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Poorer and less-educated women may be less knowledgeable about risks and therefore less able to adopt HIV risk-reducing behaviours.42 The risk of trafficking and sexual exploitation is also higher for young women and adolescent girls, especially those living in poverty.43 44 Food insecurity, often linked to poverty, acts as a barrier to treatment for women living with HIV.This increases both the risk of HIV advancing within the body, leading to ill health, and onward transmission.45 At some point in their lifetime, one in three women will experience physical or sexual violence from a partner, or sexual violence from a non-partner.Healthcare providers often lack the training and skills to deliver youth-friendly services and do not fully understand laws around the age of consent.20 In 45 countries, organisations cannot legally provide SRH and HIV services to people under 18 without parental consent.21 In some countries, doing this is an offence linked to encouraging ‘prostitution’ or the trafficking of minors.22 Some national laws also require healthcare providers to report underage sex or activities such as drug use among adolescents.23 Closely related to this is the finding, taken from evidence gathered in 28 sub-Saharan Africa countries, that 52% of adolescent girls and young women in rural areas and 47% in urban areas are unable to make decisions about their own health.24 As a result of age restrictions, in Kenya, Rwanda and Senegal, over 70% of unmarried sexually active girls aged 15 to 19 have not had their contraception needs met.25 This is despite the fact that in sub-Saharan Africa around half of young women living in rural areas and around 40% of young women living in urban areas will have been pregnant by the time they reach 18.26 A study of young women in Soweto, South Africa, found they knew where to obtain SRH information and services but that common experiences of providers’ unsupportive attitudes, power dynamics in relationships, and communication issues with parents and community members prevented respondents from accessing and using the information and services they needed.27 A study of SRH services in Indonesia found that, in large part, sexual activity outside of marriage, often referred to as ‘free sex’, was viewed as unacceptable by both service providers and young people themselves, due to dominant cultural and religious norms.As a result, service providers were often reluctant to provide SRH services to unmarried but sexually active young people, and unmarried young people were too ashamed or afraid to ask for help.28 Research into attitudes towards sexual and reproductive health among adolescent girls in Ghana found varying degrees of negative social and community norms, attitudes and beliefs about adolescent girls’ sexuality.
In the worse-affected countries, 80% of new HIV infections among adolescents are among girls, who are up to eight times more likely to be living with HIV than adolescent boys.4 5 It is estimated that around 50 adolescent girls die every day from AIDS-related illnesses.6 In East and Southern Africa young women will acquire HIV five to seven years earlier than their male peers.7 In the region, seven young women become newly infected with HIV for every three young men.
This assumption arises from harmful gendered expectations of intimate relationships; namely, that men are responsible for providing material resources and women are responsible for providing sexual and domestic services.
Many of these relationships include shared emotional intimacy, with people referring to themselves as boyfriends, girlfriends or lovers.58 Research indicates that in sub-Saharan Africa, transactional sex is one of the key factors in women’s heightened vulnerability to HIV and other STIs.
This can lead to HIV-positive women choosing to have an abortion because they are misinformed about their options and how to protect their health, as well as their child's.17 Additionally, in 29 countries women require the consent of a spouse or partner to access SRH services.18 A lack of access to comprehensive HIV and SRH services means that women are less able to look after their sexual and reproductive health and rights (SRHR) and reduce their risk of HIV infection.
A review of evidence from Latin America and Caribbean relating to HIV-positive women’s use of, and access to, SRH services found women living with HIV experienced more unplanned pregnancies, more induced abortions, a higher risk of immediate sterilisation after birth and higher exposure to sexual and institutional violence, compared to HIV-negative women.19 In many settings, where SRH and HIV services exist, they are primarily for married women with children and do not meet the specific needs of unmarried young women and adolescent girls.