Young key populations in Southern Africa: An analysis of the social determinants of HIV risk and barriers to sexual and reproductive health services


The health and well-being of young people (10-24 years) is vital to the social and economic development goals of the Africa continent, which is home to a youthful and growing population.1 Protecting the sexual and reproductive health and rights (SRHR)- of these young people is clearly a fundamental requisite. However, there remain substantial barriers to young people accessing quality health services, and they face a range of serious health challenges, particularly with regard to their sexual and reproductive health (SRH) (Kabiru, 2013; Fatusi, 2016). In sub-Saharan Africa, HIV prevention remains a persistent challenge among young people, where 37% of all new infections are among youth aged 15-24 and where females are disproportionately affected (UNAIDS, 2019). Likewise, there exist high rates of teenage pregnancy, unsafe abortion and maternal mortality and morbidity in the region, all underpinned by pervasive sexual and gender-based violence (SGBV) and harmful cultural and gendered practices (Junta and Klot, 2011; Anderson, 2015).

Adolescence is a life phase in which rapid physical maturation and psychological and cognitive change takes place, with adolescent development fundamentally impacted by their structural and social environments. Differential exposure to these environments has the potential to positively or negatively shape adolescent health and psychological well-being, with strong associations between socio-economic status and health behaviours and concomitant long-term outcomes (Fatusi and Hindin, 2010; Sawyer et al., 2012). Young people who are also members of key populations (KP)3 are one example of young people facing compounded vulnerabilities since they share a number of specific barriers and challenges concerning their SRHR, linked to legal, social and political structures, which undermine their ability to access healthcare (Cornell and Dovel, 2018), and this is reflected in the poor SRH indicators for this group. Given these overlapping and intersectional challenges, there is need to apply a comprehensive framework of analysis which draws on all aspects of their lifestyles and choices, peer groups and networks as well as broader social, economic and political structures. This comprehensive approach is indispensable to efforts to fully understand the challenges these young people face, and to plan and take action on appropriate policy and programmatic interventions to improve their overall health and well-being.

This chapter presents an overview of what is known about the SRHR of young key populations (YKP) in Southern Africa, using specific examples from five countries, namely Angola, Madagascar, Mozambique, Zambia and Zimbabwe, to anchor the discussion. The discussion draws on the social determinants of health framework to structure an analysis of what is known about the determinants and drivers of sexual and reproductive health (SRH) risk and to highlight the gaps in evidence and understanding of specific vulnerabilities of these groups of youth. The social determinants of health framework allows for an analysis that goes beyond some current approaches which are over-reliant on psychosocial or behavioural factors of risk and vulnerability and which fail to adequately consider the underlying structural and social factors which shape and limit these behaviours and psychological predispositions (Ross, 2010). The discussion is based on a review of academic and grey literature concerning the SRH of YKPs in Southern Africa, together with a series of interviews with key informants from relevant government ministries, international organisations and international and national non-governmental organisations (NGOs) working with key populations in each country. Our initial findings point to the importance of understanding the vulnerabilities and risks faced by young people in these key populations in the context of a wider consideration of the social determinants of health of all young people, as well as in the context of the full range of SRH needs and priorities which include but go beyond HIV alone. Moreover, looking more broadly at the economic situation of young people, educational and employment opportunities, health systems, and peer and family networks will give us a more complete picture that will help us to understand how and why certain young people are more at risk for negative SRH outcomes than others. This more comprehensive approach creates the foundations for the development of equally comprehensive and more inclusive policies and programmes to protect and promote the SRHR of all young people in the region in all of their diversity.

The research informing this chapter is part of an ongoing study being carried out by the Health Economics and HIV and AIDS Research Division (11EARI)) as part of a joint four-year project in collaboration with United Nations Development Programme (UNDP) and African Men for Sexual Health and Rights (AMSHeR), supported by funding from the government of the Netherlands. The overall project aims to strengthen IIIV/SRII- related rights of young key populations in law, policy and strategy in five

Southern African countries (Angola, Madagascar, Mozambique, Zambia and Zimbabwe) and at the SADC regional level. The long-term objective of the project is to improve the SRH outcomes for young key populations in SADC countries.

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