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