Youth Livelihoods and HIV/AIDS
Young and poor. Two decades into the epidemic, this is increasingly the face of the victims of HIV/AIDS in the developing world. Those working to prevent its spread and mitigate its impact increasingly recognize the links between HIV/AIDS, youth, and poverty. They struggle, however, with how best to address the economic factors driving the epidemic. This edition of In Focus examines the potential of efforts to improve the economic circumstances of youtha group of activities known as the youth livelihoods approachto help stem the spread of HIV/AIDS.
What is the youth livelihoods approach?
A livelihood is everything people know, have, and do to make a living. The livelihoods approach builds on earlier poverty reduction models, including participatory and integrated rural development.1,2 Applied to youth, the livelihoods approach comprises a broad and interrelated set of programs and policies that include:
giving youth salaried jobs and other opportunities to earn income;
providing credit, savings and other financial services and related training in job and business skills;
developing institutions, alliances and networks for youth to advance their economic interests; and
promoting policy and social changes that improve young peoples livelihood prospects. 3,4,5,6
What is the conceptual link between youth livelihoods and HIV/AIDS?
A consensus is now emerging that poverty reduction is an important component in the fight against HIV/AIDS.7,8,9
Poverty compounds the vulnerability of young people to HIV infection. Early in the epidemic, wealthier people were more likely to be infected. The opposite now appears to be true.10,11 Youth who are poor have an increased risk of infection because they are more likely to:
be in poor general health to begin with and to leave sexually transmitted diseases untreated;
yield to pressure to exchange money or goods for sex;
migrate to find work, and thus increase their chances of risky sex; and
lack hope for the future.12,13,14,15,16
Youth already infected with HIV face heightened economic concerns. One-third of the 36 million people living with HIV/AIDS are youth ages 15 to 24; youth account for half of new HIV/AIDS infections.17 As they fall sick, their ability to provide for themselves and for others who depend on them declines.
Their symptoms often reduce their capacity to work.
In many countries, discrimination against infected youth makes it harder for them to find and keep a job and to work productively.18
In the hardest-hit countries, poor youth with HIV face an even bleaker economic future as AIDS increases overall poverty and income inequality.19
The disease creates severe economic problems for young people from poor, AIDS-affected families. The current number of AIDS orphans, 13 million, is projected to triple in a decade.20,21 In the worst-affected countries, AIDS may orphan as many as 40 percent of all children.22,23
For poor youth, the onset of HIV-related illness in a parent brings immediate economic problems.
Traditional family and community support networks for surviving children are heavily burdened where the epidemic is already widespread.
Youth from affected homes often forgo schooling and other opportunities, thus threatening their livelihoods prospects and increasing their own chances of contracting HIV.24,25,26
Girls are particularly vulnerable to the economic factors that contribute to the spread of HIV/AIDS. Two of every three young persons infected with HIV/AIDS is a girl or young woman.27
Girls generally have fewer economic and educational opportunities than boys.
As a result, girls are more likely to engage in formal or informal sex work or practice involuntary or risky sexual behavior.28,29
What is known about youth livelihoods efforts and their contribution to HIV/AIDS prevention, care and support?
Recent reviews of adolescent livelihoods programs30,31,32 have found that:
a wide range of institutions have program or policy efforts to improve youth livelihoods;
most efforts are small-scale and focus on boys;
relatively few efforts explicitly link youth livelihoods activities and HIV/AIDS prevention, care and support; and
few programs have been well-documented or rigorously evaluated.
Examples of types of programs and policy efforts include:
Programs that provide jobs, work experience, and income generation. Such programs increase economic opportunities and improve life prospects. Although circumstances force many youth into exploitative and dangerous jobs, legitimate, non-harmful work may be the best option for youth whose educational opportunities are extremely limited.33 A large proportion of adolescents61 percent in Asia and 32 percent in Africaare already employed.34 AIDS is forcing more youth into the job market.35
Work experience is a component of almost all of the U.S. youth development programs that have successfully reduced rates of risky sex and teen pregnancy.36
In El Salvador, the Homies Unidos peer education program provides school and job opportunities to youth gang members combined with information on sexuality and reproductive health, including condom provision.37
One study found that young women employed as garment workers in Bangladeshi factories marry later and delay childbirth after marriage.38
The chance to earn income is also extremely important to an infected youth facing economic problems, or to a youth supporting a family when parents have fallen sick or died from HIV/AIDS.
As more adolescents enter the formal work force, their place of employment can also become a setting for prevention and care and support activities.39
One program for young female factory workers in Thailand increased workers communication with their partners about HIV/AIDS and safe sex.40
Training youth in job and business skills and providing financial services. These programs provide financial relief to AIDS-affected youth and their families.
Vocational education and job training prepare young people for specific careers and are most effective if they make strong labor market links and develop job placement components.41 Programs linking job training and improved sexual and reproductive health include:
the Good Shepherd Family Care Service in Ethiopia, which trains former commercial sex workers in hairdressing and tailoring skills;42
in Egypt, the Association for the Protection of the Environment, which teaches job skills to low-income girls, including rug weaving, paper recycling, and embroidery;43
the Salvation Armys program for AIDS orphans in Zimbabwe, which combines efforts to meet the pressing psycho-social needs of AIDS orphans with work experience in the tourism industry, one of the few growth areas of the countrys economy.44
Training in enterprise skillsfor example, planning, risk management, and decision makinghas emerged as an important, yet relatively unexamined, component of many livelihoods programs.45 Many such skills are valuable to youth in situations where they are attempting to avoid risky sexual behaviors.46,47
In Peru, the local affiliate of the International Planned Parenthood Federation linked with another nongovernmental organization specializing in business training to provide 30,000 poor urban youth with reproductive health services and business training over a two-year period. Evaluation showed increased knowledge about reproductive health and improved attitudes toward responsible sexual behavior.48
Financial services, including high-quality microfinance (credit and savings) efforts, are among the most promising approaches to mitigating the economic impact of HIV/AIDS.49,50,51 Many microfinance organizations in the hardest-hit countries in sub-Saharan Africa now offer products specifically for AIDS-affected clients and households, although some of these products may have limited applicability.52,53,54 Innovative financial products geared to AIDS-affected youth include the establishment of education trusts for minors and allowing youth from AIDS-affected households to use microfinance services.55 Microfinance programs for youth are relatively new, and the experience to date has been somewhat mixed. Some experts believe such programs have potential but that they have suffered from design and implementation problems.56,57,58 Examples include:
In Malawi, a pilot program reached 3,000 orphans with revolving savings and credit services for small business activities. The program encountered early difficulties because of the inexperience of many participants, but improved over time.59
The Tap and Reposition Youth pilot program in Kenya provided savings and credit to roughly 100 low-income girls. The programs high loan repayment rate has persuaded its sponsor, the Kenya Rural Enterprise Program, to expand the program nationwide.60,61
In Zambia, a project linking youth microfinance with sexual and reproductive health outcomes had mixed results. Loan repayment rates were far too low to sustain the microfinance effort. However, three-quarters of recipients felt the loans were useful, and half said the loan had given them a better outlook on the future. In addition, almost half of loan recipients reported safer sexual practices.62
Developing institutions that bring together youth for economic advancement also help prevention, care and support efforts.63,64 When youth belong to an organization that helps them and provides opportunities, they better avoid risky behaviors, including those that might lead to HIV/AIDS.65
Commercial sex workers in one project in India organized themselves to carry out HIV/AIDS peer education and advocate for legalizing sex work. The project also provided members with loans and a savings program.66
Several countries are putting together networks of young people living with HIV/AIDS. Most of these groups help youth find and keep jobs.67
Policies support prevention efforts by shaping the context in which jobs, training, services, and institutions operate. Many of the policies to address the HIV/AIDS-related problems of youth are livelihoods-related, and include:68,69
antipoverty policies with broad social benefits that help individuals, families, and communities cope with AIDS;70
policies that improve the job, credit, and schooling opportunities of adolescent girls and reduce their vulnerability to sexual exploitation. Evidence from Thailand shows that better educational opportunities for girls reduce their chances of becoming commercial sex workers.71
formulation and enforcement of national policies that protect and support youth in especially difficult circumstances, such as street kids, refugees and war victims;72
national legislation to protect the property rights of AIDS orphans and to address the needs of young people affected or infected by HIV/AIDS.73 One program for AIDS orphans in Uganda helps HIV-infected parents prepare for their childrens economic future. Parents receive help choosing a guardian, writing a will, and getting legal advice on property inheritance, and also participate in income-generating activities.74
What lessons have come out of the programmatic efforts to date?
Recognize diversity. Youth are an incredibly diverse group, in terms of both their economic circumstances and sexual attitudes and behavior.75 Younger youth are more economically disadvantaged than older youth. Girls are usually more economically disadvantaged than boys, but boys are often more subject to peer and societal pressure to engage in risky sex. Programmatic and policy responses must take this diversity into account.76
Focus on the poor. Those youth for whom livelihoods programs work bestpoor and marginalized youthare at highest risk of contracting and transmitting HIV/AIDS. To have maximum impact on the epidemic, programs need to maintain the focus of livelihoods programs on these disadvantaged groups.77,78
Livelihoods is one piece of the puzzle. Livelihoods strategies are one component of the range of strategies needed to prevent HIV/AIDS and mitigate its impact on children and youth.79,80,81 HIV/AIDS programs must continue to focus on the immediate needs of youth for reproductive health information and services, while incorporating a livelihoods perspective to their activities.
Linking is widespread, but little understood. Organizations are increasingly linking livelihoods programs with other HIV/AIDS prevention and mitigation activities, but relatively few of these arrangements have been documented.
Linking can take place in different ways. Health organizations can: inform livelihoods groups on HIV/AIDS and its impacts on affected youth; serve as a referral point for AIDS-affected livelihoods clients; learn from livelihoods specialists how to help affected youth; and educate youth involved in livelihoods programs on HIV/AIDS prevention and mitigation.82 Peer education has been a particularly effective means of transmitting such information.83
Evidence from the United States strongly suggests that combining HIV education and information programs with livelihoods efforts can produce a greater positive impact together than in isolation.84,85
Livelihoods programs require specialized expertise. Health organizations should either team up with livelihoods-focused groups or, if they choose to conduct such programs by themselves, ensure they have qualified staff and an in-depth understanding of programmatic issues.86,87,88,89,90
Programs should do more to link prevention with care and support. Greater linking of HIV/AIDS prevention with care and support for youth infected with HIV or from AIDS-affected families could improve the effectiveness and cost-effectiveness of both types of programs, particularly since youth tend to be more receptive to prevention messages.91,92,93
Better evaluation is needed. Relatively little is known about the effectiveness, cost-effectiveness, sustainability, and potential for scaling up of livelihoods programs. Furthermore, their impact on adolescent reproductive health has not been systematically evaluated, although efforts are under way to improve the state of knowledge.94,95,96,97,98,99
Measuring the success of livelihoods programs remains a challenge, because their impact is long term and measurement of livelihoods skills is inherently difficult. Furthermore, the interaction among the economic influences on health behavior is complex, making it difficult to determine the impact of livelihoods programs on HIV/AIDS prevention, care and support.100
Cost-effectiveness is one of the most important factors for program managers and policy makers to consider when evaluating whether to invest in the livelihoods approach. Yet, cost analyses of livelihoods programs alone, or in combination with HIV/AIDS efforts, are infrequent.101
Program sustainability and scaling up. Decisions on scaling up of programs are critically important given the enormous magnitude of the HIV/AIDS problem and the limited resources available to address it.102 Working through existing organizations is one way to ensure that programs continue to provide services at a reasonable cost. Focusing on the most vulnerable children is another way to have the largest impactboth on livelihoods outcomes and on HIV/AIDS prevention, care and support.103
The In Focus series summarizes for professionals working in developing countries some of the program experience and limited research available on young adult reproductive health concerns. This issue was commissioned and supervised by FOCUS Communications Advisor Vanessa Carroll and FOCUS Deputy Director Lindsay Stewart and was prepared by James Rosen.
1Department for International Development (DFID). 2000. "Sustainable Livelihoods Guidance Sheets." (www.livelihoods.org, September 18, 2000).
2Esim, S., N. Varia, and G. Duron. 1999. "Adolescent Livelihoods: A Selective Review of Issues and Programs." Aide Memoir for the UNICEF inter-country project on adolescent Girls Participation and Development. Initial Meeting February 1999. (www.icrw.org, January 24, 2000)
3Esim et al., op. cit.
4DFID, op. cit.
5International Development Research Centre (IDRC). 2000. "A Conceptual and Analytical Research Framework for Youth Enterprise and Entrepreneurship Development." (www.idrc.ca/socdev/research/youth/docs/framework.cfm#EED, October 11, 2000)
6Population Council and International Center for Research on Women (ICRW). 2000. Adolescent Girls Livelihoods. Essential Questions, Essential Tools: A Report on a Workshop. New York and Washington: Population Council and ICRW.
7Cohen, D. 2000. "Poverty and HIV/AIDS in Sub-Saharan Africa." SEPED Conference Paper Series. (www.undp.org/seped/publications/poverty_HIV_SSA.pdf, December 3, 2000)
8Williamson, J. 2000. "Finding a Way Forward. Principles and Strategies to Reduce the Impacts of AIDS on Children and Families." Chapter in the forthcoming book The Orphan GenerationThe Global Legacy of the AIDS Epidemic, edited by C. Levine and G. Foster, Cambridge University Press. March. (http://www.iaen.org/impact/williamson.pdf, September 15, 2000)
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10World Bank. 1997. Confronting AIDS: Public Priorities in a Global Epidemic. Washington, DC: World Bank. (www.worldbank.org/aids-econ/confront)
11World Bank 2000, op. cit.
12Adamchak, S., et al.. 2000. A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs. Tools series no. 5. Washington, DC: FOCUS on Young Adults. (www.pathfind.org/Guides&Tools/PDF/Part%20I.pdf)
13Cohen, op. cit.
14Dowsett, G. and P. Aggleton. 1999. "Young People and Risk-Taking in Sexual Relations." In Sex and Youth: Contextual Factors Affecting Risk for HIV/AIDS. A Comparative Analysis of Multi-Site Studies in Developing Countries. Geneva: UNAIDS. (www.unaids.org/publications/documents/children/children/sexandyouth99.html, September 25, 2000)
15UNAIDS. 1998a. "Young People and HIV/AIDS: Background Discussion Paper on the Elements of a Global Strategy." UNAIDS/PCB(7)/98.3. Programme Coordinating Board. Provisional agenda item 3. Second ad hoc thematic meeting. New Delhi, 9-11 December 1998.
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20UNAIDS. 2000. Report on the Global HIV/AIDS Epidemic, June 2000. (www.unaids.org. October 4, 2000)
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23Williamson, op. cit.
24Cohen, op. cit.
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26Williamson, op. cit.
27UNICEF 2000, op. cit.
28Esim, S. 2000. International Center for Research on Women. Personal Communication. December 7.
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30Esim et al., op. cit.
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33Mensch et al., op. cit.
34Population Council and ICRW, op. cit.
35Williamson, op. cit.
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37Rose-Avila, M. 1999. "Homies Unidos, El Salvador. Peer Education with Gang Members: Protecting Life and Health." FOCUS Project Highlights. Washington, DC: FOCUS on Young Adults.
38Amin, S., I. Diamond, R.T. Naved, and M. Newby. 1998. "Transition to Adulthood of Female Garment-factory Workers in Bangladesh." Studies in Family Planning 29 (2): 185-2000.
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40Cash, K., J. Sanguansermsri, W. Busayawong, and P. Chuamanochan. 1997. "AIDS Prevention through Peer Education in Northern Thai Single Migratory Factory Workers." IRCW Report-in-Brief.
41Grierson, J. 1997. Where ThereIs No Job: Vocational Training for Self-Employment in Developing Countries. Geneva: Swiss Centre for Development Co-operation.
42Onduso, P. 2000. Pathfinder International. Personal Communication. October 4.
43Bruce, J. and M. Assad. 1999. "Adolescent Girls Project/SEEDS, Egypt. Income Generation to Expand Girls Social Possibilities." FOCUS Project Highlights. Washington, DC: FOCUS on Young Adults.
44Germann, op. cit.
45IDRC, op. cit.
47UNAIDS 1998a, op. cit.
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50Donahue, Jill. 2000. "Microfinance and HIV/AIDS. Time to Talk." Unpublished. August.
51Williamson, op. cit.
52Donahue 2000, op cit.
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55Parker 2000a, op. cit.
56Khan, B. 2000. Population Council, Kenya. Personal Communication. October 5.
57Haberland, N. 2000. Population Council. Personal Communication. September 26.
58Sebstadt, J. and S. Singh. 1998. "Adolescent Livelihoods Programmes in India: A Preliminary Review." New Delhi: Population Council.
59Mutangadura, G., D. Mukurazita and H. Jackson. 1999. A review of household and community responses to the HIV/AIDS epidemic in the rural areas of sub-Saharan Africa. UNAIDS Best Practices Collection. Geneva: UNAIDS. (www.unaids.org/publications/documents/economics/agriculture/una99e39.pdf, September 25, 2000)
60Haberland, op. cit.
61Population Council. 2000b. "Pilot Savings and Micro-Credit Project for Adolescent Girls in Nairobi." Unpublished fact sheet provided by Banu Khan, Population Council, Kenya. May.
62Fetters, T., F. Munkonze, and J. Solo. 2000. "Investing in Youth: Testing Community-based Approaches for Improving Adolescent Sexual and Reproductive Health." CARE Zambia and Population Council, Africa OR/TA Project II. (www.popcouncil.org/pdfs/aor/zam6.pdf, September 26, 2000)
63Esim et al., op. cit.
64Grierson 2000, op. cit.
65Adamchak, S. et al., op. cit.
66Population Council. 2000c. "Peer Education and HIV/AIDS: Past Experience, Future Directions." Publication of the Horizons Project. (www.popcouncil.org/pdfs/peer_ed.pdf, October 2, 2000)
67UNAIDS 1998a, op. cit.
68UNAIDS 1999, op. cit.
69Williamson, op. cit.
70World Bank 1997, op. cit.
71UNAIDS 1999, op. cit.
72UNAIDS 1998a, op. cit.
74Population Council. 2000a. "Does Early Intervention Improve Orphan Support Programs?" Horizons Report. Operations Research on HIV/AIDS. Spring. (www.popcouncil.org/horizons/newsletter/horizons(1)_3.html, October 2, 2000)
75Senderowitz, J. 1997. "Young People and STDs/HIV/AIDS." In Focus. Washington, DC: FOCUS on Young Adults.
76Dowsett and Aggleton, op. cit.
77Esim et al., op. cit.
78Stevens, C. 1999. "Reaching Socially Marginalized Youth." In Focus. Washington, DC: FOCUS on Young Adults.
79Hunter, S. and J. Williamson. 1997. "Children on the Brink: Strategies to Support Children Isolated by HIV/AIDS." Prepared by the Health Technical Services Project for USAID.
80Synergy Project. 2000 (forthcoming). Handbook for Programs to Assist Children Affected by AIDS. Washington, DC: Synergy Project.
81Williamson, op. cit.
82Donahue 2000, op. cit.
83Population Council 2000c, op. cit.
84Kirby, op. cit.
85Mensch et al., op. cit.
86Donahue 2000, op. cit.
87Grierson 2000, op. cit.
88Parker 2000a, op. cit.
89Waterfield, S. 2000 "Lessons in 15 Years of Microenterprise Can Strengthen CAREs AIDS Programs." AIDSfocus.
90Williamson, op. cit.
91Germann, op. cit.
92UNAIDS 1998a, op. cit.
93Williamson, op. cit.
94Esim et al., op. cit.
95Donahue 2000, op. cit.
96Grierson 2000, op. cit.
97International Center for Research on Women. 2000. "Project Sheet. An Analysis of Programs Linking Adolescent Reproductive Health and Livelihoods."
98IDRC, op. cit.
99Parker 2000b, op. cit.
100Adamchak et al., op. cit.
101Williamson, op. cit.