Adolescents with HIV face “silence” over sex and contraception

A serious lack of information and services for adolescents with HIV in rural Senegal is leading to unintended pregnancies, unsafe abortions and more babies being born with HIV. 

What is the research about? 

What happens when adolescents who were born with HIV reach an age when they begin to think about sex, and possibly become sexually active.  

Researchers interviewed 21 adolescent girls and 19 adolescent boys with HIV (ages 12-19) in rural areas outside Dakar. They also interviewed their parents/guardians and local healthcare workers. 

Why is this research important? 

The number of adolescents with HIV is rising due to effective antiretroviral treatment (ART) keeping children with HIV alive and healthy. In Dakar, sexual and reproductive healthcare (SRH) services for adolescents with HIV have improved. But adolescents in rural areas, particularly girls, still face huge challenges due to the stigma around HIV and adolescent sexuality.  

Understanding these challenges is the first step to designing SRH programmes to reduce unintended pregnancies and HIV transmission. 

What did they find out? 

For girls, sex before marriage is not tolerated. Boys are expected to practice religious morality and ‘discretion’. Early marriage for girls is often considered the best way to deal with the issue.  

If adolescent girls have boyfriends they hide it from their family. If pregnancy outside of marriage happens it brings shame on the girl and her family. It can lead to violence and/or the girl being excluded. If exclusion happens, a girl is likely to move away from her normal clinic and risks leaving HIV care. This means she is more likely to pass HIV on to her baby.  

The fear of a bad family reaction leads some pregnant unmarried girls to seek an illegal (and unsafe) abortion. This puts their life at risk. 

Often, parents will not tell an adolescent they have HIV. They will not tell other family members either. As Zeynab, 33, says: “I have never shared my daughter’s status with my in-laws because you never know. They’re just as likely to accept or reject us.” 

Families rarely discuss sex. The issue is even more taboo in families living with the stigma of HIV.  

Some regional hospitals have SRH information corners. But most rural clinics do not offer SRH information to adolescents. Most healthcare workers said they did not like to discuss sex or offer contraception to adolescent girls. This was for moral reasons or because they were scared of being accused of promoting sex outside marriage.  

Peer educators from HIV associations did talk to adolescents with HIV about sex. But they focused on promoting abstinence before marriage.  

If adolescents found a possible marriage partner, peer educators would suggest ways to inform their future spouse, but stigma was not addressed. As one healthcare worker said: “I advise her to come in with her fiancé to do testing together and act as if she had never taken the test.” One method was to get the couple to test together then threaten the potential spouse with legal action if they disclosed the adolescent’s diagnosis to others.  

Adolescents also found it difficult to access SRH apps and online forums because they often didn’t have smartphones or internet access.  

What does this mean for HIV and SRH services? 

There is a need to work with adolescents with HIV in rural areas to design programmes that understand the challenges they face but still find ways to provide confidential, non-judgmental and accurate HIV and SRH information, plus contraception and condoms. 

Involving trained peer educators from the same age group might make it easier to discuss the taboo of sex outside marriage and HIV stigma. 

Getting adolescents with HIV, their parents and healthcare workers to take part in group discussions about adolescent sexuality could also be effective. This should focus on the health risks that adolescents (especially girls) face if they don’t get the SRH information and services they need.