This story was first published by UNESCO

Young people in Myanmar make up more than half of the national population, with 5-14-year-olds making up the largest group. This youthful population brings incredible potential for sustaining Myanmar’s recent development momentum, but only if investments are made to address the challenges that prevent them from making informed decisions about their health and well-being.

Research shows that young people in Myanmar have a limited understanding of sexual and reproductive health, with 38 per cent of adolescents admitting they did not know a woman could become pregnant if she has sex only once, and only 16.67 per cent of young people aged 15 - 24 having accurate HIV prevention knowledge.

To address these issues, UNESCO Yangon, in collaboration with the Ministry of Education, held a policy seminar on 22 March, 2019. More than 50 representatives from Government and non-Government organizations came together to share good practices and identity opportunities for strengthening sexuality education policy, curriculum and teaching in Myanmar.

The event featured the launch of the Myanmar-language version of the 2018 revised International Technical Guidance on Sexuality Education (ITGSE), developed by UNESCO, in partnership with the World Health Organization, UNICEF, UNFPA, UNAIDS, and UN Women. The Technical Guidance assists education, health and other relevant authorities in the development and implementation of sexuality education programmes and materials.

UNESCO regional advisor for health and education, Kabir Singh, said the UN Technical Guidance covers a wide range of topics; going beyond sexual and reproductive health to include broader life skills such as negotiating consent and staying safe.

“While young people in Myanmar face challenges in accessing sexual and reproductive health (SRH) information and services, the situation is further exacerbated by social and gender norms that prevent children and young people, particularly girls and other vulnerable groups, from achieving good health and well-being,” he said.

“This is why it is critical that CSE programmes begin at the ages of 5 – 8, as outlined in the UN Technical Guidance. We need to help children at the earliest ages understand gender equality, healthy relationships, and respect for themselves and one another.”

Sexuality education in Myanmar

The National Life Skills Education curriculum in Myanmar, developed by the Ministry of Education (MoE) in collaboration with UNICEF, has been part of the core curriculum in primary schools since 2006, and in middle schools as a compulsory co-curricular subject since 2008. The lower secondary curriculum (grades 5-8) covers seven themes, including reproductive health, HIV and STIs, substance use, and disease prevention and nutrition.

A 2012 assessment of Life Skills Education in middle school found that knowledge around reproductive health was low, with the authors suggesting that cultural sensitivity and lack of teacher training may be contributing factors. A recent UNICEF U-Report, a free SMS social monitoring tool for youth participation in Myanmar, also found that most survey respondents learned about sexuality education through social media, a source that is often not scientifically accurate or age-appropriate.

At the 2019 UNESCO-led policy seminar, Myanmar government representatives agreed to review Life Skills Education in the context of the UN Technical Guidance, ensuring the sexuality education being delivered is comprehensive and age-appropriate. Representatives also indicated that comprehensive sexuality education should be strengthened as part of current education reforms to the basic education curriculum and pre-service teacher education curriculum.

Min Jeong Kim, Head of UNESCO Myanmar Project Office, welcomed the close working relationship between UNESCO and the Ministry of Education in introducing comprehensive sexuality education into the education system.

“The Ministry of Education has shown strong leadership in their efforts to address the challenges faced by children and young people, such as gender inequalities, and sexual and reproductive health. UNESCO shares this commitment to positively impact young people’s lives and look forward to continuing to work in partnership the curriculum core team and the Teacher Education Colleges to integrate CSE into the new curriculum for teacher education,” Min Jeong Kim said.

Delegates at the policy seminar discussed ways in which to introduce comprehensive sexuality knowledge and related life skills to current and future generations of children and young people in Myanmar. The seminar provided a platform that bridged key stakeholders such as public service providers, development partners and non-Government organizations, with a view to starting a dialogue on comprehensive sexuality education, understanding the gaps and identifying the best way forward for full implementation.

The revised technical guidance on sexuality education

The original international technical Guidance published in 2009 positioned sexuality education primarily as part of the HIV response. However, while HIV prevention remains important, evidence and practice demonstrate that sexuality education has a much broader relevance to other issues, not only for young people’s sexual and reproductive health but also for their overall wellbeing and personal development.

The revised Guidance presents sexuality with a positive approach, recognizing that CSE goes beyond educating about reproduction, risks and disease. It reaffirms the position of sexuality education within a framework of human rights and gender equality. It reflects the contribution of sexuality education to the realization of several internationally agreed commitments in relation to sexual and reproductive health, as well as the achievement of the goals in the 2030 Agenda in relation to health and well-being, quality and inclusive education, gender equality and women and girls empowerment.

Based on a review of the sexuality education around the world and drawing on best practices in the various regions, the Guidance demonstrates that sexuality education:

• helps young people become more responsible in their attitude and behaviour regarding sexual and reproductive health
• is essential to combat the school dropout of girls due to early or forced marriage, teenage pregnancy and sexual and reproductive health issues
• is necessary because in some parts of the world, two out of three girls reported having no idea of what was happening to them when they began menstruating and pregnancy and childbirth complications are the second cause of death among 15 to 19-year olds
• does not increase sexual activity, sexual risk-taking behaviour, or STI/HIV infection rates. It also presents evidence showing that abstinence-only programmes fail to prevent early sexual initiation, or reduce the frequency of sex and number of partners among the young.

It has been 25 years since the groundbreaking International Conference on Population and Development, held in Cairo, Egypt, in 1994. Since then, significant progress has been made in the area of sexual and reproductive health and the rights of young women and adolescent girls. Voluntary access to modern contraception has increased by 25% since 1994, and the quality of sexual health and HIV services has also vastly improved.

So why are around 7000 young women and girls still becoming infected with HIV every week? And why, in sub-Saharan Africa, are girls aged 15–19 years three times as likely to become infected with HIV than boys the same age?

“We cannot wait another 25 years. We need to push for accountability to make sufficient progress in addressing the current government deficit to deliver on the sexual and reproductive health and rights commitments for women and girls,” said Gogontlejang Phaladi, from the Pillar of Hope Project in Botswana.

Her comments set the tone at an event organized by the Global HIV Prevention Coalition, during the Women Deliver conference in Vancouver, Canada. The event, co-convened by UNAIDS and the United Nations Population Fund (UNFPA) and held on 3 June, put the spotlight on why young women and adolescent girls are being left behind and why they continue to bear the brunt of poor sexual and reproductive health and HIV.

“We are facing an HIV prevention crisis,” said Shannon Hader, UNAIDS Deputy Executive Director, Programme. “While the target was to reduce new HIV infections among adolescent girls and young women to fewer than 100 000, an estimated 340 000 became newly infected with HIV in 2017. We have a huge task ahead of us.”

Speakers at the event discussed the critical importance of engaging young people as leaders of change. “We need to call out policy-makers, traditional and religious leaders, even parents,” said Monica Geingos, First Lady of Namibia. “We must never tell you what to say. Generations before, you were shamed and silenced. Never lower your voices.” She also added that the lack of progress for women and girls is being fuelled by gender discrimination, violence and denial of fundamental freedoms.

UNFPA’s Regional Director for Eastern and Southern Africa, Julitta Onabanjo, also stressed that more needs to be done. “I see a dynamic young women warrior generation here to take the agenda forward—so that by 2030 every young person can fulfil their best potential and nothing is going to hold them back,” she said, while noting that the recommendations of the event should be fed into a summit being held in Nairobi, Kenya, later in 2019.

A major issue preventing young women and girls from accessing HIV services is the requirement by many countries that young people have to be over the age of 18 before they can access health services, including sexual and reproductive health and HIV services, without parental consent. UNAIDS estimates that 78 countries have some form of restrictive laws or policies that prevent young people from accessing sexual health services without the consent of their parents.

As part of efforts to remove these barriers to young people accessing timely and effective HIV prevention, testing and care, during the youth-led Generation Now: Our Health, Our Rights preconference meeting on 2 June, UNAIDS committed to tackle parental consent laws, and their implementation, in five countries in eastern and southern Africa—Lesotho, Malawi, Namibia, Uganda and Zambia. This includes working with young people to ensure that youth are driving change and co-creating the quality services they want and need to have bright and healthy futures.

To advance progress, the participants agreed that investing in community organizations will be critical, as will taking small projects that work to the national level. Nyasha Sithole, from the Athena Network said, “People are watering the leaves, but not the roots. We need to move away from paper and pen to implementation on the ground.”

UNAIDS is a co-convener of the Global HIV Prevention Coalition, which works with countries with a high incidence of HIV to accelerate access to combination HIV prevention services. The coalition seeks to ensure accountability for delivering HIV prevention services at scale in order to achieve the targets of the 2016 United Nations Political Declaration on Ending AIDS, including a 75% reduction in HIV infections towards fewer than 500 000 new infections by 2020. The work of the coalition includes a particular focus on young women and their male partners.

While the intention of age of consent laws for medical services is often to protect children, in practice such laws do the opposite, by discouraging adolescents from accessing the services they need to stay healthy.

Age of consent laws for medical services require people aged younger than 18 years to obtain permission from a parent or guardian before accessing sexual and reproductive health services, HIV testing and treatment, pre-exposure prophylaxis and other health services. They particularly affect adolescent girls, whose sexuality tends to be stigmatized and who bear the physical and social burdens of unwanted pregnancies.

In 2017, 78 of 110 reporting countries stated that they required parental consent for a child under 18 years to access HIV testing, and 61 of 109 reporting countries required parental consent for HIV treatment. In addition, 68 of 108 reporting countries required parental consent to access sexual and reproductive health services.

Comprehensive sexuality education plays a central role in preparing adolescents and young people for a safe, productive and fulfilling life, and it is an important component of an HIV prevention package for young people. It provides opportunities to learn and acquire complete, accurate, evidence-informed and age-appropriate knowledge on sexuality and sexual and reproductive health issues.

Comprehensive sexuality education―defined as a curriculum-based process of teaching and learning about the cognitive, emotional, physical and social aspects of sexuality―have been shown to contribute to delayed initiation of sexual intercourse, decreased frequency of sexual intercourse, decreased number of sexual partners, reduced risk taking, increased use of condoms and increased use of contraception among young people.

Despite the importance of comprehensive sexuality education, however, access to it is far from universal.

Discussions about sex and HIV in Indonesia remain highly taboo, while the limited information that exists is often unclear, not easy to digest or contradictory. That’s why many young people are turning towards new technology platforms to seek answers to questions that affect their health and well-being. 

In an attempt to improve the quality of information provided to young people, the UNAIDS Country Office in Indonesia has developed Tanya Marlo, or Ask Marlo, a chatbot powered by artificial intelligence and designed to be the go-to source for all things HIV-related.

Marlo is a cute character who provides basic information about HIV through user-friendly content such as infographics, quizzes and FAQs (frequently asked questions). In just a few taps, Ask Marlo users can also book HIV testing appointments at health centres across Jakarta, Indonesia. Young people looking for a more in-depth chat are connected to real counsellors, who are on standby to talk, provide guidance and make referrals to specialized services.

The counsellors receive many questions on how to access HIV services and HIV treatment.

“Many people, particularly young people, in Jakarta still do not know basic information about HIV. I hope that as a counsellor on Marlo, I can change that,” one of the counsellors said.

The Ask Marlo chatbot is integrated into the LINE chat messaging application. Users looking to chat to Marlo can simply add @tanyamarlo on LINE and begin chatting. Indonesia is one of LINE’s top markets, with around 90 million users. Around 80% of its users are young people, many of whom use LINE Today to get news and information and to shop.

Since launching on 1 December 2018, Ask Marlo has increased the number of its users, reaching almost 3000 followers at the end of March. Reviews of Ask Marlo bear witness to how important and necessary the service is for young people.  

Upon seeing Ask Marlo for the first time, a psychology graduate from the University of Indonesia said, “It is so youth-friendly! My friends and I use LINE a lot, so this is the perfect platform for Ask Marlo. I am surprised that a chatbot can be used to teach about things as complex as HIV.”

A university student at the Atma Jaya University likes the anonymity provided by the application. “With Ask Marlo, we don’t have to be ashamed to ask anything related to HIV.”

University students, young professionals, communities, civil society activists and the Ministry of Health have endorsed Ask Marlo. Besides students and young professionals, several social media influencers and YouTube personalities have also given their stamp of approval. Their endorsement of Ask Marlo has helped to promote the chatbot to wider audiences. The idea is to eventually expand to offer testing in other major cities across Indonesia.

Towering over a throng of young people, Christine Kafando peppers the crowd with questions.

“Do you feel pressure from other boys and girls?” “Do you feel abandoned because of poverty?” “Do you have all the information you need regarding your health and HIV? If not, ask me, ask your partners, ask! Okay!”

The 40 boys and girls nod and shrug. They have come for a workshop run by the Association Espoir pour Demain (AED) in Bobo-Dioulasso, Burkina Faso, which aims to create a space for young people to learn about sexual health and to train some to become peer educators.

“After having seen a number of young students come to us pregnant, we felt a need to start these workshops,” Ms Kafando, the founder of AED, said.

Issa Diarra said the workshop enabled a dialogue. “In our society, we really don’t talk that much about sex and, I would add, health issues, but here we really had the chance to discuss all that,” he said. Another attendee of the workshop, Roland Sanou, agreed, “Sex today remains taboo for young people, but I don’t want it to stay that way.”

Many of them say times have changed and that the way they think is different from the way their parents thought. “Currently, we young people are aware and we know what we want and we know that being sick can keep us from realizing our dreams, so that’s why we are rallying,” said Baba Coulibaly.

At the beginning, AED helped women living with HIV to access treatment. It then grew to help mothers and their babies born with HIV. Fifteen years later, many of those children are now teenagers and still drop by. Reflecting on her two decades as an HIV advocate, Ms Kafando said, “For so many years, women have been the face of HIV, but it’s key to include men and boys to raise their awareness.”

Jacinta Kienou, a nurse who has been at the association since it was founded, said that there were two big challenges: a number of young people living with HIV no longer take their treatment regularly and many young people are unsure about how to deal with relationships.

“Because they live with HIV, and they are young, lots of problems bubble up concerning affection and acceptance by others with regard to their HIV status,” she said. “Often relationships end because of someone’s HIV status. We council them and their parents at that time,” she added.

In Burkina Faso, young people make up more than 60% of the population and data show that many of them do not know their HIV status. UNAIDS Strategic Information Officer André Kaboré describes two gaps concerning young people. “Despite high-quality treatment being readily available, there are children out there who don’t know they’re living with HIV. Worse, many of those who do know that they are living with HIV aren’t accessing treatment,” he said.

In the country, 94 000 people are living with HIV, 9400 of whom are children under the age of 15 years. While 65% of adults living with HIV are on life-saving antiretroviral therapy, only 28% of children living with HIV whose status is known, about 3500, are on treatment. Ms Kafando calls them the forgotten generation. “They fell through the cracks because until now they had never been sick or needed attention and thus were never tested for HIV,” she said.

The head of the National AIDS Council for Bobo-Dioulasso and the surrounding region, Suzanne Sidibé, said, “We lost sight of children born with HIV. Our aim, with the help of the Association Espoir pour Demain, is to fan out to families through health mediators.”

Hoho Kambiré, who is living with HIV, has four children, two of whom are living with HIV. As an AED health mediator, she speaks about the benefits of knowing one’s status to all who will listen. She visits families, accompanies women to clinics and provides support.

“It is necessary to test all the children to know who is sick and who is not sick and follow up to keep them healthy,” she said. AED has now more than 50 health mediators, mostly women like Ms Kambiré, who originally came to the association seeking health services herself. 

The United Nations Children’s Fund (UNICEF) and UNAIDS both support AED financially. Mireille Cissé, a UNICEF HIV specialist, said that the United Nations in Burkina Faso had identified the top priorities for the AIDS response in the country, including working with civil society.

“We agreed that a community link needed to be established, because they are our entry into families,” she said. UNICEF formalized the health mediators’ contribution by providing a stipend for their work and works hand in hand with the regional office of the Ministry of Health.

“A real victory for us was to have the health mediators integrated into the health teams of the districts,” Ms Cissé said. “That buy-in really facilitated the role of the health mediators and has raised their profile.”

UNAIDS has reinforced the capacity of the health mediators to widen their scope of work, which ranges from psychosocial counselling to training on treatment adherence. “To maintain our progress in the HIV response and end AIDS depends a lot on civil society like the Association Espoir pour Demain,” Job Sagbohan, UNAIDS Country Director, said. “We really hope for maximum impact.”

“Without our voice, you are doing it for you, not for us”, said Winny Obure, a youth leader and women’s rights defender from Kenya, at the United Nations in New York, United States of America.

She was joined by other young women demanding the removal of barriers to their sexual and reproductive rights and for adolescent girls to be empowered. The event—Step It Up!—was a call to action for the most left behind adolescent girls and was convened by UNAIDS, the ATHENA Network, the Governments of Australia and Namibia, and UN Women, with 25 partners from the United Nations and civil society.

Adolescent girls and young women are still disproportionally affected by HIV. One million adolescent girls live with HIV globally and every week 7000 adolescent girls and young women become infected with HIV. Comprehensive sexuality education is so limited that levels of knowledge about HIV prevention among young people have remained flat over the past 20 years.

“We will not reach the Sustainable Development Goals if the voices and aspirations of adolescent girls are oppressed,” said Gunilla Carlsson, UNAIDS Deputy Executive Director, Management and Governance.“Where is the accountability for the millions of adolescent girls being left behind?”

All too often, adolescent girls remain invisible to decision-makers, especially if they belong to groups that are discriminated against, criminalized or stigmatized. As many of the participants pointed out, they are subjected to human rights violations, including violence and harmful practices, and denial of their sexual and reproductive health and rights.

“We need to move away from these meeting rooms and go to communities to talk to adolescent girls and young women. We need to address the uniqueness of specific groups of girls, of their specific needs .We have the solutions, it’s just a matter of including us in the discussion,” said Maximina Jokonya, a young woman from Zimbabwe.

“Teenage girls are often out of sight and out of mind and they are not where the power is, it’s still with men,” said Sharman Stone, Australia’s Ambassador for Women and Girls. She highlighted the barriers that girls face in the Pacific, where they are denied contraception and subjected to high levels of violence. She said that a key priority for Australia during humanitarian crises is to ensure access to sexual and reproductive health services.

The Minister of Gender Equality and Child Welfare of Namibia, Doreen Sioka, spoke about championing the rights of adolescent girls and young women, comprehensive sexuality education and integrated sexual and reproductive health and HIV services. She outlined major achievements in fulfilling international HIV targets. A new law in Namibia enshrines the right of all children to access critical services—at 14 years of age, children can now be tested for HIV without permission from their parents or guardians.

The young women at the event underscored their realities and restricted opportunities, as well as what works to improve their lives. Deneka Thomas, from Trinidad and Tobago, described how she uses art in schools to interact with lesbian, gay, bisexual and transgender young people and girls traumatized by bullying, rape and other forms of violence.

Raouf Kamel of AIDS Algérie spoke about the first-ever initiative in the Middle East and North Africa to hear the voices and experiences of especially marginalized groups of women. They had all experienced violence, pointing to adolescence as a crucial point in life when the risks to their health and safety, and of HIV infection, are especially marked.

The participants concluded that much more needs to be done to address the needs and rights of adolescent. Investing in inclusive, quality education, in HIV, sexual and reproductive health services and in mental health is key. Other important actions include preventing and responding to gender-based violence, promoting women’s rights, engaging boys and investing in youth organizations and community-based initiatives led by, and for, young women.

The event was held on 13 March on the margins of the sixty-third session of the Commission on the Status of Women.

Quotes

Colour my HIV is an HIV prevention and empowerment campaign led by and focused on young people in South Africa. It was launched on World AIDS Day 2018 in Johannesburg, South Africa.

The aim of the campaign is to create an information platform to debunk myths and misconceptions about HIV in order to reduce HIV-related stigma and discrimination, increase knowledge of HIV by presenting new findings by experts and researchers, promote human rights, advocate for political commitment and accountability by policy-makers and other partners and highlight issues around HIV prevention among young people.

UNAIDS sat down with Sibulele Sibaca, the founder of the campaign, to ask her a few questions.

Question: Describe Colour my HIV in five words

Vibrant. Youthful. Life-changing. Futuristic.

Hopeful in all that we do. We hope that by 2030 we will end AIDS. With Colour my HIV we’re hopeful that young people themselves will change the course of HIV.

Question: What do you want to achieve with Colour my HIV?

Firstly, I want get to a point in South Africa where being HIV-positive is like having any other chronic disease—diabetes, high blood pressure—in that it’s a manageable illness.

Secondly, to change the narrative where people think that when you contract HIV it is a death sentence. It’s no longer that at all. South Africa has one of the most well-implemented HIV treatment programmes in the world. I remember when a very close person in my life contracted HIV, the doctor said, “You should be so glad you got HIV in South Africa. This is the country to be in when you have HIV. In other countries people are still crying for HIV treatment and you have it here; all you have to do is adhere to it.”

Thirdly, the stigma around testing for HIV is that if I test positive I am going to die, so people must know that they will not die when they are HIV-positive. It’s one of the reasons I have called the campaign Colour my HIV. We must own it. We must celebrate how far we’ve come with HIV as a country. Let’s not discriminate or stigmatize, instead we must go out and get tested for HIV.

Question: Why the focus on young people?

Primarily, we were thinking of adolescent girls and young women between the ages of 15 and 24 years, because they are the most at risk of HIV infection in South Africa. In this age group, nine girls contract HIV every hour in South Africa. My question is, how and why? Where are they? What are the circumstances that lead to the moment they contract HIV? Are they hungry? This group can be influenced. The messages planted in their heads are critical, as they are still growing. So, Colour my HIV looks to be that voice of reason, to teach and educate them about why they should get tested, to prevent themselves from contracting HIV.

However, it is difficult to focus on girls in isolation. We can’t solely speak to girls, we have to engage boys as well. Men and boys hardly visit the clinic, test or take medication. They have to be included in the narrative, which is why Colour my HIV focuses on young people in general.

Question: Where do you see Colour my HIV in five years?

In the short term, we are looking to start touring South Africa from April until the next World AIDS Day, going into communities and really just spreading HIV awareness. As HIV is not only an issue on World AIDS Day, we are looking to engage communities on how they can embrace HIV and live in colour.

We actually need to end AIDS by 2030. We have 11 years to go. So, the question is what are we doing now? Hopefully this year we are going to take Colour my HIV countrywide. In the next three years, I want to see it journey from the Cape to Cairo. When they talk about ending AIDS by 2030, I want Colour my HIV to be part of the narrative.

Ahead of Zero Discrimination Day, young people came together in Cairo, Egypt, to learn how to respond to HIV-related stigma and discrimination and to hear about how the HIV epidemic affects Egypt and the role that young people can play in the AIDS response.

“The burden of the epidemic is higher on young people. In Egypt, it is for young people to lead the HIV response,” said Walid Kamal, Egypt’s National AIDS Programme Manager.

During a discussion on stigma and discrimination, people living with HIV shared some of their testimonies and experiences, helping to give the participants a deeper understanding of how stigma and discrimination affects people living with HIV.

“It is our responsibility to help people living with HIV feel part of the community,” said one of the participating young people.

“It is not only about AIDS, it is about social justice, equality, the empowerment of women and promoting healthy gender norms,” said Ahmed Khamis, the UNAIDS Country Manager for Egypt.

The participants also learned how to plan, design and implement online awareness and advocacy campaigns on social media.

At the end of the meeting, organized by UNAIDS and the National AIDS Programme and held on 21 February, the young people agreed to lead social media campaigns to highlight the harm caused by stigma and discrimination. Starting on 1 March, Zero Discrimination Day, and running for three weeks, the campaigns will be supported by the UNAIDS country office in Egypt and are endorsed by Egypt’s Ministry of Health and Population.