The global epicentre
Southern Africa is the global epicentre of the AIDS epidemic, with recent data highlighting the continuing urgency of ensuring sustained and effective prevention and protection efforts particularly addressing the vulnerability of young women and girls. Southern Africa comprises nine countries with the highest HIV prevalence in the world. Over 12% of all adults aged 15–49 years are infected with HIV in each of these countries . By the end of 2007, southern Africa alone was home to one of every three individuals living with HIV worldwide. In 2007, 35% of all new HIV infections and 38% of all AIDS deaths occurred in southern Africa [1,2].
New infections in young women
The broader sub-Saharan Africa region is experiencing a generalized epidemic, with HIV transmitted largely through heterosexual intercourse and with high levels of new infections being found among young people, notably young women. Globally, 45% of all new infections in 2007 occurred among young people aged 15–24 years . In southern Africa, of all new adult infections aged 15–49 years, young people in the 10-year span from 15 to 24 years of age represented an estimated 42%, ranging from 37.9% in South Africa to 61.5% in Swaziland . Almost two-thirds of all young people with HIV live in sub-Saharan Africa, where approximately 75% of all infections among young people aged 15–24 years are among young women . Although similar disparities in HIV infection are seen between young women and men aged 15–24 years throughout sub-Saharan Africa (young women with a prevalence three to four times higher than their male counterparts) the level of infection is significantly higher among young people in southern Africa than it is in other parts of sub-Saharan Africa. HIV prevalence in young men aged 15–24 years in Rwanda and Uganda, for example, was 0.5% and 1.5% respectively between 2005 and 2007, whereas it was 2% and 4% in young women in these countries during the same period . In contrast, in Malawi, South Africa, Swaziland and Zimbabwe, HIV prevalence in young men aged 15–24 years was 2%, 4%, 4% and 6%, respectively, between 2005 and 2007, whereas in young women of the same age, the prevalence in these countries was reported as 9%, 17%, 22% and 11% .
HIV prevention efforts to reach young people, and in particular young women and girls, in southern Africa have focused on some general programmatic areas: awareness raising; HIV education and information dissemination; reduction of socioeconomic vulnerability; service provision; and life skills development.
The 2005 Secretary General's Task Force on Women, Girls and HIV  attempted to specify priority actions further and raise awareness about the importance of prevention among young women and girls in southern Africa. Since then, however, increased attention to women and girls through advocacy and increased resource allocation for general HIV prevention measures have failed to make significant inroads to reduce the levels of infection and vulnerability across the region. Although there is emerging evidence of encouraging declines in HIV prevalence among young pregnant women aged 15–19 years in countries such as Botswana and Zimbabwe , HIV prevalence is high or even rising in most southern Africa countries among young women in their twenties and early thirties, indicating the continuing failure of HIV prevention efforts in this age group.
Persistent high levels of HIV infection reflect the fact that HIV prevention responses are not adequately tailored to address the principal drivers or causes of new infections with the scale, targeting and intensity required for success. National responses are also hampered by variable and sometimes inconsistent leadership, lack of state accountability for prevention, weak institutional capacities for implementation, stigma, denial, and sensitivity to addressing the social and cultural determinants of new infections. Responding to the evident need to understand these challenges and rise to them, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the Reproductive Health and HIV Research Unit of the University of Witwatersrand in South Africa convened a technical meeting in June 2008 that brought together regional researchers, representatives of national AIDS councils, government departments and the Southern African Development Community, and members of the eastern and southern Africa United Nations Regional AIDS Team to reassess why young women and girls living in the HIV hyperendemic countries of southern Africa are so vulnerable to HIV infection. Meeting participants were selected purposely to ensure strong representation from all countries of southern Africa of high-level policy, social and scientific research, and programming expertise related to women, girls and HIV.
The background technical papers commissioned for the meeting were reviewed by global and regional peers in their respective subject areas. They have been collected here to form a cohesive summary of the evidence, the research gaps, and the actions required to turn the epidemic around for girls and young women in southern Africa. The papers address the current status of the epidemic in southern Africa: age-disparate and intergenerational sex; biological vulnerability; economic empowerment; education; gender-based violence; and knowledge, risk perceptions and behaviour.
The meeting concluded that to respond effectively to the exceptionally high levels of HIV infection among young women and girls in southern Africa and to achieve greater impact on preventing HIV transmission, an aggressive movement for social transformation is required. Such a movement must address the immediate practices that lead to HIV infection as well as the fundamental human rights violations, harmful social norms, weak community and leadership capacities and action to challenge these, and the disparities that underpin HIV risk for women and for men in southern Africa. The meeting agreed that in order to achieve reduced HIV incidence, particularly in young women and girls, a set of proved effective interventions should be implemented to drive the outcomes required to make that fall in infections a reality. The outcomes of this combination prevention approach should be delayed sexual debut, increased knowledge of HIV serostatus, reduced numbers of sexual partners – particularly concurrent partners, reduced age-disparate sex, increased condom use and male circumcision, and increased coverage and utilization of testing and counselling services by those at highest risk of HIV exposure. To achieve these goals, the meeting recommended the concurrent implementation of four key sets of action at community and country levels. In addition, participants noted that sustained and effective implementation of these actions requires the full engagement and commitment of leadership that is able to mobilize and influence strategic use of resources based on an objective and robust understanding of the epidemic in each context. The four actions must themselves be grounded in a set of strategies and processes defined by countries to address their specific contexts and existing gaps in capacities at all levels: state, service provision, communities, families and individuals.
The first key action is the mobilization of communities for HIV prevention, with strong male involvement, to design relevant strategies and messages about the causes, consequences of and solutions to young women and girls' vulnerability. These must focus on reduction of concurrency of sexual partners, delaying early sexual debut, and increasing condom use, while raising awareness about and understandings of risk associated with age-disparate, intergenerational, transactional sex and concurrent partnerships. This mobilisation should encourage the rejection of cultural practices that are harmful to women and girls and strengthen advocacy for ‘zero tolerance’ for gender-based violence and exploitation in any form.
The second key action, as highlighted by the World Health Organizatoin in a series of global consultations and reviews on linkages between sexual and reproductive health services and HIV, is to expand access to high quality, well-integrated essential sexual and reproductive health and prevention services, while mobilising the demand for and use of them [5–7]. This means bringing to scale improved public health interventions to result in: (1) Increased condom use based on improved access to male and female condoms, age-appropriate information, and support on condom use for HIV prevention; (2) Effective sexually transmitted infection treatment and improved sexually transmitted infection awareness and treatment-seeking behaviour; (3) Prevention of teenage pregnancy through improved delivery of adolescent-friendly health services and high quality school-based HIV prevention programmes; (4) Prevention of mother-to-child transmission services that include systematic provider-initiated HIV testing and prevention counselling for all pregnant women, as well as HIV testing and counselling after delivery to counter any increased risk of HIV infection during pregnancy and lactation as a result of hormonal changes and reduced condom use; (5) Rapid scale up of adult and neonatal male circumcision services within comprehensive HIV prevention programmes; and (6) Delivery of services that address the sexual and reproductive health needs of people living with HIV and improved implementation of positive prevention within treatment services.
The third key action is to develop and ensure adequate technical and financial resources for implementation of national strategies that address the structural drivers of vulnerability. These strategies must include: economic empowerment to reduce the effect of income disparities on women's choices and vulnerability; expansion of opportunities for secondary education and continued learning opportunities to extend the protection provided through formal education and training; preventio.
The fourth action is significantly to strengthen country capacities for epidemiological and behavioural surveillance, priority research, and monitoring the coverage and impact of prevention responses – all of which can generate strategic information to improve decision-making for strategic planning. This requires a stronger investment in data collection and information management systems.
There is no time to lose if HIV prevention is to make significant strides against the relentless HIV epidemic of southern Africa, which is mortgaging the future of hundreds of thousands of young women and girls. The articles included in this supplement are being transformed into hard-hitting issues briefs that will be used to influence policy makers and leaders across the region and at all levels through appropriate advocacy and communication. Nothing less than social transformation is needed now to turn this epidemic around. Every individual must see himself or herself as implicated in his or her personal and professional lives in either condoning the status quo or confronting it.
Publication of this article was funded by UNAIDS.
Conflicts of interest: None.