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Since the beginning of the AIDS pandemic it has been clear that not everyone is equally at risk of becoming infected with HIV. This remains true in generalized epidemics, concentrated epidemics and low-level epidemics. Preventing transmission of HIV to and from individuals and groups who are most at risk will be crucial if governments are to contain the epidemic and achieve the Millennium Development Goal on AIDS. In low-level and concentrated epidemics, groups with an increased risk of becoming infected include injecting drug users, sex workers, men who have sex with men, and people who are incarcerated or live in institutions. In addition, in generalized epidemics, young girls, men who have many sexual partners and the women who are married to them, mobile groups and groups living in relative poverty may also be particularly at risk.

With the exception of injecting drug use, the virus is transmitted the same way among the groups most at risk and other groups in the population. For those most at risk, however, there are many factors that increase their chances of becoming infected, and underlying these factors are structural determinants, such as inequity and discrimination, exploitation and abuse. Interventions that aim to change these determinants of vulnerability are outside the scope of this chapter.

Many young people are particularly at risk of becoming infected with HIV because of the situations in which they live, learn and earn and as a result of behaviours they adopt, or are forced to adopt, as a result of social, cultural and economic factors. The ultimate long-term challenge is to decrease these causes of vulnerability. In the short term, however, the groups most at risk of HIV are particularly in need of the interventions outlined in the United Nations General Assembly Special Session on HIV/AIDS (UNGASS) goals and targets for young people, notably the goals of providing them with access to information, skills and services. Achieving these goals will mitigate their vulnerability and decrease their risk of HIV infection.

During the process of developing this series of papers that review the evidence for policies and programmes to achieve the global goals on HIV and young people, it was felt important to review the evidence for achieving these targets among young people aged 15-24 years who are most at risk of becoming infected. Many of these young people live on the fringes of society, and they are unlikely to be reached by the majority of interventions outlined in this series, such as those implemented through schools, health services or the media. To complicate matters, these groups frequently suffer from discrimination and marginalization, and their behaviours - such as drug use or sex work - are often illegal, making it even harder for interventions delivered through mainstream settings to reach them.

What then do we know about the evidence for reaching the global goals on young people who are most at risk and most in need of the interventions that governments endorsed during UNGASS? Clearly it is important to prevent HIV infection in these groups, and national responses need to focus strongly on these groups. They also need to receive explicit attention because it would be possible for countries to achieve the UNGASS targets without ensuring coverage of these groups, who are at the centre of the HIV epidemic.

This is not to imply that young injecting drug users necessarily require separate or parallel services from those provided to adult drug users. And this is the same for young sex workers, young men who have sex with men, young prisoners or other groups of young people at high risk from HIV. It is likely to be neither necessary nor practicable to provide separate services. However, it is clear that any assessment of interventions designed to achieve the global goals must not ignore these groups. It is important to review what we know about reaching these groups through the interventions outlined in the global goals. It is also important to clarify whether young people most at risk have specific needs relative to older age groups and whether these needs require explicit attention from policies and programmes.

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