Comment: Bring back the lost girls

In the true spirit of Friday's second annual International Day of the Girl Child, we're issuing a very specific call to action: we must do more to help young women in Eastern and Southern Africa to avoid the disproportionately higher risk they face of being infected with HIV and dying of Aids.

South Africa is at the forefront of new HIV prevention technologies research, including the quest for effective microbicides and HIV vaccines. 

Yet, despite all the progress we have made, young South African women are still more than twice as likely to be infected with HIV as their male peers. The theme of this year's Day of the Girl Child – education and innovation – is at the heart of our call. We must find ways to keep girls in school and educate them about HIV prevention. In addition, we must find new HIV prevention methods that work for them and that they can control.

The past decade has seen remarkable progress in efforts to respond to the HIV epidemic across Eastern and Southern Africa. 

In South Africa (and every other country in the region), HIV programmes have grown in scale, quality, effectiveness and impact. South Africa has the largest treatment programme in the world, and more than two million people receive life-saving antiretroviral therapy. New HIV infections among adults and children, and Aids-related deaths, are declining.

Many factors combine to contribute to these results, including behaviour change bolstered by effective education and communication (such as age-appropriate education about sexuality) that has helped to lead to postponement of sexual debut, better and more consistent condom use, prevention programmes targeted at sex workers and other key populations, wider access to HIV treatment, and availability of medical male circumcision. 

Shouldering the HIV burden
However, Eastern and Southern Africa still shoulder half the global HIV burden, with close to six million people living with HIV in South Africa alone. Studies indicate that anywhere from 60% to 95% of new infections occur from unprotected sex in the general heterosexual population, often fuelled by gender inequalities as well as social and economic imbalances that contribute to HIV risk among women. 

In South Africa, for reasons that include physiological and social vulnerability, gender inequalities and intergenerational sex, more than one in 10 young women aged 15 to 24 is living with HIV. 

Power imbalances in relationships between young women and older men can make it very difficult for young women to insist on condom use, or for them to refuse unsafe sex. Gender-based violence is also a major driver of the HIV epidemic in South Africa. Studies have shown that more than half of sexually active girls under the age of 18 avoid discussing condoms with their partners because they fear violence.

We have seen overwhelming evidence that girls' education, especially high school education, is a powerful transformative force for societies and for girls themselves. 

Although there has been significant progress in improving girls' access to education over the past 20 years, many are still deprived of this basic right, and girls in Eastern and Southern Africa are still less likely than boys to attend secondary school. In South Africa, an equal number of boys and girls enter primary school. But by grade 10, 50% of girls have dropped out. However, the evidence suggests that HIV infection risk falls when girls stay in school. 

According to a survey in South Africa, each additional year of education lowers a young woman's HIV infection risk by 7%, and a wider body of evidence shows that better-educated women are more likely to delay marriage and childbearing, have fewer children, earn a better income and have greater decision-making power within their relationships. 

We are also seeing considerable promise from interventions that can reduce women's financial dependence on male partners, including economic development and anti-poverty programmes that can alter the terms on which sexual decisions are made. 

Life skills and peer-education programmes have also proved effective in helping young people to protect themselves against HIV.

Education: a "social vaccine"
We support the view of education as a "social vaccine" to HIV and urge greater efforts to widen girls' access to education and improve their rates of secondary-school completion. 

We support the United Nations' recommendation that school curricula integrate positive messages on gender norms related to violence, child marriage, sexual and reproductive health, and male and female family roles. We call for education innovations that include life skills, entrepreneurship and gender issues in school curricula.

The South African Medical Research Council, the International Aids Vaccine Initiative and the Joint United Nations Programme on HIV and Aids (UNAids) continue to highlight the need for sustained global HIV prevention research efforts that partner with governments and incorporate relevant innovations in both education and technology. 

Young women in Eastern and Southern Africa need new HIV prevention tools such as microbicides and vaccines they can use and control and, where necessary, without consent from (or even the knowledge of) their male partners.

In celebration of the Day of the Girl Child, we commend young girls worldwide for their resilience in the face of many enormous challenges. 

To make that annual celebration a year-long commitment, governments, researchers and civil society groups must work together to widen access to education, strengthen school curricula and fund further HIV-related research. We must equip all girls and young women with the information and tools they need to protect their health.

Salim S Abdool Karim is the president of the Medical Research Council, the director of the Centre for the Aids Programme of Research in South Africa and the chair of the UNAids Scientific Expert Panel; Sheila Tlou is the director of the UNAids team for East and Southern Africa; and Gwynn Stevens is a senior director at the International Aids Vaccine Initiative in South Africa


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