compulsory until age 15, and school attendance levels for 16 year olds are
94%, and for 17 year olds, 89%. Pregnancy accounts for 5% of the total school drop-out (or 10%
among teenage girls).
Pregnancy is not a reason for school exclusion and studies show that, in general, teachers and
principals actively support this policy. It remains, however, that pregnant teens in school also
face moralistic and judgmental attitudes from educators. 150 Although there have been
suggestions of links between Child Support Grants and incentivisation for childbearing by girls in
South Africa, this has been shown to be untrue.151
A comprehensive study of teenage pregnancy with a focus on schooling in South Africa found
that early pregnancy risks increased after school dropout, and that early pregnancy was more
likely in situations of poverty. Although pregnant learners are allowed to remain in school, only
about a third returned to school after the birth of their children. It was also found that little
attention has been given to young fatherhood.152
The concept of Health Promoting Schools is endorsed by the WHO and focuses on broad-based
health of all within school environment, while fostering links with key stakeholders in the broader
community. This includes addressing the needs of disadvantaged learners, promoting
contextually-relavant healthy decision-making, and addressing SRHR, HIV and other aspects of
health.153
There are 23 public higher education institutions (HEIs), 50 public further education colleges
(FETs) in South Africa. HEIs comprise around 550,000 contact students, and FETs around
400,000.154 HIV prevalence among students in HEIs was 3.4% in 2009, ranging from 6.4% in the
Eastern Cape to 1.1% in the Western Cape.155 Female students were more than three times more
likely to be HIV positive in comparison to males (4.7% vs 1.5%). A high proportion of students had
more than two partners in the past month – 19% of males and 6% of females – and 7% of
females reported having partners who were 10 or more years older than themselves. Over 90%
Page 18
of students fall within the 18-24 year age range. HIV in HEIs and FETs is addressed through
HEAIDS, with programmes including training of staff and integrating HIV into the curriculum,
‘First Things First’ – which promotes HIV testing, ‘Future Beats’ which includes an HIV focus
through campus radio stations, ‘Brothers for Life’ – which is linked to the national programme
focusing on health and sexuality of men, ‘Zazi’ which addresses sexuality and health among
women, a dedicated LGBTI support programme, and links to HIV treatment and care.156
Gender and relationships
The vulnerability of girls and young women to HIV and unplanned pregnancy is shaped by gender
inequalities and there have been numerous initiatives to reinforce SRHR through multisectoral
leadership, including action plans to address GBV in South Africa. 157 Considerations for
addressing gender equality among girls and young women and their sexual partners include:
 …avoiding universalizing girls and young women as exclusively disempowered, and boys and
young men as exclusively empowered, while also taking into account economic
marginalization of both sexes.158
 …focusing on the social contexts and needs of young people as they negotiate their way
through vulnerabilities to HIV and pregnancy and emphasise constructive engagement
between sexes.159
 …avoid characterising teenage sexuality as risk-seeking,160 and to share examples of gender
equitable and safer relationships.161
 …focusing on sexuality, masculinity, femininity and relationship equality,162 while placing
emphasis on contexts of risk and relationship values and moving away from exclusive focus on
simplistic approaches such as ‘abstain, be faithful, condomise’.163
 …avoiding positioning masculinity as centered on sexual desire, lacking care or concern for
partners, and male dominance as irrevocable.164 Instead there is a need to engage boys and
men and draw them into the HIV, sexual and reproductive health and GBV prevention
response.165
 …improving integration of men into sexual and reproductive health (SRH) services. 166
 …engaging men in transformative HIV and violence prevention programmes.167
 …engaging with disempowerment of young women in traditional settings.168
 …focusing on community health,169 and emphasising the social agency of women, men and
communities with a view to overcoming the individual focus of biomedical approaches. 170
 …engaging underlying factors that influence vulnerability including alcohol and drug use and
economic exclusion.171
 …extending focus beyond service and welfare provision and include engaging and mobilizing
communities with emphasis on leadership to address gender inequality in relation to HIV
risk.172
Age-disparate and transactional relationships can be challenged by highlighting the shortcomings
of disempowerment and loss of self-worth that link directly to adverse short and long-term
Page 19
health consequences. 173 Discouraging men from seeking out and sustaining exploitative
relationships, and highlighting the responsibilities of men to provide protection and support to
younger women, are useful emphases. Leaders should also be engaged to support social
response on such issues.174 Stepping Stones and Community Conversations have been identified
as programmes with promise for supporting relationship equality, with strengths including
engaging sensitive topics, working with both sexes, and collectively identifying appropriate local
responses to SRHR challenges.175
Economic support
South Africa provides a number of grants to alleviate poverty including grants for child support
and foster childcare. Although amounts are relatively small (approximately R280 and R770
respectively) for recipients who meet means test criteria, it has been found that girls aged 12-17
living in households where grants are received were significantly less likely to engage in
transactional sex or have age-disparate relationships.176 Similar effects were not found for boys.
An integrated cash plus care study that explored the impacts of households receiving grants and
with enhanced care provided through various social services found reduced HIV risk behaviours
for both sexes.177
Addressing poverty and gender – with HIV prevention as a downstream outcome – has been the
focus of various microfinance programmes, including savings schemes and group empowerment.
A South African study – the Intervention for Microfinance and Gender Equity (IMAGE) study
addressed violence reduction and improved women’s empowerment, but HIV incidence and
unprotected sex among youth was not adequately impacted.178 While stand-alone microfinance
programmes have limited impact, integration of microfinance into broader programmes has
potential.179 A systematic review of adolescent focused programmes concluded that while some
conditional cash transfer trials to keep girls in school have shown impact on biological outcomes,
these applied mainly in contexts where there were significant financial barriers to school
attendance. Analysis of cost-effectiveness and sustainability of interventions was necessary
before scale-up could be recommended.180
Social and community mobilisation
Long term approaches to addressing HIV prevention are shifting away from an exclusive focus on
individuals to more comprehensive socio-ecological strategies that address communities as a
whole.181 A review of health governance and social capital in countries where HIV prevalence has
declined markedly highlights the beneficial outcomes of ‘intense social communication’ led at
national level with HIV prevention being engaged systematically through social networks, local
leaders, community groups and coalitions, with support provided by mass media and communitylevel dialogue.182
Community mobilization is operationalized through engaging groups, networks and organisations
at community-level with a focus on bringing about sustainable change in the interests of
improving community health and wellbeing. Community mobilization programmes create
enabling environments for change while also ensuring local-level sustainability local leadership.183
Community mobilization involves holistic, community-wide response focused on embedding new
social norms and practices, and allows for a shift from narrowly focused short-term programmes
and funding cycles.184
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Promoting ‘critical consciousness’ towards community mobilization through dialogue and
reflection for action is readily mobilized to address gender equality and empowerment,185 with
emphases on shared rights and mutual responsibilities and accountabilities being an appropriate
emphasis. 186 Community-level approaches that have been most effective in improving SRH and
addressing HIV among girls and women include: 187
 Training, peer and partner discussions and community-based education
 Community-based participatory learning approaches involving women and men
 Increasing employment opportunities, microfinance or small-scale income generating
activities
 Increasing educational attainment and abolishing school fees
 Community-level interventions clarifying HIV transmission risks and training of health
providers.
HIV and violence prevention, included training, involved community-based and participatory
approaches, included both sexes, engaged in peer support, utilised mass media campaigns,
improved law enforcement and addressed school attendance.
Engaging through communication
Communication related to HIV prevention functions interactively with response and improves
HIV knowledge while prompting shifts in behaviour and synergistically increasing access to
services. Mass media has been shown to influence health-risk behaviours, and is enhanced when
these are conducted in conjunction with other programmes and service provision.188 Significant
effects on HIV-related knowledge and risk behaviours have also been demonstrated. 189
Evaluation of health communication programmes has however been noted to be inconsistent.190
In South Africa, the social and structural environment includes national and sub-national
communication on HIV and other aspects of sexual and reproductive health and rights (SRHR).
Modalities include mass media as well as various other formats of communication including
interactive dialogue. The National HIV Communication Survey 2012 provides insight into the
extent to which communities have been reached through HIV Communication Programmes
(HCPs) with a focus on persons aged 16-55. Key findings include: 191
 Most people have been reached by HCPs, although exposure to at least one programme has
declined from 90% being exposed to at least one HCP in 2009, to 82% in 2012
 Levels of having ever been tested for HIV, and being recently tested for HIV are high and HCPs
have directly increased the proportion of persons testing in the past 12 months. HIV testing
with partners had also increased.
 Condom use at last sex has remained high and exposure to HCPs had increased uptake.
 There was lower awareness of the risks of multiple sexual partnerships in comparison to other
prevention approaches and HCPs have not adequately impacted on reduction of multiple
sexual partnerships.
 Intention to consider circumcision among men has been increased by HCPs.
Page 21
The extent to which HCPs addressed and impacted upon age disparate sex, transactional sex,
delayed sexual debut and the risks of alcohol abuse was not assessed in the 2012 NCS.
Various participatory dialogue-oriented programmes that focus on HIV prevention, sexual and
reproductive health have been conducted at community level in South Africa. These include:
 Stepping Stones, which was found to have reduced HSV-2 and violence, 192 and is now being
linked to a broader programme called Creating Futures that includes livelihood activities.
 lovelife youth and community programmes which include peer engagement through
‘groundbreakers’ and ‘mpintshis’, sports activities and youth and community dialogues.193
 The Zazi programme, which focuses on empowerment and resilience among young women.194
 Grassroot Soccer, which promotes sport as a means for dialogue through a structured
curriculum to address HIV among youth.195
 Brothers for Life, which focuses on HIV prevention and supporting gender equitable values
among men.196
 Prevention in Action, which addresses GBV prevention through community mobilization, with
participants widely reporting actions taken to tangibly address GBV in their communities.
Violence free zones were established that have included impacts on broader community
safety and crime prevention.197
 The Mpondombili Project in KwaZulu-Natal which focused on delay of sexual debut and
condom use as complementary strategies. The project improved outcomes in relation to
condom use but did not impact on sexual debut.198

The SATZ programme, which was conducted in South Africa and Tanzania. While the
programme was effective in delaying debut in Tanzania, there was no impact in South Africa,
leading to the conclusion that complementary programming was needed.199

The ‘Let us protect our future’ intervention in South Africa focused on adolescents. The
intervention achieved a number of risk reduction outcomes, and illustrated additional sociocognitive mediating factors supported change processes.200

Women’s Health CoOp – which addresses sexual risk, substance use and gender-based
violence among girls and young women.201

The CHAMP model, which has been implemented in multiple countries and emphasizes
collaboration between researchers and communities, including power-sharing towards
supporting individuals, families and communities for HIV prevention. The programme has
improved family functioning and addressed precursors to sexual risk taking.202

Soul Buddyz clubs, which have a developmental orientation that strengthens child welfare.203

Male engagement programmes such demonstrate how beliefs and practices related to
masculinity can be transformed to improve response to HIV and address violence,204 as has
been shown through implementation of the One Man Can programme.205
Analyses of abstinence programmes have found insufficient engagement with the realities of
adolescents, moral framing of sexual behavior, mixed messaging about condoms and secular
schooling to be among the challenges of such programmes.206
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While engaging youth through peer programmes has been a popular format for youth
intervention – in particular in relation to capacity to work directly with youth – gendered power
and dynamics of poverty are noted to have been insufficiently contextualized which has limited
the transformative impacts of such programmes. 207 Fostering youth engagement and
participation at community-level to address HIV requires social spaces for critical thinking, a
sense of ownership, and mechanisms for building and sustaining collaborative relationships
between adults and youth.208
3.
ACCELERATING HIV PREVENTION AMONG GIRLS AND YOUNG WOMEN
To address and accelerate HIV prevention among girls and young women aged 15-24 in South
Africa over the short-term, it is necessary to prioritise strategies that will have the most impact
on HIV incidence. Although factors underpinning HIV vulnerability are complex, and options for
preventing new infections are diverse, the goal of intensified HIV prevention will not be achieved
unless the repertoire of strategies adopted can be scaled up with immediate effect.
Reducing new infections in this high incidence sub-population of girls and young women aged 1524 will contribute to containing South Africa’s overall HIV epidemic and reducing the overall
burden of disease. This strategy contributes to the reduction of new infections among men,
reducing the burden for HIV care including ART, reducing the prevalence of STIs and reducing
unplanned and unwanted pregnancies.
The following six priority strategies focus on the epidemiological outcome of reducing new
infections girls and young women aged 15-24.
among build on strong foundations within the existing response to HIV prevention in South
Africa, with outcome goals being identified for each strategy over the 2015-2019 period:
1. Increasing age at first sex: Vulnerability to HIV and unplanned pregnancy is directly linked to
sexual debut. Risks for girls and young women under the age of 20 are particularly severe and
the data highlight that new infections occur over the course of relatively few sex acts.
Increasing age at first sex will moderate physiological and biological risks for HIV and avert
new HIV infections. Furthermore, exposure to STIs including HSV-2 which is an incurable and
leading co-factor in HIV vulnerability will be attenuated, as will exposure to possible
pregnancy. Increasing age at first sex will also improve opportunities to engage with girls and
young women and their potential partners to prevent unwanted and coerced early sexual
experiences. Outcome goal: Reduce the proportion of girls and young women who report
having ever had sex among girls aged 15-17 by 50%, and young women aged 18-19 by 25%
over a five-year period.
2. Reduce sex with older partners among girls and young women under 20: The data highlight
that among girls and young women under 20, there is considerable overlap with having
transactional sexual partnerships, casual sexual partnerships, concurrent sexual partnerships,
and experienced coerced sex and physical violence. Together these factors increase the
likelihood of new HIV infections occurring among girls and young women who have
heightened vulnerability to HIV and pregnancy. The markedly higher HIV prevalence between
girls and young women under 20 in comparison to boys and young men of the same age
indicate exposure to high-risk men who HIV positive, and are likely to be older than
themselves. Older partners are more likely to have the economic means to support
Page 23
transactional relationships with girls and young women, and opportunities for transactional
sex with older partners contribute to the likelihood of having concurrent and casual sexual
partnerships with both younger and older men. Disempowerment and vulnerability to
coercion and physical violence flows directly from skewed an unequal expectations that
constrain the establishment of love, trust, responsibility and mutual accountability for HIV,
STI and pregnancy prevention. Outcome goal: Reduce the proportion of girls and young
women aged 15-19 who have a sexual partner five or more years older than themselves by
50% over a five-year period.
3. Reduce unplanned pregnancy among girls and young women under 20: At least one in nine
girls and young women under 20 have been pregnant in the past year. The data indicate that
a high proportion of teenage pregnancies are unplanned and unwanted. The vast majority of
pregnancies carried to term occur mostly out of the context of marital relationships, and
establishing paternity and negotiating co-parenting responsibilities are prominent challenges.
Single parenting increases economic and other vulnerabilities for young mothers, and poses
downstream risks for HIV and STI infection for young mothers. Contraception and
termination of pregnancy (TOP) services are widely available, and are within the ambit of
control of young women, and prioritizing unplanned and unwanted pregnancy is a
complementary responsibility of male partners. Outcome goal: Reduce the proportion of girls
and young women aged 15-19 who report having been pregnant in the past year by 50% over
a five-year period.
4. Reduce multiple sexual partnerships: Multiple sexual partnerships (defined in surveys as
persons who have had previously had sex who have had more than one sexual in the past
year) are acknowledged as a key driver of new HIV infections. Having multiple sexual
partnerships may also include having higher risk concurrent sexual partnerships where sexual
relationships overlap in time. HIV prevalence declines over relatively short periods of time
have been attributed to downward shifts in the extent of multiple sexual partnerships. While
girls and young women aged 15-24 may reduce the extent to which they have multiple sexual
partners, risks of exposure remain as a product of their partners having multiple or
concurrent partners. The goal of reducing multiple sexual partnerships therefore pertains to
the population as a whole. Outcome goal: Reduce the proportion of sexually active persons
aged 15 years and older who report having had two or more sexual partners in past year by
50% over a five-year period.
5. Increase consistent condom use among girls and young women aged 15-24: Male condom
use at last sex is already at high levels in South Africa, particularly among youth. Male
condoms are also used at similar levels between girls and young women aged 15-24 and boys
and young men in the same age range. Condoms are effective for averting new HIV infections
and STIs in South Africa, and are mainly constrained by inconsistent use including
discontinuation, while higher levels of gender equity increase consistent condom use. While
female condoms offer promise for increasing the number of protected sex acts,
strengthening and sustaining male condom promotion and distribution – including through
public sector, social marketing and commercial distribution – remains a priority. To further
reinforce high levels of condom use at last sex, emphasis should be placed on consistent
condom use when couple HIV status is not known, when a person knows they are HIV
positive, or when couples are aware of HIV discordancy. Outcome goal: Increase the
Page 24
proportion of girls and young women aged 15-19 who have had sex in the past year reporting
having used a condom at last sex by 30% over a five-year period.
6. Increase uptake and retention of eligible PLHIV on ART: ART markedly reduces the viral load
of PLHIV, which, in-turn, reduces community level viral load when ART programmes are
operating at scale. Increasing the extent of ART uptake among eligible men is likely to
contribute to reduced transmission efficacy among HIV positive men who have female
partners who fall into the 15-24 year age group. Increasing ART uptake among eligible
women will also impact on HIV prevention as a product of reducing HIV transmission to HIV
negative boys and men. It should be highlighted that not all PLHIV are immediately eligible
for ART, and transmission risk remains for those who fall below the threshold CD4 count
remain at higher risk for transmitting HIV. Consistent condom use for all PLHIV remains a
priorty. ART initiation and retention is an existing goal of the South African NSP. Outcome
goal: Increase ART coverage by initiating at least 80% of eligible patients onto antiretroviral
treatment (ART) on an annual basis.
Figure 3 provides a graphic depiction of the logic model for HIV incidence reduction as a product
of the effects of the six priority strategies. The social and structural response is detailed further
below.
Figure 3: Logic model for incidence reduction among girls and young women in South Africa
Table 2 summarises the six priority areas and outcome goals. Programme activities and baseline
indicators are described further below.
Table 2. Priority strategies and outcome goals for accelerating HIV prevention among girls and
young women aged 15-24 in South Africa
Priority strategy
Outcome goal
Increase age at first sex
 Reduce the proportion of girls and young women who report
having ever had sex among girls aged 15-17 by 50%, and
young women aged 18-19 by 25% over a five-year period
 Reduce the proportion of girls and young women aged 15-19
who have a sexual partner five or more years older than
themselves by 50% over a five-year period
Reduce sex with older partners
among girls and young women
under 20
Reduce pregnancy among girls
and young women under 20
 Reduce the proportion of girls and young women aged 15-19
who report having been pregnant in the past year by 50%
over a five-year period.
Page 25
Reduce multiple sexual
partnerships
Increase consistent condom use
among girls and young women
aged 15-24
Increase uptake and retention of
eligible PLHIV on ART
3.1
 Reduce the proportion of sexually active persons aged 15
years and older who report having had two or more sexual
partners in past year by 50% over a five-year period.
 Increase the proportion of girls and young women aged 15-19
who have had sex in the past year reporting having used a
condom at last sex by 30% over a five-year period.
 Increase ART coverage by initiating at least 80% of eligible
patients onto antiretroviral treatment (ART) on an annual
basis
A multilevel, combination HIV prevention approach
An analysis of strategies to prevent HIV transmission highlights that behavioural approaches are
insufficient when used without adopting a multilevel approach that includes couple, families,
social and sexual networks, institutions and communities as a whole.209
Country-level successes in reducing HIV prevalence and incidence have had political support at
the highest levels, as well as devolving leadership of response to sub-national and community
level. Participatory structures, coalitions, networks, and activism in combination with mass and
folk media and local-level dialogue have helped to reinforce understanding of prevention
priorities and the means to address them. Biomedical and behavioural responses have been
bolstered and reinforced through leadership and coordination by community committees which
have supported community mobilization, while maximising equitable access to services, and
efficient service delivery have provided the foundation for sustained response.210
Socio-ecological approaches include emphasis on individual, couple, family, community and
societal domains. These principles are embodied in the combination approach to HIV prevention
which focuses on achieving ‘the greatest and most lasting impact on reducing HIV incidence and
on improving the wellbeing of all affected communities’.211 The approach balances biomedical,
behavioural and social level strategies and follows a rights-based orientation.
Highlighting evidence informed strategies, and multisectoral leadership, combination prevention
emphasizes the importance of:
 Tailoring interventions to local conditions, including resources, services, socio-economic and
cultural circumstances
 Ensuring community ownership, including partnerships with communities that involve
participation in the planning, design, resourcing, management and implementation of HV
prevention response
 Being learning oriented, including ongoing capacity development, while also being adaptive
through analyzing how interventions work in context, and making changes as the response to
interventions evolves.
 Monitoring and evaluating interventions and tracking change, which should be routinized at
all levels, with feedback on progress allowing for community and social level awareness of
tangible change.
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3.2
Heterogeneity of HIV prevalence and prioritizing response
HIV is distributed heterogeneously throughout South Africa, occurring predominantly in areas
where population is denser, and in communities where populations are poorer. Analysis of HIV
prevalence by district at population. level for both sexes for the 15-49 year age group, and
among pregnant women attending antenatal clinics aged 15-49 consistently illustrate the
concentration of HIV in six high prevalence provinces. In 2012, prevalence was highest in –
KwaZulu-Natal (27.9%/37.4%),212 Mpumalanga (21.8%/35.6%), Free State (20.4%/32.0%), North
West (20.3%/29.7%), Gauteng (17.8%/29.9%) and Eastern Cape (19.9%/29.1%). HIV prevalence is
however at high epidemic levels in the remaining three provinces. District level analysis shows
varying patterns of concentration that are generally consistent with provincial HIV prevalence
distribution. Figure 4 shows the distribution of HIV at population level by district.
Analysis by the HSRC in 2012, highlights that sociodemographic factors are the primary
distinguishing feature of vulnerability to HIV, with highest concentrations being found in informal
urban settlements and farms.213 Persons who have insufficient money for basic necessities are
nearly seven times more likely to be HIV positive in comparison with people who have disposable
income for luxuries. Among the population as a whole, it was found that persons with disabilities
were among the groups with higher prevalence, while among youth, orphans who had lost one
parent were more than three times more likely to be HIV positive.
Figure 4: Distribution of HIV prevalence in South Africa by district, 2012214
3.3
Segmentation of youth sub-populations
To address HIV prevention among girls and young women in South Africa, a national orientation
should be followed, given that although HIV prevalence varies by province and district, HIV
prevalence is sufficiently high to justify intervention in all districts. Poorer urban and rural
communities should be prioritized.
Within these contexts, segmentation of vulnerable youth is a necessary first step to engaging
Page 27
with vulnerability of girls and young women. While there are merits in focusing specifically on
girls and young women exclusively in some instances, emphasis should be placed on inclusion of
male partners, and engaging and addressing boys and men towards reducing overall vulnerablity
to HIV, as well as highlighting the importance and urgency of addressing high HIV incidence
among girls and young women. Figure 5 outlines the focal categories of vulnerable youth to be
engaged.
Figure 5: Categories of vulnerable youth to be engaged
Youth in school aged 15 and older
School enrolment in South Africa is high, and teenagers aged 15 and older are readily accesses
through the school system. The school-based Life Orientation curriculum is well established and
includes a focus on SRH and HIV. While the focus of this curriculum is knowledge oriented, there
is a need for schools to adopt an institutional approach to addressing HIV incidence and
unplanned teenage pregnancy among their learners, while also providing support to learners
who are HIV positive, who become pregnant, or who are teenage fathers.This requires
affirmation of values that reiterate commitment to the health of learners, while also clearly
promoting understanding of vulnerabilities that underpin HIV and unplanned pregnancy –
notably casual and transactional sex, multiple and concurrent sexual partnerships, and sex with
older partners. Emphasis should be given to highlighting the illegality of statutory rape. A
proactive approach should be adopted to mobilising youth in school to reflect on vulnerabilities
and risk reduction, in combination with fostering linkages with local health facilities,
organisations and networks engaging teenagers on these issues. Potentials for adopting
principles and practices of the health promoting schools model should be explored.
 Key groups for capacity development and programming support include: Schools principals,
teachers, school governing bodies, student bodies, learner clubs, school nurses, non
governmental and communty-based organisations working with youth (gender, HIV, SRH),
HCT services, clinics (including PMTCT providers), hospitals (including TOP providers), social
services, parents, families, PLHIV organisations, commmunity leaders.
Youth attending clinics and hospitals
The provision of adolescent friendly health services is a well established and proven modality for
increasing uptake of young people to key services including contraception, condoms, STI
treatment, HCT, antenatal care, post-natal care, PMTCT, TOP, and VMMC among others.
Emphasis should be placed on: regularly assessing adolescent friendly standards and services;
improving consistent access to services; access by men; emphasizing the importance of
Page 28
knowledge of partner status and couple access to HCT and other services; and male involvement
in antenatal and post-natal care. Guidelines for practice should be developed and adopted for
assisting orphans, youth with disabilities, youth who have experienced physical and sexual
violence, youth sex workers, LGBTI and youth PLHIV. Supportive linkages and collaborations
should be developed with youth oriented NGOs and CBOs, youth networks and clubs. Facilitating
post-test and other club formats should be explored.
 Key groups for capacity development and programming support include: Clinic managers,
doctors nurses, non governmental and communty-based organisations working with youth
(gender, HIV, SRH), HCT services, clinics (including PMTCT providers), hospitals (including TOP
providers), social services, parents, families, PLHIV organisations, commmunity leaders.
Unemployed youth out-of-school
Unemployed youth out-of-school are a broad category with diverse vulnerabilities. While some
youth also fall into other categories of vulnerability as well, general challenges relate to securing
sufficient income for survival and other needs.
There is a need to reduce the extent of transactional sexual partnerships and to mitigate
vulnerabilities to HIV and unplanned pregnancy when such relationships occur.
Unemployed out-of-school youth are particularly vulnerable to alcohol and drug abuse, and
substance abuse is growing in prevalence. Exposure to alcohol and drug dependency are linked to
exposure to violence, and for girls and young women, sexual violence poses a severe risk for HIV
infection. Alcohol and drug dependency includes risks of engaging in petty and other criminal
activities to secure cash to support substance abuse. There is a need to offer and expand
programmes that address alcohol and drug dependency – particularly for youth in poorer
communities.
Economic support programmes including opportunities for sustainable and unsupported
engagement in informal trading through microcredit arrangments, or group-based economic
activities hold promise. Diversionary activities including involvement in sport or various formats
of community service are also relevant.
 Key groups for programming support include: Youth organisations, youth networks, groups
and organisations addressing alcohol and drug abuse, clinics, hospitals, rehabilitation services,
police, community safety structures (neighbourhood watch, community policing forums, ward
structures), social services, owners/managers of alcohol venues, microfinance entities, PLHIV
organisations, parents, sports and recreation clubs, families and commmunity leaders.
Pregnant teens (and partners)
It is estimated that around one in eight teenage girls aged 15-19 are pregnant or have recently
been pregnant. It is unclear to what extent these pregnancies are unplanned or unwanted, nor is
there clarity on the characteristics of fathers.
Engaging pregnant teens is necessary to determine interest in carrying the pregnancy to term.
Improved knowledge and support to first trimester termination of pregnancy, where desired, is a
key intervention. Where continuation of pregnancy is intended, it is necessary to engage with
responsibilities for paternity and paternal support.
Page 29
Fatherhood programmes have been found to be successful, although there is scant information
on fathers who wish to minimise their paternal involvement or responsibilities. The extent of
paternal responsibility adopted by older partners of pregnant teens is also unclear, and reasons
for denying paternity or avoiding claims to paternity may be linked to their current marital status,
their status within the community, or links to the schooling system.
It is necessary for fatherhood and parenting programmes to address paternal involvement in
antenatal care, as well as emphasising the importance presence during childbirth. Such
involvment supports close bonding between parents, and bonding with the child.215
Knowledge of couple HIV status is important. Paternal support and involvement in prevention of
mother to child transmission (PMTCT) should be emphasised if the mother is HIV positive.
Whether or not the mother is HIV positive, risks of HIV transmission should be addressed and
may include the possibility that the father may be HIV positive.
Pregnancy and young motherhood is not a reason for school exclusion, and studies have found
that teen mothers are able to pursue schooling and academic goals even though they have
parenting responsibilities. 216
While emphasis is placed on pregnant teens aged 15-19, extending the age range to younger girls
or young women may be relevant in some contexts.
Girls and young women who carry their pregnancies to term have increased challenges in
relation to their freedom to attend school, engage in employment, or undertake tertiary
education. In economically impoverished contexts, these burdens are likely to be exacerbated by
minimal access to income, potentially low or no paternal support, and variations in relation to
support to childcare arrangements. While some economic support is provided via childcare
grants, it is necessary to address the needs for comprehensive support.
Parenting and fatherhood programmes are particularly relevant for young parents. It is also
important to engage with concepts of parenting and fatherhood where parents choose are not
cohabiting, or choose not to continue their relationship. It is important to highlight that devolving
paternal involvement to financial support only, in the case of absentee fathers, is not in the
interests of the child. Programmes should therefore focus on maintaining paternal bonds
including identifying and promoting a range of care and contact arrangements between fathers
and their children.217
 Key groups for programming support include: Schools (principles, teachers, school governing
bodies, student bodies, learner clubs, school nurses), HCT services, clinics (including PMTCT
providers), hospitals (including TOP providers), social services, parents, families, PLHIV
organisations, commmunity leaders.
Page 30
Youth in tertiary institutions
There is a sizable population of young people enrolled in tertiary institutions in South Africa. The
extent of HIV prevalence in HEIs has been established and comprehensive policies and strategies
are in place through HEAIDS. These policies and strategies extend to FETs, and broad-based
interventions include links to key programmes such as Brothers for Life and Zazi, with HIV testing,
VMMC and other aspects of SRH. Addressing HIV and pregnancy in HEIs and FETs serving poorer
communities where HIV prevalence is higher should be prioritised.
 Key groups for programming support include: University management and teaching staff,
health support staff, student bodies (leaders, clubs, networks), NGOs working with tertiary
institutions (gender/HIV/SRH), HCT services, clinics (including PMTCT providers), social
services, and PLHIV organisations.
Orphaned youth
The vulnerabilities of orphaned youth include higher than average exposure to sexual coercion,
sexual exploitation, sexual and other violence as a product of disempowering care arrangements,
and girls are more vulunerable than boys. In addition, orphaned youth in their late teens and
transition out of school or care arrangements, face diminishing access to support resources to
address their immediate needs.
While programmes mostly focus on younger orphans, orphans in their late teens and early 20s –
particularly girls and young women – are likely to require higher levels of psychosocial support
than their non-orphaned peers. Given that definitions of orphaning include having lost one or
both parents, support programmes need to take into account diverse residential and care
arrangements.
 Key groups for programming support include: Youth organisations and networks, social
services, grant providers, carers and guardians, sports and recreation clubs, microfinance
entities, PLHIV organisations, families, and commmunity leaders.
Youth with disabilities
The vulnerabilities of youth with disabilities include higher than average exposure to sexual
coercion, sexual exploitation, sexual and other violence as a product of disempowerment that
flows from disability. The extent of vulnerability is linked to types of disability, and girls and
young women are more vulnerable than their male counterparts.
Youth with disabilities may have less access to information on HIV, pregnancy prevention, and
GBV. Challenges include inadequacies in capacities of families, carers, educators and health
providers to understand the HIV and related vulnerabilities of youth with disabilities, in
combination with less capacity to address sexuality, including sexual vulnerabilities.
Consequently, the focus of programmes should be to initially address persons within care and
support environments, and then to engage vulnerable youth in organised dialogue to clarify
vulnerabilities and best approaches to providing support.
 Key groups for programming support include: Disability organisations and networks, youth
organisations and networks, social services, grant providers, microfinance entities, PLHIV
organisations, parents, families, carers and guardians, and commmunity leaders.
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Youth who have experienced physical and sexual violence
There is ample evidence demonstrating that physical and sexual violence affect youth as a whole.
While girls and young women are particularly vulnerable, boys and young who experience similar
violence are less able to report and address these experiences. Under-reporting is a general
challenge, and perpetrators are protected by the absence of negative consequenceis to their
actions, thereby perpetuating the likelihood of recurrence.
While health and legal services provide support, it is necessary to expand assistance given to
victims who elect not to pursue legal recourse, as well as all in need of ongoing psychosocial care.
Victim support groups are a relevant format for assistance, and the need to address perpetrators
in reformative processes should not be overlooked.
 Key groups for programming support include: Clinics and hospitals (including PEP providers),
police, social services, women’s organisations and networks, men’s organisations and
networks, youth organisations and networks, PLHIV organisations, parents, families, carers
and guardians, community safety structures (neighbourhood watch, community policing
forums, ward structures) and commmunity leaders.
Youth sex workers and clients
While sex workers are recognised as a key population, with some recognition given to the need
to address clients of sex workers, there has been minimal focus on disaggregating and addressing
the specific needs of young sex workers. This includes the need to address sex work among girls
younger than 16, where there is a legal necessity to pursue the occurrence of statutory rape.
Other aspects include illegal trafficking or various formats of exploitation, which may include
fostering drug dependency to ensure sustained participation in sex work.
While sex workers may have strong commitments to consistent condom use, client preferences,
including violence or threats of violence are inhibiting factors. Exploitation as a product of legal
and other formats of disempowerment also reproduce vulnerability, and persons in authority
including security guards, police, managers or owners of bars or hotels, border officials, among
others, may demand sex in exchange for various forms of protection.
It is necessary for programmes addressing sex work to include emphasis on young girls and
women sex workers with a particular emphasis on addressing legal and rights violations and
exploring approaches to more fully address clients of younger sex workers. Potentials for
integration of smaller subsets of male sex workers could also be considered.
 Key groups for programming support include: Sex worker organisations and networks, PLHIV
organisations, managers and owners (alcohol venues, accommodation venues), community
safety structures (neighbourhood watch, community policing forums, ward structures) and
commmunity leaders.
LGBTI youth
LGBTI youth face varying challenges inter-related with their sexual orientation and relationship
practices. While HIV risks are most prominent for men who have sex with men (MSM), girls and
young women who have sex with women or who are bisexual remain vulnerable to HIV. This
includes vulnerability to sexual and other violence perpetrated on the basis of their sexuality,
Page 32
some of which includes the risk of HIV transmission and/or pregnancy.
It is necessary for programmes to focus on stigma reduction, assertion of rights related to
sexuality, and support to address experiences of violence.
1. Key groups for programming support include: LGBTI organisations and networks, PLHIV
organisations, clinics and hospitals, parents, families, community safety structures
(neighbourhood watch, community policing forums, ward structures) and commmunity
leaders.
Youth PLHIV
Although surveys indicate overall low levels of stigmatising attitudes, living with HIV includes
challenges in relation to sexuality and expressions of femininity218 and masculinity. 219 Young
PLHIV may face negative responses and discrimination from family members, peers and
community members when they disclose their status. The Positive Health Dignity and Prevention
(PHDP) framework follows a rights-based orientation and includes focus on a broad spectrum of
support towards health and wellbeing, and includes a focus on the prevention of HIV
transmission in the context of knowledge of HIV status. Support groups, clubs and networks
provide support to PLHIV.
While there is a strong emphasis on integrating PLHIV into ART and PMTCT programmes, there is
a need to expand the fuller integration of young PLHIV into the HIV prevention response
including mobilizing skills of unemployed PLHIV and promoting ‘champions’.
 Key groups for programming support include: PLHIV organisations, clinics and hospitals,
microfinance entities, parents, families, and commmunity leaders.
3.4
Implementation through six key programme areas
Six key programme areas requiring multisectoral and collaborative leadership are identified. It is
necessary to prioritize capacity development of personnel in each key programme area on the
urgency of addressing HIV and pregnancy among girls and young women, and the six priority
strategies for accelerated impact. Key programme areas include:
1) Political and civil society leadership at national, provincial and local level;
2) Civil society organisations including non-governmental organisations and activists focused on
HIV, SRH, youth and gender;
3) Leadership, management and personnel and youth within key institutions (health, education
and social development);
4) National and sub-national health communication programmes focused on gender, SRH and
HIV;
5) Municipal, district and local programmes;
6) Networks, coalitions and community groups focused on gender, SRH, HIV and youth.
Functions within each programme area are detailed in Table 3.
Page 33
Table 3. Functions in six key programme areas for accelerating HIV prevention among girls and
young women aged 15-24 in South Africa
Programme area
1) Political and civil society
leadership at national,
provincial and local level
2) Civil society organisations
including non-governmental
organisations and activists
focused on HIV, SRH, youth
and gender
3) Leadership, management and
personnel and youth within
key institutions (health,
education and social
development)
4) National and sub-national
health communication
programmes focused on
gender, SRH and HIV
5) Municipal, district and local
programmes
6) Networks, coalitions and
community groups focused
on gender, SRH, HIV and
youth
Functions
 Promote urgency of addressing high incidence of new infections
among girls and young women in South Africa
 Promote six key priority areas for action
 Promote a multisectoral response emphasising joint responsibility
and accountability
 Promote rights and values of shared responsibility and accountability
in sexual relationships with an emphasis on HIV and unwanted
pregnancy prevention
 Promote values of non-violence and gender equality in relationships
 Promote urgency of addressing high incidence of new infections
among girls and young women in South Africa
 Promote six key priority areas for action
 Intensify or add emphasis on six key priority areas for action through
plans, strategies and programmes with a focus on accelerating gains
on HIV prevention over the 2015-2019 period
 Conduct dialogue and empowerment activities with youth focused on
gender, SRH and HIV, as well as guidance on pathways for
managing and overcoming economic and other disadvantageous
circumstances
 Promote urgency of addressing high incidence of new infections
among girls and young women in South Africa
 Promote six key priority areas for action
 Intensify or add emphasis on six key priority areas for action through
plans, strategies and programmes with a focus on accelerating gains
on HIV prevention over the 2015-2019 period
 Conduct dialogue and empowerment activities with youth focused on
gender, SRH and HIV, as well as guidance on pathways for
managing and overcoming economic and other disadvantageous
circumstances
 Promote urgency of addressing high incidence of new infections
among girls and young women in South Africa
 Promote six key priority areas for action
 Intensify or add emphasis on six key priority areas for action through
mass media and dialogue-oriented communication with a focus on
accelerating gains on HIV prevention over the 2015-2019 period
 Promote urgency of addressing high incidence of new infections
among girls and young women in South Africa
 Promote six key priority areas for action
 Intensify or add emphasis on six key priority areas for action through
plans, strategies and programmes with a focus on accelerating gains
on HIV prevention over the 2015-2019 period.
 Conduct dialogue and empowerment activities with youth focused on
gender, SRH and HIV, as well as guidance on pathways for
managing and overcoming economic and other disadvantageous
circumstances
 Promote urgency of addressing high incidence of new infections
among girls and young women in South Africa
 Promote six key priority areas for action
 Intensify or add emphasis on six key priority areas for action through
plans and strategies, with an emphasis on active citizenry and
community mobilisation with a focus on accelerating gains on HIV
prevention over the 2015-2019 period.
 Conduct dialogue and empowerment activities with youth focused on
gender, SRH and HIV, as well as guidance on pathways for
managing and overcoming economic and other disadvantageous
circumstances
Page 34
Figure 6 outlines the implementation framework for six key programme areas through which an
intensified focus on the six priority strategies will be achieved. To accelerate implementation,
SANAC through government departments and supported by the CSO sectors of SANAC.
Sensitisation on the six priorities for HIV and pregancy prevention is a key intervention. This
should incorporate capacity development to strengthen exisiting strategies and interventions,
and to expand the repertoire of activities and collaborations to intensify prevention gains and
mitigate impacts.
3.5
Affirmation of values
HIV prevention response in South Africa has been characterized by a strong focus on biomedical
and behavioural approaches that have been directed towards individuals. This includes emphasis
on HIV prevention technologies and services in combination with promoting awareness of risk
behaviours.
Table 4: Sexual rights and relationship values to support priority strategies
Rights
Relationship values
 Right to delay sexual debut
 Right to initiate sex when ready
 Right to engage in sexual relationships
on the basis of free choice
 Right to sex free from coercion
 Right to sex free from violence
 Support for delayed sexual debut
 Support for caring and healthy sexual relationships
 Relationship spacing
 Right to sex free from
disempowerment
 Right to sex free from risk of HIV, STI
transmission











 Right to sex free from risk of
unplanned pregnancy
 Right to shared parental obligations of
children


Rejection of coerced sex
Rejection of violence
Recognition of the illegality of statutory rape
Rejection of dependent, exploitative or disempowering
relationship formats including age disparate relationships with
teens and transactional sex
Commitment to not having concurrent sexual partnerships
Avoiding frequent partner turnover (multiple partners)
Recognition of the importance of mutual knowledge of couple
HIV status
Mutual commitment to consistent condom use if couple HIV
status is unknown
Supportive approach to HIV disclosure between partners
Emphasis on love, care, sharing and relationship equality
Commitment to addressing HIV discordancy, and PHDP
supportive values
Mutual commitment to addressing contraception.
Mutual commitment to addressing unplanned pregnancy
 Mutual commitment to supportive parenting including mutual
responsibilities for addressing potential HIV risks to unborn
children
 Mutual support to antenatal care (including PMTCT if required)
 Birth attendance by both parents
 Mutual support to childcare
While these approaches have contributed to HIV incidence reduction in South Africa, there is a
need to deepen the extent to which partners in sexual relationships are actively engaged.
Accelerated HIV prevention will be achieved through supporting rights to sexual determination
and promoting healthy and equitable relationship values that address responsibilities and
accountabilities of both partners. It is necessary to take into account that relationships among
youth may be of very short duration, and emphasis is placed on reducing the extent of frequent
Page 35
partner turnover, in combination with fostering values that foster relationship stability –
particularly in relation to pregnancy and parenting. The approach also focuses on addressing
sexual and physical violence. It is necessary for these rights and values to be articulated and
affirmed as part of supporting the six priority strategies. These rights and relationship values are
outlined in Table 4.
3.6
Community mobilization and engaging youth
An overview of structural interventions highlights four key concepts:
 Community mobilization – which involves a focus on altering the relations of power between
marginalized and dominant groups, engaging to address rights and power differentials, and
taking action towards mutual support and community level change.
 Integration of HIV services – oriented oriented towards integration of SRH services, but should
also give attention to addressing the needs of men, given that primary health care services are
predominantly focused on providing services to women.
 Contingent funding – which involves the allocation of funding to boost particular focal areas.
Economic and educational interventions – for marginalized youth, of hypervulnerable groups
(eg. Orphans, sex workers, young women).
 Monitoring and evaluation – requires relevant empirical studies, appropriate outcome
measures and means to measure them, and evaluation including implementation studies
(informing or informed by theoretical models for change).220
Community mobilization is most effective when vulnerable groups and sub-populations are
drawn together through group activities involving dialogue and reflection that is oriented
towards identifying common goals and identifying pathways for action to achieve these goals.
Community mobilization involves stepwise processes towards engaging and activating problemsolving and leadership competencies among community members. Processes include building
knowledge and basic skills; creating social spaces for dialogue and critical thinking; promoting a
sense of local ownership of the problem; incentives for action; identifying community strengths
and resources; mobilizing existing formal and informal local networks; and building partnerships
between marginalized communities and more powerful outside actors and agencies, locally,
nationally and internationally.221
An analysis of community mobilization strategies relevant to HIV prevention highlighted a mix of
domains relevant towards establishing a community-level response in South Africa. These
include: shared concerns, critical consciousness, organizational structures and networks,
leadership at individual or institutional level, collective activities and action, and social
cohesion.222
Page 36
Figure 6: Community mobilization process
As shown in Figure 6, community mobilization includes the following sequence of activities:
1. Identify most vulnerable sub-populations –
2. Engage vulnerable sub-populations in voluntary, group-based dialogue and reflection
3. Identify pathways and steps for action
4. Integrate short-term strategies into a long term vision
5. Link with community-level services, organisations, and networks to mobilise support for
action
6. Mobilise action through collective ownership and leadership
7. Support ongoing action through approaches that aid collective identity (eg. Manifestos,
slogans, symbols)
8. Identify and communicate successful actions and tangible changes
9. Monitor, collate and evaluate change outcomes and adapt or modify activities.
Figure 7 outlines the integrated intervention approach through the six key programme areas
conducting interventions tailored to local conditions, wit a focus on most vulnerable youth subpopulations. Interventions are oriented towards relationship rights, values, responsibilities and
accountabilities, with dialogue for action and community mobilization all focused on
transforming vulnerabilities of girls and young women to HIV.
Page 37
Figure 7: Implementation framework and logic model
4.
SCALE-UP AND RESOURCE ALLOCATION
This implementation strategy focuses on mobilizing and intensifying six strategies that are
already in place in South Africa. Emphasis has been placed on drawing on research and
epidemiological data to determine an appropriate mix of interventions that can be applied to
bring about accelerated HIV prevention among girls and young women aged 15-24.
Scale-up is directly linked to adoption and priority of the six strategies through the identified six
key programme areas.
Intensified programming to address HIV and pregnancy towards accelerating impacts on HIV
incidence requires a multisectoral response through six key programme areas directed towards
six priority strategies. Figure 8 outlines a stepwise process towards achieving accelerated
programming.
Initial steps involve briefing and mobilising leaders at all levels to address the urgency of HIV and
unplanned pregnancy prevention among girls and young women. This should occur in parallel
with engaging with policymakers, donors and planners to ensure integration and resource
allocations directed towards the six priority strategies. Other steps include:
 Engage with HCPs to ensure increased emphasis is placed on the six priority strategies
Page 38
 Brief and mobilising health service personnel to improve focus on key elements of response
with emphasis on the provision of youth friendly services and promoting improved male
access. In addition, giving emphasis to the six priority strategies.
 Brief and mobilise schools and tertiary education institutions to accelerate HIV and unplanned
pregnancy prevention including through linkages with broader community structures.
 Engage with Municipal, District and Local government personnel and programmes to
accelerate focus on girls and young women and to give emphasis to the six priority strategies.
 Support and expand community groups focusing on vulnerable sub-populations and integrate
community mobilisation activities.
Figure 8 outlines the steps for accelerated programming, highlighting that research, monitoring
and evaluation are necessary throughouth the process.
Figure 8: Steps for accelerated programming
Particular emphasis is given to segmenting vulnerable youth to adress vulnerabilities with
support to programmes being aided by key groups for programming support.
To address sexual exposure to HIV and pregnancy, emphasis is placed on sexual rights and
relationship values.
Physiological and biological factors addressed include the range of factors that heighten
vulnerability of girls in particular, as well as young women, with an emphasis on inhibiting the
efficiency of HIV transmission.
Page 39
Sexual risk and relationship factors addressed include early sexual debut, coerced sex, early and
unplanned pregnancy, knowledge of HIV status, age disparity between teens and older partners,
statutory rape, and multiple partners.
Social and structural support is provided through the legal and policy environment (including key
government initiatives and programmes, health and social services, economic support
programmes, and mobilizing vulnerable sub-populations at community level.
Sustainability is achieved through embedding principles and approaches to accelerated HIV
prevention through ongoing community mobilization and internalisation of new values and
norms.
Resource allocation should be prioritised in the following areas:
 Collation of research towards detailed guidance for each priority strategy
 Development of a resource package and dissemination of the implementation strategy to
personnel and stakeholders within the six key programme areas
 Capacity development in implementing programmes in partnership with vulnerable youth in
relation to the six priority strategies, including community mobilisation
 Integration of the six priority strategies into national and sub-national health communication
 Integration of monitoring systems to measure key indicators related to the strategy, and
systems for regular reporting within the six key programme areas.
5. RESEARCH, MONITORING AND EVALUATION
South Africa has a wide body of research that has been conducted on HIV, STI, GBV and
pregnancy prevention among girls and young women aged 15-24. There is also comprehensive
data on the epidemiological context of girls and young women in this age group as well as for the
population as a whole. While this body of has informed the present implementation strategy, a
number of gaps are evident.223 Priorities include:
 Analysis of factors to be reinforced to increase age at sexual debut among youth under 20,
and reduce multiple sexual partnerships post-debut
 Analysis of partner dyads in relationships involving girls and young women aged 15-24
including concurrent sexual partners, transactional sexual partners and age disparate
relationships
 Approaches to addressing relationship norms and values that are protective for HIV, GBV and
unplanned pregnancy
 Analysis of paternity among pregnant teenagers, and strategies for bolstering paternal
involvement for pregnancies carried to term
 Analysis of implementation of TOP services for pregnant girls and young women
Page 40
 Analysis of group and peer activities among vulnerable youth to support HIV, GBV and
pregnancy prevention strategies, including linkages with services and support organisations
and social activism
 Addressing HIV, GBV and pregnancy in school environments through linkages with the
broader community, including potentials for health promoting schools approaches
 Community mobilisation approaches to address HIV, GBV and pregnancy vulnerabilities
among youth
 Identification of best practices for increasing uptake and retention in ART programmes.
5.1
Targets and indicators
Table 5 outlines indicators for the six key programme areas to accelerate HIV prevention among
girls and young women aged 15-24 in South Africa.
Table 5: Key programme areas and indicators for HIV prevention among girls and young
women aged 15-24 in South Africa
Key programme area
1) Political and civil society
leadership at national,
provincial and local level
2) Civil society organisations
including non-governmental
organisations and activists
focused on HIV, SRH, youth
and gender
3) Leadership, management and
personnel and youth within
key institutions (health,
education and social
development)
Indicators
 Political and civil society leaders perceived to be promoting urgency
of addressing high incidence of new infections among girls and
young women in South Africa
 Six key priority areas for action perceived to be promoted by political
and civil society leadership
 Political and civil society leaders perceived to be promoting rights
and values of shared responsibility and accountability in sexual
relationships with an emphasis on HIV and unwanted pregnancy
prevention
 Political and civil society leaders perceived to be promoting values of
non-violence and gender equality in relationships
 CSOs, NGOs and activists perceived to be promoting urgency of
addressing high incidence of new infections among girls and young
women in South Africa
 Six key priority areas for action perceived to be promoted by CSOs,
NGOs and activists
 CSOs and NGOs report adding emphasis on six key priority areas
for action through plans, strategies and programmes with a focus on
accelerating gains on HIV prevention over the 2015-2019 period
 CSOs and NGOs report conducting dialogue and empowerment
activities with youth focused on gender, SRH and HIV, as well as
guidance on pathways for managing and overcoming economic and
other disadvantageous circumstances
 Girls and young women aged 15-19 and 20-24 report increased
awareness and engagement in activities related six priortity
strategies through CSOs, NGOs and health activism
 Leadership, management, personnel and youth in educational
institutions perceived to be promoting urgency of addressing high
incidence of new infections among girls and young women in South
Africa
 Six key priority areas for action perceived to be promoted by
Leadership, management, personnel and youth in educational
institutions
 Leadership, management, personnel and youth formations in
educational institutions report intensifying or add emphasis on six
key priority areas for action through plans, strategies and
programmes with a focus on accelerating gains on HIV prevention
over the 2015-2019 period
Page 41
4) National and sub-national
health communication
programmes focused on
gender, SRH and HIV
5) Municipal, district and local
programmes
6) Networks, coalitions and
community groups focused
on gender, SRH, HIV and
youth
 Leadership, management, personnel and youth formations/clubs in
educational institutions conduct dialogue and empowerment
activities with youth focused on gender, SRH and HIV, as well as
guidance on pathways for managing and overcoming economic and
other disadvantageous circumstances
 Orphans, youth with disabilities, pregnant teens, teen parents report
receiving increased support through institutional activities for HIV
prevention and mitigation
 Girls and young women aged 15-19 and 20-24 report increased
awareness and engagement in activities related six priority strategies
through health, education and social development
 HCPs romote urgency of addressing high incidence of new infections
among girls and young women in South Africa
 HCPs promote six key priority areas for action
 HCPs intensify or add emphasis on six key priority areas for action
through mass media and dialogue-oriented communication with a
focus on accelerating gains on HIV prevention over the 2015-2019
period
 Girls and young women aged 15-19 and 20-24 report increased
awareness and engagement in activities related six priority strategies
through HCPs
 Municipal, district and local programmes promote urgency of
addressing high incidence of new infections among girls and young
women in South Africa
 Municipal, district and local programmes promote six key priority
areas for action
 Municipal, district and local programmes add emphasis on six key
priority areas for action through plans, strategies and programmes
with a focus on accelerating gains on HIV prevention over the 20152019 period.
 Municipal, district and local programmes conduct dialogue and
empowerment activities with youth focused on gender, SRH and
HIV, as well as guidance on pathways for managing and overcoming
economic and other disadvantageous circumstances
 Girls and young women aged 15-19 and 20-24 report increased
awareness and engagement in activities related six priority strategies
through Municipal and District programmes
 Networks, coalitions and community groups promote urgency of
addressing high incidence of new infections among girls and young
women in South Africa
 Networks, coalitions and community groups romote six key priority
areas for action
 Networks, coalitions and community groups ntensify or add
emphasis on six key priority areas for action through plans and
strategies, with an emphasis on active citizenry and community
mobilisation with a focus on accelerating gains on HIV prevention
over the 2015-2019 period.
 Networks, coalitions and community groups onduct dialogue and
empowerment activities with youth focused on gender, SRH and
HIV, as well as guidance on pathways for managing and overcoming
economic and other disadvantageous circumstances
 Girls and young women aged 15-19 and 20-24 report increased
awareness and engagement in activities related six priority strategies
through networks, coalitions and community groups
Page 42
Table 6 outlines key change indicators for the six priority strategies.
Table 6. Priority strategies, outcome goals and indicators for HIV prevention among girls and
young women aged 15-24 in South Africa
Priority strategy
Increase age at
first sex
Outcome goal
Indicator
 Reduce the proportion of
girls and young women who
report having ever had sex
among girls aged 15-17 by
50%, and young women
aged 18-19 by 25% over a
five-year period
Reduce sex with
older partners
among girls and
young women
under 20
 Reduce the proportion of
girls and young women
aged 15-19 who have a
sexual partner five or more
years older than
themselves by 50% over a
five-year period
Reduce
pregnancy
among girls and
young women
under 20
 Reduce the proportion of
girls and young women
aged 15-19 who report
having been pregnant in the
past year by 50% over a
five-year period.
Reduce multiple
sexual
partnerships
 Reduce the proportion of
sexually active persons
aged 15 years and older
who report having had two
or more sexual partners in
past year by 50% over a
five-year period.
 Proportion of girls aged 15-17 reporting ever
having had sex by single age
 Proportion of girls and young women aged 1819 reporting ever having had sex by single age
 Proportion of girls and young women aged 1519 reporting coerced first sex (including
characteristics of perpetrator)
 Proportion of girls and young women reporting
having had sex that falls within the definition of
statutory rape
 Proportion of girls and young women aged 1519 reporting ever having had a partner fiver or
more years older than themselves
 Proportion of girls and young women aged 1519 reporting a partner five or more years older
than themselves in the past year
 Proportion of men aged 20 and older reporting
having had a female partner aged 19 or
younger in the past year
 Proportion of girls and young women aged 1519 reporting transactional relationships with
men five or more years older than themselves
 Proportion of girls and young women aged 1519 reporting coerced sex or sexual violence by
men five or more years older than themselves
 Proportion of girls and young women aged 1519 reporting having been pregnant in the past
year
 Proportion of girls and young women aged 1519 reporting having carried a pregnancy to term
 Number of children of girls and young women
aged 15-19
 Proportion of sexually active girls and young
women aged 15-19 and 20-24 using hormonal
contraception
 Proportion of girls and young women reporting
have had a TOP
 Proportion of boys and men aged 15+ reporting
having fathered a child with a girl or young
woman aged <20
 Proportion of boys and men aged 15+ reporting
having fathered a child that is not under their
immediate care
 Proportion of girls and young women aged 1519 and 20-24 reporting having had two or more
partners in the past year
 Proportion of girls and young women aged 1519 and 20-24 reporting having had an
overlapping/concurrent sexual partnership in
the past year
 Proportion of girls and young women aged 1519 and 20-24 reporting having had an
overlapping/concurrent sexual partnership in
the past year
 Proportion of youth aged 15-24 reporting
physical or sexual violence victimisation or
Page 43
Increase
consistent
condom use
among girls and
young women
aged 15-24
 Increase the proportion of
girls and young women
aged 15-19 who have had
sex in the past year
reporting having used a
condom at last sex by 30%
over a five-year period.
Increase uptake
and retention of
eligible PLHIV on
ART
 Increase ART coverage by
initiating at least 80% of
eligible patients onto
antiretroviral treatment
(ART) on an annual basis
perpetration
 Proportion of youth aged 15-24 reporting
physical or sexual violence victimisation or
perpetration
 Proportion of youth aged 15-19 and 20-24
reporting alcohol and drug use
 Proportion of youth aged 15-19 and 20-24
reporting condom use at last sex
 Proportion of youth aged 15-19 and 20-24
reporting condom use at every sex with current
partner(s)
 Proportion of youth aged 15-19 and 20-24
reporting STI symptoms in the past 3 months
 Standard ART reporting indicators
Page 44
6.
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