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Understanding the Relationships Between HIV and Child Marriage: Conclusions From an Expert Consultation

      Research on child marriage from the first decade of the 2000s was largely, and we now know, often mistakenly, interpreted to suggest that child brides—girls who marry under the age of 18 years—faced a higher vulnerability to and higher rates of HIV acquisition than girls and women who married later [
      • Clark S.
      Early marriage and HIV risk in sub-Saharan Africa.
      ,
      • Clark S.
      • Bruce J.
      • Dude A.
      Protecting young women from HIV/AIDS: The case against child and adolescent marriage.
      ,
      • Nour N.M.
      Health consequences of child marriage in Africa.
      ,
      • Glynn J.R.
      • Caraël M.
      • Auvert B.
      • et al.
      Why do young women have a much higher prevalence of HIV than young men? A study in Kisumu, Kenya and Ndola, Zambia.
      ]. In one of the starkest statements on the perceived connection, a paper stemming from a December 2003 global consultation stated that “married adolescent girls tend to have higher rates of HIV infection than their sexually active, unmarried peers” [
      • Bruce J.
      • Clark S.
      The implications of early marriage for HIV/AIDS policy, brief based on background paper prepared for the WHO/UNFPA/Population Council Technical Consultation on Married Adolescents.
      ]. Indeed, some advocates, academics, and practitioners understood these limited, early publications as evidence of a positive correlation, and even a causal relationship, between child marriage and HIV, asserting, for example, that HIV prevalence rates would decline in tandem with rates of child marriage [
      • Mathur S.
      • Greene M.
      • Malhotra A.
      Too young to wed: The lives, rights, and health of young married girls.
      ,
      ,
      ,
      ]. More recent studies have, however, produced contrary findings, including one that suggests that unmarried young women have a higher vulnerability to HIV than those who marry early [
      • Bongaarts J.
      Late marriage and the HIV epidemic in sub-Saharan Africa.
      ], and another, which reviewed data from 97 countries across the world and found no association between child marriage and HIV [
      • Raj A.
      • Boehmer U.
      Girl child marriage and its association with national rates of HIV, maternal health, and infant mortality across 97 countries.
      ].
      Indeed, although we have gained over the years a more nuanced understanding of the factors that may make some child brides more vulnerable to HIV than women who marry later, there is a dearth of evidence regarding the relationships between child marriage and HIV.
      Stimulated by careful reviews of the literature undertaken by the World Health Organization and Girls Not Brides, in November 2018, the United Nations International Children's Emergency Fund (UNICEF) and Girls Not Brides convened experts from academia, civil society, and bilateral and multilateral institutions for a consultation that aimed to better understand what is and what is not known about this relationship, as well as to identify priorities for policies and programs. Below, we summarize some key conclusions and recommendations from that convening.

      Recommendations

      First, many factors associated with child marriage and HIV acquisition among adolescent girls overlap; perhaps, most significant are harmful gender norms and a range of gender inequalities that underlie girls' vulnerability to these and other negative outcomes. Early sexual onset, unsafe sex, frequency of sex, age-disparate relationships, low educational attainment, limited access to information and services, social isolation, and experience of intimate partner violence are all characteristically higher within child marriages, and all have been shown to be associated with an increased incidence or prevalence of HIV among adolescent girls [
      • Raj A.
      • Boehmer U.
      Girl child marriage and its association with national rates of HIV, maternal health, and infant mortality across 97 countries.
      ,
      • Kidman R.
      Child marriage and intimate partner violence: A comparative study of 34 countries.
      ]. But although these are common factors facing girls across cultures and settings, it is also critical to understand the context in which child marriage and the sexual transmission of HIV are occurring and the factors that may make adolescent girls particularly vulnerable to either or both in each context. This will most typically imply a need for subnational-level research, including program and policy evaluation and analysis at local levels.
      Second, programs that reach adolescent girls in high-vulnerability settings for both child marriage and HIV have historically been delivered in silos, with some focusing on child marriage prevention and others on HIV. Rarely do program designers and implementers overtly address the adolescent girl as a whole, recognizing the multiple underlying vulnerabilities and multiple deprivations that girls face and rarely do they measure and report on HIV, child marriage, and other outcomes that result from their interventions. Relatedly, the evidence base regarding the effectiveness of multicomponent programming that addresses both outcomes remains thin. This has begun to change, however, with a number of comprehensive interventions for adolescent girls and young women now being delivered. These include, for example, the $800 million DREAMS initiative of the U.S. government, which aims to help girls develop into “Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe women.” The UNFPA-UNICEF Global Programme to Accelerate Action to End Child Marriage works in 12 countries to promote skills and the rights of girls, address the underlying conditions that keep child marriage in place, and support girls already in union and is complemented by increasingly comprehensive commitments toward adolescent girls' rights and well-being from the African Union, the government of India and others.
      The Global Fund to Fight AIDS, tuberculosis, and Malaria, in line with its Strategy (2017–2022) [
      The Global Fund
      The Global Fund Strategy 2017-2022: Investing to end epidemics.
      ], has significantly increased investments toward more multisectoral programming for adolescent girls and young women and is supporting structural, behavioral, as well as biomedical interventions for this key group in settings where they are disproportionately affected by HIV. The UK government is supporting a 9-year longitudinal study of gender and adolescence [
      GAGE Consortium
      Gender and adolescence: Why understanding adolescent capabilities, change strategies and contexts matters.
      ], and the Spotlight Initiative, a €500 million program focusing on violence against women and girls, has tremendous potential to address key structural drivers of HIV and child marriage, particularly in high-prevalence contexts. Multifaceted programs led by nongovernmental organizations, such as BRAC's Empowerment and Livelihoods for Adolescents [
      • Bandiera O.
      • Buehren N.
      • Burgess R.
      • et al.
      Women's empowerment in action: Evidence from a randomized control trial in Africa (English).
      ], Stepping Stones, [
      • Wallace T.
      Evaluating Stepping Stones: A review of existing evaluations and ideas for future M&E work.
      ] and the Population Council's BALIKA, [
      • Amin S.
      • Saha J.S.
      • Ahmed J.A.
      Skills-building programs to reduce child marriage in Bangladesh: A randomized controlled trial.
      ] for example, are also contributing to rigorous new evidence of positive impacts for girls. At the same time, there is increased interest in making government-sponsored social protection programs more integrated and adolescent-focused, which has the potential to scale up and make sustainable poverty alleviation efforts for particularly marginalized households and individuals.
      These are among the many initiatives that offer opportunities to leverage investments to catalyze broad outcomes for adolescent girls and to generate learning on how to most effectively implement and evaluate multicomponent and multioutcome-oriented programs at scale, with quality and equity. Alongside increased multisectoral programming should be investments in coordination structures and mechanisms, so that governments, donors, and program implementers can most effectively and efficiently complement and learn from each other's work.
      Third, to most effectively advance the health, well-being and rights of adolescent girls, policies, and programs should address the multiple levels of girls' socioecological environments across diverse contexts. This includes working not only with girls who may be vulnerable to HIV and child marriage but also to change the attitudes, behaviors, and norms of those individuals, communities, and systems that perpetuate the conditions that contribute to girls' vulnerability [
      • Lundgren R.
      • Beckman M.
      • Prasad Chaurasiya S.
      • et al.
      Whose turn to do the dishes? Transforming gender attitudes and behaviours among very young adolescents in Nepal.
      ]. To the extent feasible and relevant, programs and policies should be girl-centered, comprehensive, gender-transformative, and should identify context-specific ways to respond to both child marriage and HIV prevention where these are both a concern. Given the relatively high prevalence of both child marriage and HIV among adolescent girls in parts of Eastern and Southern Africa, it is timely and appropriate to highlight both issues concurrently in this region. With recent models indicating a growing HIV epidemic among adolescent girls in Western and Central Africa [
      UNICEF
      Children, HIV and AIDS: The world today and in 2030.
      ], which has some of the highest rates of child marriage in the world, this region is also appropriate for increased attention when addressing both issues.
      Fourth, there must be greater attention to the fact that adolescent girls are not a homogenous group; neither are the types of relationship structures and vulnerability pathways they face. There is thus a need to respond to the specific priorities of those with the greatest vulnerability to HIV and child marriage, as well as to understand that different drivers of vulnerability for girls in different settings, and different stages of the adolescent life course, may require different interventions. For example, few programs reach pregnant, “in union” or ever-married girls (i.e., those who are currently married, informally married, divorced or widowed), including through interventions that aim to prevent them from acquiring HIV or to support those who are already living with HIV. Likewise, few programs adequately prepare the world's estimated 1.8 million children aged younger than 15 years already living with HIV [
      UNAIDS
      Miles to go: Global AIDS update 2018.
      ] to address issues related to sexuality and marriage. Meaningfully involving girls and young women throughout policy and program design, implementation, and evaluation will help ensure that programs, policies, and outcomes are grounded in the realities of girls' lives and are achieved effectively and ethically [
      Community for Understanding Scale Up (CUSP)
      “Social norm change at scale: CUSP's collective insights,” CUSP 2018 case study collection, community for understanding scale up.
      ].
      Finally, better understanding the relationships and shared determinants of HIV and child marriage in diverse settings around the world may bolster both program design and advocacy arguments to more effectively end both child marriage and the transmission of HIV and to promote the overall health and well-being of girls. This does not always necessitate significant new research investments, however. Rather, there are likely numerous opportunities to better use existing datasets related to adolescent girls; to add questions relating to HIV, child marriage and common drivers to already-planned and newly designed surveys and evaluations; to make better use of existing programmatic and administrative data; to encourage the publication of studies demonstrating not only positive but also negative associations or unexpected findings; to stimulate innovation in policy research; and to undertake qualitative research on the underlying dynamics and opportunities for and between HIV and child marriage.
      In sum, as the global health and development communities increasingly focus on adolescent girls, we recommend that—whether they aim to stem the HIV epidemic, end child marriage, and/or achieve other positive outcomes for this critical population—they address the underlying, structural inequalities that drive girls' vulnerability, and that they invest in multisectoral, rights-based, gender-transformative policies and programming that respond to the holistic and multifaceted nature of girls' lives.
      A complete report from the expert consultation, which was supported by Girls Not Brides and UNICEF, can be found at www.girlsnotbrides.org.

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