There is no doubt that the rollout of anti-retroviral treatment to some 21 million people living with HIV over the past two decades has been a milestone in public health. There still remains unfinished business of course: 16 million people remain off treatment and getting to affected populations such as sex workers, migrants, men who have sex with men, injecting drug users and transgender people remains a key challenge as does prevention in hotspots such as sub-Saharan Africa, Eastern Europe and South East Asia.

But nearly four decades on into the epidemic, if we’re serious about getting on the path to ending it, we also have to have a very loud and sincere conversation about how it is young adults have been so neglected in the HIV/AIDS response.

Discussion around adolescent sex and sexuality make so many people uncomfortable. It is one of the reasons that HIV still spreads generally speaking, but much more so among young people. And we know that when sexual education is not discussed within families, young adults turn to their school, or failing that, their government. But what happens when all of those options fail as they do most of the time in some areas, for instance, in the epicentre of the epidemic, sub Saharan Africa?

Well, young people are needlessly infected and young people needlessly die. 

More than half of those newly infected with HIV today are between 15 and 24 years old. An estimated 11.8 million young people aged 15 to 24 are living with HIV/AIDS. Young people are at the centre of the global HIV/AIDS pandemic. Adolescent girls and young women are particularly vulnerable, accounting for a startling 91 per cent of new HIV infections among people aged 15-19 in sub-Saharan Africa, whereas young men in the same age group represent roughly 11 per cent. Young women are more than twice as likely to acquire HIV as young men.

In 2019, we should be collectively ashamed that AIDS is still the leading cause of death of young people in Africa and the second leading cause of death among young people worldwide. While AIDS related deaths have halved in children since 2010, they have only fallen by five per cent in adolescents.

This is grotesquely unfair and it is wrong. We cannot continue to fail a generation whose best years are ahead of them. In the first instance our young people need to be valued and respected, then protected.

And the need to do so is more urgent than ever.

Africa, the epicentre of the epidemic, is experiencing a youth bulge. Many African countries already have youthful populations—for example, 51 per cent of the population of South Sudan are under the age of 18. It is estimated that the number of 10 to 24-year-old Africans is set to rise to more than 750 million by 2060. This means that, even if current progress is maintained, new HIV infections among young people are expected to increase. If progress stalls, the results could be devastating. Estimates suggest that as many as 740,000 additional adolescents could become infected between 2016 and 2030.

Moreover, In South Africa alone there are some 300 000 children up to the age of 14 living with HIV. It is also the first time since the epidemic began that we have a generation of adolescents born and living with HIV in sub-Saharan Africa.  

Both scenarios raise questions about avoiding HIV (prevention) and living with HIV for young people and we need vastly improved solutions. All the condoms and PrEP in the world is not going make a dent in the epidemic if the root causes are structural and if these are not addressed.

Those young people currently at risk are at risk because so many forces work against them. Many do not have parents at all or parents who can talk them through sex education. Many do not have a school environment that is amenable to talking about sex. Many do not have sufficient access to education at all. And not being of adult age means it is hugely confronting if you need to go to a clinic or counsellor—in fact for many young people it’s near impossible.

While there are many non governmental organisations who do marvellous work with young people across sub-Saharan Africa, they are in reality applying a plaster to a much bigger sore. It is government at all levels which has to step up. Governments need to ensure that young people at risk of infection have somewhere to go. 

But young adults need more. They need to feel that their own governments are actually on their side. That they count and will be looked after. Governments have to take the initiative here. Put simply, the notion of child welfare needs to be expanded to include infectious disease risk. Governments need to invest in educating the community about sexual health. They need to do what they are paid to do—lead.

Child welfare also includes schooling. We know that if entrenched sexist male attitudes at all levels of society changed, the risk factor for young girls, who are most vulnerable to HIV across so many cultures, would  instantly drop. But in many cultures across sub-Saharan Africa and Asia that is not going to happen overnight. We are going to have to empower young women. While science is is helping and PrEP might now be a possibility for a young woman to protect herself, that in itself is not likely to happen unless girls are actually in a position where they are educated and informed about sexual health decisions.

Keeping young people in school increases HIV prevention, as a young girl’s risk of contracting HIV is halved for every additional year of secondary school that she obtains. The DREAMS project of the United States Emergency Plan for AIDS Relief, as well as youth-oriented national initiatives, such as those in South Africa and Kenya, are working to strengthen HIV prevention by investing in efforts to mitigate the social and structural factors that increase young women’s HIV risks.

For young people already living with HIV, they face the same myriad issues that older adults do, but they are considerably less prepared to deal with them. Stigma and discrimination begins in the family where issues around HIV status disclosure can be a minefield. Efforts in some countries to legislate for the rights of children to legally obtain their HIV status at 16 ( and bypass their parents) are a long overdue step, but meanwhile the harsh reality is that many young adults do not find out their status early enough. 

At school things can be just as intimidating. HIV positive kids often face bullying and have their ARVs stolen from them by their peers. ARV adherence in social situations can be difficult, intiating sexual relations and all that that involves, is a mountain to climb. Lack of tolerance and training in government departments also means that teachers themselves can be the first to discriminate. For young adults who live in lower income countries, all these barriers are magnified.  ARV stock-outs, bureaucratic incompetence, corruption, and discrimination in clinics, hospitals, government departments, and places of worship are a frightening daily experience for a young person living with HIV. 

It is often said that the HIV/AIDS epidemic cannot be ended globally unless it is eliminated in South Africa, and sub-Saharan Africa. How true that is but the same applies to ending the epidemic amongst young people. What’s more, the key will be getting governments and funders to actually see the issue through another lens: realising that young people are in fact our greatest hope of moving towards the end of AIDS.

But first we’ve all got to start talking about sex—seriously.

Julio César Jiménez Guzmán is a 3rd year medical student at the Autonomous University of Chiapas, Mexico and an IAS Youth Ambassador. The 10th IAS Conference on HIV Science (IAS2019) is being held this week in Mexico City.