Adolescent Violence: A veiled threat to HIV epidemic control.

Violence against adolescents with HIV results in trauma, deterrence in ART adherence and epidemic control. Within the ECEWS SPEED project, adolescents aged 10–19 accounted for 40% of the 1,412 identified sexual violence survivors. Violence has profound implications for HIV epidemic control. For adolescent teens already a vulnerable fraction of the population in the HIV response, exposure to violence creates major barriers across the entire HIV cascade. Addressing adolescent violence is essential to improving HIV control in teens and breaking down these critical barriers.

Forms of Violence and Their Impact on the HIV Cascade

Sexual Violence: Sexual violence affects the HIV cascade in the following ways:

• HIV Testing Services (HTS): Survivors, especially adolescent girls, often avoid testing due to stigma because of the SV experience, fear of SV disclosure, fear of retribution by the perpetrator, and weak protection systems.
• ART Linkage and Adherence: Those who test positive face difficulties initiating or continuing ART because of trauma, depression, or family rejection.
• Viral Suppression: Poor adherence linked to unresolved trauma leads to lower viral suppression rates.
• HIV Prevention: Fear and silence around sexual assault hinder uptake of post-exposure prophylaxis (PEP) and PrEP.

Physical Violence: This remains the most visible form of violence affecting adolescents.

• Injuries or chronic stress from violence can interrupt ART schedules, leading to poor treatment outcomes and a higher risk of onward transmission.
• Physical violence contributes to unstable home environments, which reduce access to HTS and adherence support.

Emotional and Psychological Violence: Though less visible, emotional violence, including verbal abuse, humiliation, isolation, intimidation, psychological manipulation, and deliberate attempts to undermine an adolescent’s self-esteem and mental health, can be equally damaging.

• It undermines self-worth, reducing their motivation to seek HTS or remain in care.
• Depression and anxiety from prolonged psychological violence correlate with treatment fatigue and poor viral suppression.
• Fear of disclosure, especially in hostile family settings, discourages preventive behaviors and uptake of HIV services.

Technology-Based Violence: Approximately 15% of adolescents (around one in six) experience cyberbullying, according to recent WHO data. Technology-based violence also includes online sexual exploitation, sextortion, non-consensual sharing of intimate images (revenge porn), online grooming by predators, and exposure to violent or traumatic content.

• It increases exposure to HIV through coerced sexual encounters.
• Victims often withdraw socially, avoiding clinics or HIV services out of shame.
• Cyber harassment perpetuates stigma, further limiting prevention-seeking behavior.

Economic Violence: Though less commonly discussed, it significantly impacts adolescents, particularly in contexts of intimate partner relationships and family dynamics. Adolescents in vulnerable households are often denied resources, forced into exploitative labor, or coerced into transactional sex to survive. Child marriage, which affects 43% of girls in Nigeria before age 18 (UNICEF, 2020), is another form of economic and structural violence that perpetuates poverty and poor health outcomes.

• Transactional sex and coercion driven by poverty expose adolescents to HIV risk.
• Economic dependence reduces girls’ ability to negotiate condom use or access PrEP.
• Survivors are less likely to adhere/achieve suppression due to unstable living conditions.

Peer-to-Peer Violence: This encompasses a broad spectrum of harmful behaviors that occur between adolescents, including bullying, fighting, gang violence, dating violence, peer pressure, and various forms of harassment, which all significantly impact adolescents.

• It directly increases HIV risk through forced or risky sexual encounters. Victims often miss HTS opportunities and experience poor ART adherence due to mental health consequences, stigma, and disengagement from health or school systems.

Factors that enable violence

Understanding violence among adolescents requires examining the interplay of individual, relationship, community, and societal factors that contribute to both perpetration and victimization.

Individual factors include a history of abuse, mental health conditions, substance abuse, impulsiveness/poor emotional regulation, and a lack of conflict resolution skills. Adolescent brain development, particularly the ongoing maturation of the prefrontal cortex responsible for impulse control and decision-making, contributes to heightened risk-taking and reactive behaviors.

Family and relationship factors play a crucial role, including exposure to domestic violence, lack of parental supervision or involvement, and poor parent-child communication.

Community and environmental factors include poverty, lack of access to quality education, lack of positive role models, and community norms that tolerate violence.

Societal factors encompass media violence, non-implementation of policies and laws to protect youth, and insufficient investment in prevention and intervention programs.

Consequences of Violence

Apart from affecting HIV epidemic control, violence also has the following consequences:

Increased risk of other STIs and unintended pregnancies, poor mental health outcomes, including depression, anxiety, and suicidal tendencies, post-traumatic stress disorder, substance abuse, Injuries, disability, perpetuation of the cycle of violence, as survivors may later become perpetrators, reduced productivity, poor academic outcomes, and early dropout.

Strategies for improvement

• Routine Violence Screening during HTS, ART, and adolescent health services.
• Trauma-Informed Care to support adherence and retention in care.
• Integrated Response Pathways ensuring immediate access to PEP, STI management, psychosocial support, and legal aid for survivors.

• Awareness of violence using different platforms: adolescent clinics, OTZ, IEC materials, social media platforms, article publishing, etc.
• Community-Based Interventions, such as the No Means No program to prevent violence and shift harmful norms.

• Socioeconomic Support for survivors to reduce reliance on transactional sex or abusive relationships.
• Awareness of technology-based violence: equipping adolescents with information to recognize manipulation/grooming tactics and practicing responsible online behavior.

• Anonymous reporting systems; that allow adolescents to report concerning behaviors without fear of retaliation.
• Utilizing the INSPIRE approach, which includes Implementation and Enforcement of Law, Norms and Values, Safe Environment, Parent and Caregiver Support, Income and economic strengthening, Response and support services, education, and skills.

Interventions for Victims of Violence

For adolescents who have experienced violence, targeted interventions include;

• First-line support and a minimum package of post-violence intervention as needed that are accessible, age-appropriate, affordable, and culturally appropriate.
• Training health care providers to recognize signs of abuse, respond sensitively to disclosures, effectively communicate with adolescents, provide appropriate referrals, document injuries and reports properly for potential legal proceedings.

Unless violence is addressed systematically, gains in epidemic control will be undermined. Protecting adolescents from violence safeguards not only their health and rights but also the future of HIV prevention, treatment, and epidemic control.

Rosemund Onuoha is a public health professional whose areas of expertise include violence prevention and child protection. She supports the integration of survivor-centered responses within ECEWS’s CDC-funded SPEED Project, championing equity and improved well-being for vulnerable populations.