Most at risk young Most at risk young people in people in
concentrated concentrated epidemic scenarios - epidemic scenarios -
Asia and Pacific Asia and Pacific Advancing UNAIDS support to empowering young people to protect themselves from HIV
New York 26 – 27 October 2009
R. Gray Sattler, Regional Adviser HIVEast Asia and Pacific
HowHow has universal access increased for most-at-risk young people in concentrated epidemic scenarios in Asia and the Pacific?
Not sure that it has, has ithas it?
We have a broad consensus on HIV in Asia
• Varied epidemics: shared characteristics – Unprotected paid sex– Sharing contaminated needles and syringes among drug
users – Unprotected sex between men
• Concentrated epidemics require targeted interventions – With drug users – With men who have sex with men– With sex workers and their clients
• Not mutually exclusive - quite the opposite.
Sources: Commission on Asia Report, James Chin, Elizabeth Pisani
• 10 m FSW and 75 m clients; 20 m MSM and IDU - with links to ‘low risk women’
• An estimated 75% of all HIV infections are directly or indirectly caused by these behaviours in Asia
• 95% of new infections in young people are in most at-risk young people – those who are drug users, sex workers, men who have sex with men (only 5% of young people)
Report of the Commission on AIDS in Asia 2008
HIV prevalence/ incidence in Most at Risk young people
Percent of female sex workers testing HIV +ve Myanmar
0
10
20
30
40
50
15-19 20-24 25-29 30-34 35-39 40+
Perce
nt H
IV po
sitive
IBBS MARPs, FHI & CDC MoH, 2007
18.9
12.1
29.9
18.8
0
5
10
15
20
25
30
18-22
23-29
30-56
All
Cu
mu
lati
ve H
IV i
nci
den
ce
Source: Myanmar surveillance reports 2003
Cumulative HIV incidence in the Bangkok MSM Cohort Study by age, 2006 – 2009 (N=1,002)
Courtesy Dr F van Griensven, Thailand MOPH-US CDC collaboration
Challenges?
• Data • Planning/programming • Coverage • Additional barriers • Increased risk taking
Fighting the epidemic with little data
Clients of FSWs
T% F M <25 ≥ 25 T% F M <25 ≥ 25 T% M <25 ≥ 25 T% <25 ≥ 25 M T%
Afghanistan 2007-2008 0 13 - - - - 0 13 - - - - - - - - - - - - -
Bangladesh 1 2005-2006 - 0.8 7.0 - - - 0.2 0.7 - - - 0.2 - - - - - - -
Bhutan - - - - - - - - - - - - - - - - - - - -
Brunei - - - - - - - - - - - - - - - - - - - -
Cambodia 2 2006-2007 24.4 - - - - - 13 - 7.2 20.9 - 4.5 - - - - - - -
China - - - - - - - - - - - - - - - - - - - -
Fiji - - - - - - - - - - - - - - - - - - - -
Hong Kong - - - - - - - - - - - - - - - - - - - -
India 3 2006 6.92 - - - - - 5 - - - - 6.4 - - - - - - -
Indonesia 4 2007 52.4 56.1 52.2 41.7 57.9 9.4 7.1 20.3 8.4 10.0 - 5.2 1.6 3.6 - - - - -
Korea PDR - - - - - - - - - - - - - - - - - - - -
Lao PDR 5 2007 - - - - - - - - - - - 5.6 - - - - - - -
Malaysia 6 2006-2007 11 - - - - - - - - - - 7.1 - - - - - - -
Maldives - - - - - - - - - - - - - - - - - - - -
Mongolia 7 2005 - - - - - - 0 - - - - 0.0 - - - - - - -
Myanmar - - - - - - - - - - - - - - - - - - - -
Nepal 8 2006-2007 34.7 - - - - - 1 2.9 - - - 3.3 - - - - - 1.0 1.9
Pakistan 9 2007 - - - 18.3 15.4 - - - 0.0 0.0 - 2.0 1.1 2.8 1.8 1.9 2.2 - -
Philippines - - - - - - - - - - - - - - - - - - - -
PNG - - - - - - - - - - - - - - - - - - - -
Singapore - - - - - - - - - - - - - - - - - - - -
Sri Lanka 10 2005-2006 - - - - - 0.2 - - 0.0 - - - - - - - - - -
Thailand 11 2007 27.8 - - - - - 5 - - - - 24.6 - - - - - - -
Timor Leste - - - - - - - - - - - - - - - - - - - -
Vietnam 12 2005-2006 - - 23.1 - - - 4 - - - - 9.0 - - - - - - -
TransgenderMSM
HIV prevalence among most-at-risk population, data since 2005
MigarntsCountry Year
IDUs SWs
Source: www.aidsdatahub.org from multiple sources of country data, 2008, UNICEF, UNAIDS, WHO & ADB
• We do not have age disaggregated data on UNGASS indicators for most countries
A lack of data/poor data• World drug report 2009:
– few countries know the prevalence of illicit drug use – large data gaps - in Asia and Africa very few countries report
illicit drug use
Programming: the Big Mismatch
Source: reported allocation of resources for young people by Joint UN Work-plan Commission on AIDS in Asia 2008
Coverage of most-at-risk populations reached by Coverage of most-at-risk populations reached by targeted prevention programmes is low intargeted prevention programmes is low in
South-East AsiaSouth-East Asia
Source: Coverage of selected services for HIV/AIDS Prevention, care and treatment in low and middle income countries in 2005. USAID, UNAIDS, WHO, UNICEF, POLICY. July 2006
• Young people are reached less than those over 25
Percentage of MARP reached by HIV prevention
programmes Indonesia
0
20
40
60
MSM IDU SW
<25
>25
IBBS MARPs, FHI & CDC MoH, 2007 cited by the National AIDS Commission, Republic of Indonesia, in UNGASS Country Report (2006-2007)
Challenges
Young people face greater barriers to safe sex
2007 Survey of SRH of sex workers in Thailand, unpublished data
FHI AIDS in Asia, Bangladesh MOHFW 2002
Percentage of Thai sex workers reporting physical or sexual violence in last week
0
5
10
15
20
25
30
14-17 18-25 >25
%
Percentage of sex workers beaten or raped in the last year Bangladesh
01020304050607080
%
<25
>25
Challenges
The use of psychoactive substances is to be expected,
• Young people react to changes in drug availability and social perceptions about drug use more quickly than older people (more adventurous?)
substance use is also more prevalent among young people than in older age groups Sources: Neuroscience of Psychoactive Substance Use and Dependence. WHO 2004; World Drug Report 2009.
Challenges
Drug dependence among young people is part of a broader vulnerability
Starting to use at an early age is linked to negative health and social consequences later Sources: Spooner, C. (1999). Evidence Supporting Treatment. ANCD research paper 3. ANCD 2001; World Drug Report 2009.
Challenges
Source: World Drug Report 2009
Illicit drug use appears to be lower in developing countries,
but signs of increase in cannabis, cocaine and ecstasy
• Interventions for young people need different delivery: – E.g. successful peer education programmes for MSM in
China did not reach young MSM. While older MSM meet in social venues, younger MSM were making social contact through internet.
• Policy is an enormous barrier for youngeryounger agedaged most at risk young people
• Research often does not include most at risk young people
• Representation is missing for most at risk young people – rarely members of sex work, MSM and IDU networks and so
are not involved in community consultation and development initiatives
Challenges
• How to reach them? The most vulnerable and at risk young people do not identify as ‘young’
• Identity and education
• What are their lifestyle determinants? – how do they see themselves?
– Which tribe are you?
• Policy change to accommodate work with those who are younger
Challenges
What can the UN do (in Asia)?
• Policy • Technical Assistance• Scale up/mainstreaming
– Where we are implementing agencies• Community development
– What tribe do you belong to? • Strategic information/research capacity development
Involve young people who are vulnerable and most-at risk in the development and implementation of interventions
Make a compelling case for a focus on most at risk young people – Age-disaggregated data (including IBBS)– How /if most at risk young people differ from most at risk people – Need estimates to better inform programming– Similarities, differences and overlaps between people engaging high risk behaviours
Strengthen the evidence-base for interventions to decrease risk– How best to reach the most at risk with services - INTEGRATION
National plans for HIV and on drugs should include dedicated research capacity building strategies
Provide leadership and advocacy
– Target the programme – Key policies and legislation that protect those most vulnerable and at risk; and service
providers to allow them to reach those who are younger and at risk
With thanks, Bruce Dick, WHO
Planning and Programming
Programme Activities focused on most at risk young people in the Region
Policy– Thailand lowered the age from 18 to 15 (without parental consent) for access
to medical service and testing in public sector (including reimbursement)
Strategic Information– Pakistan, Nepal conducted situational analysis and mapping of MARA/MARYP
and developed policies and programmes– Joint data collection processes on MARA and MARYP in Bhutan, Cambodia,
Lao PDR and Pacific countries
Some success and new developments
Programme Activities focused on most at risk young people in the Region
Services– Outreach / PE programs using 15-19 IDU’s for young IDUs and drug use
prevention education programs (Vietnam)
Partnerships– Most at risk young people, service providers, community based organizations,
researchers, policy makers, development partners – ICAAP, August 2009– Regional Task Team established, September 2009 – ASEAN meeting planned
Some success and new developments
Thank you Acknowledgements: Asia Pacific Regional Task Team on most at risk young people Jan Wijngaarden, UNESCO, Jo Sauvarin, UNFPA Margaret Sheehan, UNICEF Judith Ulrisch, UNODC
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