unicef by laxmi Panicker Graber

EXPERIENCES FROM THE FIELD: HIV PREVENTION AMONG MOST AT RISK ADOLESCENTS in Central and Eastern Europe and the Commonwealth of Independent States

FOREWORD The countries of Central and Eastern Europe and the Commonwealth of Independent States (CEE/CIS) have the fastest growing HIV epidemic in the world. The number of people living with HIV has almost tripled since 2000 and there are currently over 1.4 million people living with HIV in CEE/CIS1. The HIV epidemic is affecting ever younger, vulnerable adolescents in CEE/CIS, and yet it is masked by official overall HIV prevalence rates that are, for the most part, relatively low. Still, within these countries, we are seeing sub-groups of young people with infection rates on a par with the worst-affected populations in sub-Saharan Africa. The spread of HIV in this region goes hand in hand with the social exclusion of those who are most vulnerable. Those who are most likely to become infected with HIV are those who are already shut out of society or denied services because of their poverty, ethnicity and behaviours that put them at risk, or who are made vulnerable because of family breakdown, violence, social exclusion or conflict with the law. The experiences of UNICEF, working together with government and civil society partners, have increased our understanding of the needs and vulnerabilities of most-at-risk adolescents. Much of what we know about adolescents and HIV in the CEE/CIS region has emerged from programming in numerous countries of Eastern Europe. Those featured in this publication, including Albania, Bosnia and Herzegovina (BiH), Moldova, Montenegro, Romania, Serbia and Ukraine, have been working with those adolescent boys and girls who inject drugs or engage in transactional sex, young males who have sex with males, street-connected adolescents and those coming from disadvantaged socio-economic or ethnic backgrounds. Tragically our work is deepening our understanding that a growing number of adolescents are being drawn into sex work and drug abuse

as a way to cope with or escape from family problems, poverty, violence and a sense of isolation, creating vicious cycles of risk and vulnerability to HIV. These adolescents, who are most vulnerable to HIV infection, are also the least likely to know the risks or how to avoid them, least likely to have access to services that they need, and least likely to be adequately protected by regulations, policies and laws. UNICEF believes that the experiences in this publication represent an important source of information that can motivate global learning and continued work to prevent HIV infection and provide care and support to those who are already affected by HIV. This in turn can help to pull most-at-risk and vulnerable adolescents back into societies, giving them a â&#x20AC;&#x153;second chanceâ&#x20AC;? and supporting them in the full realization of their rights. Some of the photographs in this document may cause discomfort among readers. Nevertheless, they portray the realities of the lives of these young people. True equity means reaching out, protecting and caring for all, including those who have been excluded and pushed to the margins of society. This publication is a call for change in policies, services and programmes to protect their rights and reduce their vulnerabilities.

Marie-Pierre Poirier UNICEF Regional Director CEE/CIS http://www.unaids.org/en/regionscountries/regions/easterneuropeandcentralasia/

ÂŠ Amer Kapetanovic

FOREWORD

ACKNOWLEDGEMENTS UNICEF Regional Office for Central and Eastern Europe/Commonwealth of Independent States (CEE/CIS) would like to acknowledge the support received from many individuals who helped make this documentation possible. Regional Office for CEE/CIS: Paul Nary and Nina Ferencic, with support from Marie-Christine Belgharbi, Nicola Bull, Jadranka Mimica, Ruslan Malyuta, John Budd, Lely Djuhari, and Sharad Agarwal. Special thanks to Marie-Pierre Poirier and Kirsi Madi for their support and leadership. Support for development of Country Experiences from: UNICEF Country Offices; Albania: Alketa Zazo; Bosnia & Herzegovina: Selena Bajraktarevic, Alma Herenda, Nineta Popovic; Moldova: Angela Capcelea, Svetlana Stefanets, Sergiu Thomsa; Montenegro: Branka Kovacevic, Ana Zec, Jadranka Vucinic; Romania: Eugenia Apolzan; Serbia: Jelena Zajeganovic â&#x20AC;&#x201C;Jakovljevic, Jadranka Milanovic; Ukraine: Olena Sakovych, Sergiy Prokhorov. Thanks to UNICEF Representatives and Deputy Representatives for their support in finalizing the Country Stories: Albania: Detlef Palm; BiH: Anne-Claire Dufay, Lesley Miller; Moldova: Alexandra Yuster, Sandie Blanchet; Montenegro: Noala Skinner, Benjamin Perks; Romania: Edmond McLoughney, Voichita Pop; Serbia:

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Judita Reichenberg, Lesley Miller; Ukraine: Yukie Mokuo, Ritta Poutiannen. Photography: Albania: Rob Few; BiH: Edin Tuzlak, Amer Kapetanovic, Almin Zrno; Moldova: Corina Zara, Angela Munteanu, Lina Osolianu; Montenegro: Silke Steinhilber; Romania: Mugur Varzariu; Serbia: Zoran Jovanovic Maccak, Sladjana Stankovic; Ukraine: Michal Novotny, G. Pirozzi; Content styling, creative direction and design:Laxmi PanickerGraber and bylines.ch

ACKNOWLEDGEMENTS

INTRODUCTION In recent years, UNICEF has worked together with national and local authorities and civil society partners in a number of countries in Eastern Europe and Central Asia to develop and implement HIV prevention programmes intended to reduce risks and vulnerabilities among most-at-risk adolescents (MARA.) This document presents programming experiences from seven countries: Albania, Bosnia and Herzegovina (BiH), Moldova, Montenegro, Romania, Serbia and Ukraine.

nerable, including living and/or working on the streets, living in institutions or in settlements for displaced persons.

The overarching goal of these programmes has been to promote HIV prevention among MARA and to ensure their integration into national HIV/AIDS programme strategies and monitoring and evaluation frameworks. Specific objectives included: • Contributing to the evidence base on the risk profiles of MARA and other vulnerable adolescents • Advocating for protective policy environments • Building capacity of government and civil society stakeholders and service providers to support and provide MARA-oriented services • Piloting and monitoring interventions to reduce the risk and vulnerability of MARA to HIV. Programmes began by targeting MARA who are at highest risk of HIV infection, including: adolescent injecting drug users (IDU,) adolescents selling sex1, and males who have sex with males (MSM,) to prevent risk behaviours (sharing needles and having unprotected sex.) However, it soon became clear that these HIV risks could not be addressed in isolation. Programmes had to also respond to the circumstances that make adolescents vulv

The UN restricts its definition of “sex workers” to adults over 18 years of age and affirms that the involvement of children (under the age of 18) in transactional sex/ sex work and other forms of sexual exploitation and abuse contravenes United Nations conventions and international human rights law. Children under 18 years of age who sell sex are victims who cannot be viewed as sex workers. Every reference to “sex workers” in this report is used only as “short-hand” and should only be interpreted with the full understanding and in full agreement with the above definition.

INTRODUCTION

ABOUT THIS DOCUMENT The purpose of this document is to share experiences, including the results of research, advocacy and interventions and to support programmers, policy makers and donors to carry out and strengthen further programming among MARA and other vulnerable adolescents in the CEE/CIS Region and beyond. Country Experience Country Experiences illustrate HIV Prevention programming for MARA in seven Eastern European countries and include the personal stories and perspectives of most-at-risk adolescents and young people themselves. Each Country Experience includes: • Personal stories and photographs of MARA/young people • Summaries of data, HIV Prevention programming processes and results • Hyperlinks to research reports, guidelines, case studies and tools for programmes Regional Perspective The Regional Perspective section provides a “bigger picture” look at the MARA programme development process, comparing country findings and experiences, and including hyperlinks to many of the more universally-applicable tools, guidelines and advocacy documents developed by the UNICEF Regional Office for CEE/ CIS.

Please note: All subjects of photos in this document granted consent to be photographed and featured. UNICEF in no way endorses, supports or promotes the behaviours and scenarios described and/or pictured in this document. The resource documents referenced and hyperlinked throughout this publication are intended to further inform work on MARA; their content does not necessarily reflect UNICEF official policies or programming positions.

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INTRODUCTION

TABLE OF CONTENTS FOREWORD

PAGE i

ACKNOWLEDGEMENTS

PAGE iii

INTRODUCTION

PAGE V

COUNTRY EXPERIENCE

ALBANIA

PAGE

READ ABOUT THE ALBANIA COUNTRY EXPERIENCE AND THE STORY OF ARMAND, A YOUNG INJECTING DRUG USER (IDU) FROM ALBANIA WHO IS TRYING TO “BREAK THE CYCLE” OF INITIATION OF INJECTING DRUG USE FROM OLDER TO YOUNGER

IDUs.

TABLE OF CONTENTS

BOSNIA & HERZEGOVINA

PAGE 11

READ ABOUT THE COUNTRY PROGRAMMING EXPERIENCE IN BOSNIA & HERZEGOVINA. AND READ ABOUT ANDREA AND LAMIJA, YOUNG INJECTING DRUG USING (IDU) WOMEN WHO SHARE THEIR STORIES OF DRUG USE, VIOLENCE AND STIGMA IN THE HOPES THAT OTHERS LIKE THEM MIGHT FIND BETTER TREATMENT AND ACCEPTANCE IN THEIR COMMUNITIES.

MOLDOVA

PAGE 25

READ ABOUT MOLDOVA’S PROGRAMME EXPERIENCE AND READ ABOUT TAMARA, A YOUNG HIV-POSITIVE MOTHER FROM MOLDOVA, WHO HAS OVERCOME FEAR AND FOUND A SOURCE OF STRENGTH AT A YOUTH-FRIENDLY HEALTH SERVICE (YFHS) IN THE FACE OF STIGMA AND DISCRIMINATION AGAINST HER AND HER SON.

MONTENEGRO

PAGE 37

READ ABOUT THE MONTENEGRO COUNTRY EXPERIENCE AND READ ABOUT IRFAN, A 16-YEAR OLD ROMA BOY FROM A CAMP FOR INTERNALLY DISPLACED PERSONS (IDPs) IN MONTENEGRO, WHO STRUGGLES TO DEAL WITH SOCIAL EXCLUSION IN PURSUIT OF HIS DREAMS.

ROMANIA

PAGE 47

READ ABOUT THE ROMANIA COUNTRY EXPERIENCE AND READ ABOUT MARIA, A YOUNG INJECTING DRUG USER (IDU) FROM ROMANIA WHO HAS FOUND TRUST AND HOPE IN COMMUNITY-BASED SERVICES (NGOs.) BUT WILL IT BE ENOUGH TO HELP HER CHANGE HER LIFE?

SERBIA

PAGE 59

READ ABOUT THE SERBIA COUNTRY EXPERIENCE AND READ ABOUT MIRELLA, A 17-YEAR OLD ROMA GIRL LIVING IN SERBIA WHO HAS LEARNED TO COPE WITH CHALLENGES SUCH AS VIOLENCE AND POVERTY THAT WOULD MAKE EVEN THE STRONGEST AMONG US GIVE US HOPE.

UKRAINE

PAGE 69

READ ABOUT THE UKRAINE COUNTRY EXPERIENCE AND READ ABOUT VIKTOR, A 14-YEAR OLD HOMELESS ORPHAN WHO, AMONG OTHER STREET CHILDREN IN UKRAINE, HAS SUFFERED REPEATED TRAUMAS DURING HIS SHORT LIFE YET MAY HAVE A CHANCE OF AN EASIER FUTURE.

TABLE OF CONTENTS

REGIONAL PERSPECTIVE

PAGE 89

READ ABOUT THE MARA PROGRAMME DEVELOPMENT PROCESS; A SUMMARY OF RESEARCH FINDINGS ACROSS EASTERN EUROPEAN COUNTRIES; ETHICAL CHALLENGES OF RESEARCH AND PROGRAMMING WITH MARA; RESULTS OF ADVOCACY TO CHANGE NATIONAL POLICIES AND STRATEGIES; AND CONSIDERATIONS AND LESSONS LEARNED FROM DEVELOPMENT OF INTERVENTIONS AND SERVICES FOR MARA.

REFERENCES (ON-LINE)

PAGE 101

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“I see great value in Break the Cycle. It has changed the way I think and act. I see it changing others, too.”

We work with ARMAND

in ALBANIA “I’ve been injecting for 10 years,” says 24-year-old Armand, as he shares his story with a counsellor at STOP AIDS, an NGO supported by UNICEF. “A few years ago I started to get wounds on my feet because I couldn’t find any veins ... People were saying I would have to cut my feet off.” Armand now works with STOP AIDS, promoting Break the Cycle, an intervention designed to prevent adolescent drug users from beginning to inject.

ALBANIA

ARMAND’S STORY In Tirana’s extreme summer heat, Armand keeps his body completely covered. It’s only when he sits that his blistering legs might be seen. “I have been living on the streets since I was 12 years old,” he says. “Heroin has been a part of my life from a very early age.” Sharing needles is very common among Tirana’s heroin users. Armand took his first injection at age 14, sharing a syringe with strangers on a train. Armand is among thousands of injecting drug users (IDUs) in Albania who risk contracting HIV. While Albania has low HIV prevalence overall, concentrated epidemics occur in specific geographical areas and among defined populations. Drug injection is the second-highest means of HIV transmission in Albania (after unsafe sex). The situation is ripe for the rapid spread of HIV. Several months ago, Armand met a fellow heroin user who is an outreach worker for STOP AIDS. STOP AIDS offers free harm reduction services such as syringe exchange, emphasizing the necessity of safe injection to reduce risk. It also offers

confidential HIV testing and counselling. “STOP AIDS helped heal my legs,” says Armand. “They also explained the risks of sharing needles – the chance of contracting HIV.” With his feet healed, Armand became a leading participant in Break the Cycle. He and other counsellors and drug users from STOP AIDS reach out to young people. He knows that young, non-injecting drug users are particularly vulnerable to entering the cycle of injection. “I see myself in some of the younger people. I know what path they are walking down,” he says. “I don’t encourage young people to try (injecting). I know that once you start with the first hit, you won’t finish for a long time.” “I feel really committed to engaging with other drug users,” Armand says. Most days he goes to “hot spots”– common meeting points for drug users – to explain the risks of HIV and the services available at STOP AIDS, and to distribute clean needles. “Armand has a real talent for this,” says his colleague Kamani. ”When Armand talks to another drug user, he is able to refer to their shared experience and that helps them relate

in a different way.” Advocating for HIV prevention and behaviour change among fellow drug users has helped Armand realize a new sense of self-worth. Since Break the Cycle began, Armand and Kamani have noticed significant changes in attitudes among drug users. “I am impressed with how quickly this message has spread. I know people now who are afraid of sharing needles,” Armand explains. Kamani is confident that 20 per cent of these users will themselves become active in Break the Cycle and help their peers avoid injection. “By preventing young heroin users from injecting, and by helping injectors to stop, we are helping to slow the spread of HIV in Albania.”

ALBANIA

THE APPROACH Following discussions with government, NGOs and other partners, UNICEF and key stakeholders prioritized work with adolescent IDUs. Owing to a lack of data, the first priority was to build an evidence base about adolescent and young IDUs to guide development of an appropriate programme.

ÂŠ Rob Few

A 2008 baseline survey1 of injecting drug use in Tirana1 collected data on 121 young males aged 15â&#x20AC;&#x201C;24 in Tirana. The research, carried out by the Institute of Public Health with UNICEF support, painted an alarming picture of the extent to which adolescents are putting themselves at risk of HIV transmission. Despite best efforts, only young males were recruited for the survey, suggesting that female injectors face important gender barriers, are extremely marginalized and remain hidden.

DATA AT A GLANCE Research among 15–24-year-old males in Tirana (See data summary2) • 86% had shared needles in the previous month and more than 50% injected every day. • One-third of the sample group had tested for HIV but none of the adolescents in the study had done so. • Up to 34% of IDUs were Roma adolescents. • Condom use among respondents at last sex was extremely low – 14% with regular partners and 19% with casual partners. • Over one-quarter (26%) of young IDUs surveyed had never been to school and 30% were homeless.

Qualitative research was also carried out to clarify the social dynamics and networks among adolescents and young IDUs. The research confirmed that young people are commonly introduced to injecting heroin by older friends, siblings or sexual partners. The study also found that girls are often initiated into injecting by their boyfriends and that harm reduction services typically do not reach them. A Service Capacity Assessment3 confirmed that existing harm reduction service providers lack the capacity and resources to target and address the needs of adolescent IDUs or those at high risk of initiating injecting.

ALBANIA

“For too long we have been content with providing services for young people when in reality we have mainly been reaching those who are aged 23 and above. This programme put pressure on us and our partners to think carefully about how we could help those who are truly young – the adolescents ... because the problems are there.”

UNICEF Programme Specialist

THE PROGRAMME Having reviewed the research findings, UNICEF, government partners and other stakeholders agreed to: • advocate for most-at-risk adolescents (MARA) to be placed on the national agenda and strengthen capacity of policymakers to address them • strengthen capacity and adapt existing HIV prevention and harm reduction services to better respond to the needs of adolescents • prevent the transition to injecting among adolescent “pre-injectors.” 1. Advocating for MARA to be placed on the national HIV/AIDS agenda From the beginning of programming with MARA, UNICEF had to convince stakeholders that targeted, gender-sensitive interventions for MARA should be part of a long-term approach to addressing HIV/AIDS in Albania.Results of ongoing advocacy include a gender-sensitive National Action Plan for MARA, an-

nexed to the National HIV/AIDS Strategy 2011–2015. It defines MARA as adolescents who inject drugs, adolescent boys who have sex with males, adolescents who are trafficked and forced to engage in transactional sex, and adolescents engaged in sex work. UNICEF advocacy also contributed to development of a new HIV/AIDS law that includes a definition of MARA and sets out principles for HIV prevention among most-at-risk populations, including adolescents. The law also provides for harm reduction services for young IDUs (although the age range is not yet specified) and protection services for HIV-infected children (Study: “Don’t Forget About Us4...”). In addition, advocacy strengthened government commitment to integrating outreach work for MARA into existing services. HIV testing and primary health care centers will henceforth use the skilled staff, tools and experiences resulting from the UNICEF Programme to increase young people’s access to voluntary counselling and testing.

2. Strengthening capacities to develop appropriate responses To identify service delivery gaps, NGOs were assessed for their capacity to provide services to at-risk and vulnerable adolescents. A Service Capacity Assessment3 was used to identify the training needs of 20 organizations. Training programmes were developed and UNAIDS integrated findings from the Assessment into its National Technical Support Plan. Given the complex social challenges that MARA face, as highlighted by the qualitative research, new partnerships were set up to link HIV prevention interventions to child protection and social welfare services. The Municipality of Tirana established a special unit of social workers to receive and refer MARA and their families to a range of social protection services.

This suggested an opportunity to intervene to prevent non-injectors from becoming injectors, through Break the Cycle6, an intervention originResearch findings confirmed that a MARA pre- aly developed in England. injector population warranted special attention, and revealed: In Albania, Break the Cycle was delivered through two NGOs: STOP AIDS, which provides needle/ • a young injecting drug population with a risk syringe exchange services, and Aksion Plus7, of rapid spread of HIV which offers methadone substitution treatment. • insufficient national capacity to scale up HIV Both work with IDUs to exert a positive influprevention interventions for IDUs as rapidly ence on young non-injectors within their social as required networks. The programme targets adolescents • evidence that transitions to injecting who are already dependent on heroin and at high frequently occur during adolescence. risk of beginning to inject. IDUs who express a willingness to be involved are taught about HIV/ 5 An assessment of the drug-using environment AIDS and other health risks associated with inalso confirmed that there were several sub- jecting drugs. They are also trained to share this groups of users, each administering heroin in information with others, particularly adolescents, different ways, through snorting, smoking or and to provide them with information about where they can access medical services and support. injecting. 3. Developing and piloting Break the Cycle in Tirana and Vlora

The programme builds on the fact that many IDUs disapprove of initiating new injectors. It supports them to avoid injecting in the presence of non-injectors and discourages them from talking about the drugâ&#x20AC;&#x2122;s effects, telling a non-injector to inject, or demonstrating how to inject in front of non-injecting drug users. The programme also aims to increase IDUsâ&#x20AC;&#x2122; skills to resist any request from a non-injector for a first hit. Those interested were taught about HIV/AIDS and other health risks from injecting and trained to share this information with their peers. Early evaluation of Break the Cycle6 is encouraging. IDUs responded well to the notion that they could help protect young drug users from starting to inject drugs. They were motivated to take part in the programme and reported heightened self-worth because they were consulted and saw their views being taken into account. Peer educators provided information and encouraged young IDUs to access services. Strategies were developed to reach marginalized young female injectors.

ALBANIA © Rob Few

Results from Break the Cycle in Albania From April to September 2010, participants in Break the Cycle achieved 111 “interventions” (peer-to-peer discussions following guidelines designed to prevent initiation of drug injection). Thirty-four percent of those reached by STOP AIDS were under 19 years of age. Comparison of pre- and post-intervention monitoring data from 82 of the 111 people who received the intervention was encouraging, particularly the drop in the number of those who reported injecting someone for the first time or showing them how to inject. Results are summarised to the left.

THE WAY FORWARD Further monitoring will be required to assess the potential for Break the Cycle to have longterm impact in Albania. But the intervention has also provided other useful findings: • Participants stressed the need for a range of other services and interventions, including: hepatitis B and C testing, treatment and immunization; overdose prevention and management; relapse prevention and training; family support services; and leisure and recreation activities. • The intervention made even clearer the challenges of reaching young female injectors – further work in this regard will be required. Implementers will continue collecting monitoring data with a view to scaling up services, after completion of the pilot and further evaluations of Break the Cycle.

UNICEF will continue to support interventions for MARA and other vulnerable adolescents in Albania. Assistance has been given to endorsing and implementing the National Plan of Action.UNICEF is supporting the government to develop and implement a five-year National Drug Use Prevention Strategy for 2011–2016. Albania’s submission to the Global Fund Round 10 included a specific request for funds to scale up Break the Cycle. UNICEF will continue to work with government and NGO partners to support and expand Break the Cycle and integrate it into the broader Drug Use Prevention Strategy and other HIV prevention services. Particular attention will be paid to reaching young female injectors and pre-injectors. In addition, it will be critical to continue to address the broad behavioral and socioeconomic factors that influence risk taking among adolescents.

â&#x20AC;&#x153;You know, as the saying goes, that we have an angel on one shoulder and a devil on the other. I had the devil on both of them ...â&#x20AC;?

We work with ANDREA and LAMIJA

in BOSNIA AND HERZEGOVINA Andrea and Lamija are among a small number of young female injecting drug users (IDUs) from Bosnia and Herzegovina (BiH) who agreed to discuss their lives, their experience of drug use, violence, stigma, discrimination and other sensitive topics with UNICEF and partners. UNICEF collaborated with the NGO Viktorija in Banja Luka and Association of Citizens Proi in Sarajevo to conduct qualitative research aimed at better understanding how the health and social sectors and society in general can better help these marginalized and misunderstood young women.

BOSNIA AND HERZEGOVINA

ANDREA’S STORY Andrea, from Banja Luka, discussed how she got started as an injecting drug user: “You know, as the saying goes, that we have an angel on one shoulder and a devil on the other. When I was young, I had the devil on both of them ... male and female friends who persistently said, ‘Take it, take it.’ Almost two months they nagged me – ‘Take it, you will feel better, why do you think you are any different?’ ... and I had an aversion to heroin. I thought that it was the rock bottom, the black hole that sucks up everything, the family, yourself ... Then I succumbed, I just put out my arm. I took it intravenously right away.”

She went on to describe the abuse she has suffered at the hands of the police: “I was walking and two men were approaching me, and all of a sudden they caught me – one from one side and another from the other side, gripping me by my arms, and taking me to the station. I did not want to say my name because I was pretty much drugged and then [they] started saying, ‘Oh, you’ll get the crisis, if you’re female we will kick you, you will get yours when the crisis hits ...’ They banged on the wall above my head ... they changed their methods and after 15 hours of harassment they released me. When I exited the station I was beside myself, I flung myself in front of a car, but it slammed on the brakes in time and I continued on, home.”

LAMIJA’S STORY Lamija, from Sarajevo, described the mistreatment she experienced at an outpatient clinic following complications from injecting: “[My] arms were swollen, full of pus, I had abscesses ... I came [to the clinic] at 5:30, I was first in line with a temperature of 40 degrees ... They did not call me in first; several people were examined before me ... A male nurse, not knowing that I could hear him – because I sat alone next to the door of the office – said, ‘Junkie, let her drop dead, she got what she deserved ... let her arm burst up.’ And I was in pain, I cannot describe how much ... The driver of their van came in and saw me lying on the tiles [with] cold hands, and yelled to them, ‘What’s the wait? She could die ...’ Only then they entered me in the clinic and began to work.”

Yet Lamija, and many other female IDUs showed exceptional motivation to become actively involved in drug abuse and HIV prevention activities. They express the view that if they quit, they could offer their own personal experience and they would feel useful and fulfilled: “It is incredible how much desire I have to save at least one person ... to explain how many bad situations there will be and to tell the person that the beginning should be the end ... that’s it ... so that, in some way, the person would know that what they think and what the drugs provide is a false sense of security, an escape from reality ... I have been there and lived to regret it. I put my grandmother and my brother in difficult situations ... It is a big step that leads to chaos … That is what I want to tell them.”

Although there is low HIV prevalence in BiH, the seeds of a rapid increase of HIV are being sown. Risk behaviours are present among young people and data from recent bio-behavioural surveys (BBS) indicate that these behaviours are starting at an early age. Working with national partners, UNICEF built a foundation for an effective HIV/AIDS response for vulnerable and at-risk adolescents through: • conducting research among IDUs and children and adolescents living in institutions, to support programm planning • supporting changes in strategies and legislation to ensure that policies support an enabling environment for adolescents’ access to service • improving the provision of confidential HIV voluntary counseling and testing (VCT) through the development of protocols and guidance, and building the capacity of service providers to work more effectively with at-risk populations, including adolescents • developing behaviour change communication (BCC) initiatives to increase knowledge and reduce violence, stigma and discrimination, and encourage understanding and support for most- at-risk adolescents (MARA) and other vulnerable adolescents, including those in institutions UNICEF supported national efforts to include young people and adolescents in the 2007 BBS among IDUs1, with the aim of developing targeted interventions for adolescent IDUs. However, because legal barriers prevented testing minors under age 18 for HIV, the focus of the study was shifted to behavioral factors among younger respondents. Still, very few adolescents under

BOSNIA AND HERZEGOVINA

THE APPROACH

18 were reached, suggesting that the same legal barriers would also prevent adolescents from accessing HIV prevention services. Consequently, the Ministry of Health of BiH and UNICEF decided to use the BBS to gain a retrospective understanding of the risk behaviours and vulnerability of young IDUs. The decision was made to build a more effective response to prevention among IDUs in general, to address legal and other service access barriers, and to explore risk and vulnerability among other marginalized adolescents. Findings from the BBS confirmed that risk behaviours start at an early age. The research also found that younger IDUs are not being reached by existing harm reduction and HIV prevention services. While the high prevalence of hepatitis B and C showed that there is no room for complacency, low HIV prevalence suggested there was a temporary window of opportunity for the Government and its partners to take action with effective HIV prevention interventions.

Research among 18–24-year-old IDUs in Sarajevo, Banja Luka and Zenica1 • The median age of first drug use among respondents in Banja Luka was 14. • More than half in Banja Luka, half of respondents in Sarajevo, and one-third in Zenica first used drugs when aged 15 or younger. • More than half of those surveyed (55%) in Sarajevo, 39% in Zenica and 38% in Banja Luka had shared injection equipment during the previous month. • Half of IDU respondents in Sarajevo, and more than onequarter in Zenica experienced first sexual intercourse before the age of 15. • Approximately three-quarters of respondents in Sarajevo, 62% in Banja Luka, and 67% in Zenica had not used a condom during last intercourse with their regular partner. • Prevalence of Hepatitis C was 36% in Sarajevo and 34% in Banja Luka. HIV prevalence was extremely low. • Less than half the respondents in Banja Luka

BOSNIA AND HERZEGOVINA

DATA AT A GLANCE

“I was terribly afraid of crisis. I attempted suicide in the moments of crisis. I would see it all before me, as in some misty mirror, all that gnawed on me and burdened my conscience … that was horrible, I did not endure and I tried to cut my veins. But the intervention by doctors was swift, they stitched me up and sent me home. When I came home, I threw myself on the railroad tracks. I remember the sound of the train and the strong pressure from my mother. She managed to pull me off the rails and save me. I do not know where she got her strength … ” (Young female IDU, Sarajevo.)

Qualitative research among female IDUs2 found that young female IDUs are influenced to start injecting by peers and partners, denied access to health and prevention services including counselling, and abused by law enforcement officers.

ÂŠ Amer Kapetanovic

BOSNIA AND HERZEGOVINA

UNICEF and government partners explored the risks and vulnerabilities of adolescents living in institutions without parental care, and those in boarding schools. These adolescents grow up outside the family environment and experience particularly difficult, often traumatic, circumstances which can affect their physical and mental health. They are usually hard to reach with health and social protection services, particularly HIV/AIDS prevention. A behavioural study examined the risk behaviours, knowledge and social experiences of 392 adolescents in 10 collective accommodation institutions. The study was led by the Health Protection Institute in Republika Srpska and the Public Health Institute of the Federation of BiH. The majority of respondents (83%) were under age 18. Less than one-third of respondents (29%) had correct knowledge about HIV/AIDS. Just under half knew where HIV testing and counselling services were available. As many as 84% of both girls and boys reported using alcohol. One-quarter of the boys and 13% of the girls had initiated sexual activity. Ten percent of respondents

reported that they had experienced violence within or outside their institution once or twice within the last 12 months. Those exposed to violence said that the perpetrators were most often other children who did not live in collective accommodation (57%), or their peers who lived in the same institution (35%), or staff of their institution (17%). Although this survey did not find strong evidence of risk behaviours for HIV, it did find other areas that required attention. Their limited knowledge about HIV, high levels of alcohol consumption and experience of violence meant that these adolescents were vulnerable to a number of health and social development problems. The data also showed that adolescents in institutions are heavily stigmatized in their communities, and vulnerable to violence and discrimination from other young people.

â&#x20AC;&#x153;When advocating for MARA, it is easier to take advantage of ongoing legislation development processes or the adjustment of those laws that have recently been endorsed by the authorities, rather than putting efforts into the development of completely new legislation or strategies.â&#x20AC;? UNICEF Programme Specialist

BOSNIA AND HERZEGOVINA

THE PROGRAMME The research findings and need to develop policies and services for young IDU led UNICEF and partners to agree that programming should focus on: • advocating for changes to legislation to support data collection and service provision among adolescents, including a review of policies related to parental consent requirements for the provision of medical services • improving the quality of HIV testing and counselling services • promoting an enabling community environment which would increase awareness of HIV/AIDS, encourage HIV testing, and reduce stigma and discrimination • increasing HIV knowledge and promoting safe services for adolescents in institutions.

1. Advocating for changes to legislation UNICEF and partners recognised that interventions would not be able to reach MARA and other vulnerable adolescents if legal barriers, including policies requiring parental consent for prevention and care services for adolescents remained. Therefore, significant efforts were focused on advocating for changes to legislation and including adolescents in the National AIDS Strategy. Significant progress was made – new laws were developed, and national strategies for drug use and HIV/AIDS now make specific reference to MARA and other vulnerable adolescents.

Laws and strategies to increase adolescent access to HIV testing and other health services • Laws, policies and practices were reviewed3 to assess legal barriers to adolescents accessing information and health services related to HIV/ AIDS and sexually transmitted infections (STIs). The analysis3 found that adolescents under age 18 were not accessing services and not allowed to request “invasive” health interventions without prior parental consent. These interventions included HIV testing. • UNICEF and health sector partners advocated for changes to the law, providing technical assistance and data from the BBS surveys to support the case of adolescents. In response, the Ministry of Health and Social Welfare of Republika Srpska developed the Law on Health, and the Ministry

of Health of the Federation of BiH developed the Law for the Protection of Patients’ Rights. Both laws lower the age at which a young person can access health services, including HIV testing, without parental consent – from age 18 to age 15. Both laws have been endorsed. • A Strategy for Diminishing Drug Use was developed under the leadership of the Ministry of Security of BiH. The strategy provides a legal framework for NGOs to provide HIV prevention and harm reduction services without coming into conflict with the law. Adolescents and young people are included in the strategy. • The National AIDS Strategy refers to adolescents as a sub-group of most-at-risk populations.

2. Improving the quality of HIV testing and counselling services The work to develop a protective legislative environment for HIV prevention services was complemented by efforts to increase access to VCT services that meet the needs of at-risk and vulnerable adolescents. With support from UNICEF, protocols were approved for VCT for HIV for most-at-risk populations (MARPS), including adolescents. A VCT Guidebook for Service Providers4, which includes guidance on providing services to MARA, was produced. A pool of trainers was established to train service providers in VCT, including testing for MARA and other vulnerable adolescents. Health workers and NGO staff were trained to provide VCT to MARPs, including adolescents.

At community level, the VCT centre in Banja Luka was strengthened to provide improved HIV counselling and testing services for MARA, people living with HIV, and other at-risk populations. In the first few months after capacity building, 563 clients were seen, nearly a quarter (24%) of whom were adolescents. Test kits were supplied to increase testing and improve access to health information, in recognition of the high levels of Hepatitis B and C evidenced in the BBS. UNICEF strengthened the capacities of local NGOs dealing with MARPS and other key stakeholders to respond to the needs of MARA. Partnerships were also built at various levels, ranging from the Ministry of Security of BiH at the central level, as well as “entity” ministries of health, education, social welfare and interior, and the cantonal and municipal level governments and ministries responsible for health, education and social welfare. These new partnerships have been critical as the Global Fund project is implemented. 3. Promoting an enabling community environment UNICEF is also working to change community attitudes and increase social support for MARA, other vulnerable adolescents and those affected by HIV/AIDS. A BCC strategy to fight stigma and discrimination was developed in partnership with young people. UNICEF advocated for this strategy to be integrated into the National AIDS Strategy. An edutainment mass media campaign, “Without Risk,” which addresses alcoholism, drug use and safe sex, was developed for the wider youth population. A television serial for youth, and videos and radio clips promoting HIV prevention, were produced for national broadcast.

4. Increasing HIV knowledge and promoting safe services for adolescents in institutions UNICEF and local NGO Viktorija developed an intervention to increase knowledge about HIV-related risk behaviours and improve the social environment of adolescents living in collective accommodation. This intervention targeted adolescents and staff in institutions, school children from those primary schools attended by the adolescents in institutions, and key stakeholders responsible for the adolescents at the municipal level. In addition to learning about HIV and AIDS, adolescents were introduced to HIV testing facilities and youth-friendly health services. Peer education sessions were conducted in schools and institutions, staff members were trained, and roundtable discussions were held for key stakeholders. In all, 954 adolescents and 294 adults were reached.

BOSNIA AND HERZEGOVINA

THE WAY FORWARD The partnerships established with institutions demonstrate how initiatives that begin with HIV prevention are relevant to broader child protection interventions. The research findings and the networks established will be used to inform and implement UNICEF’s support for the reform of collective accommodation institutions and other interventions focusing on juvenile justice. The HIV programme’s emphasis on building an enabling environment at policy, health system and community levels should have a wide-reaching and sustainable impact. The new laws and VCT protocols will facilitate the Global Fund project’s efforts to provide services for MARPS and MARA. Additional work is still needed to tackle stigma and discrimination.

UNICEF and partners will continue to work with national authorities and civil society organizations to support the development and implementation of HIV prevention, care and support services targeting the needs of MARA, including adolescent IDUs. Emphasis will also be given to the children of at-risk populations and the needs of the at-risk partners of drug users – mostly women, as well as vulnerable adolescents. UNICEF will promote increased awareness of HIV among young parents through Integrated Early Childhood Development Centres. In addition, UNICEF will continue to collaborate with institutions for the collective accommodation of adolescents to support institutional reform, strengthen

institutions’ collaboration with local services and support increased attention to juvenile justice. Additional funds were obtained to provide VCT and other HIV prevention services to adolescents across BiH. UNICEF and partners successfully advocated for MARA to be included in Global Fund grants. In 2010, BiH received an unprecedented US$11.4 million in Global Fund programme funds for two years. Of this amount, US$ 400,000 was dedicated to prevention of HIV among MARA, including through VCT services. UNICEF will continue to work on improving the health and wellbeing of the most vulnerable adolescents, including by addressing the broader determinants of HIV risks.

“We try to hide my HIV status, because people do not know a lot about HIV and they do not understand there is nothing to be afraid of.”

We work with TAMARA

in MOLDOVA Tamara is one of about 5,000 young people who regularly benefit from the services of ATIS1, a youth-friendly health service (YFHS) that opened in 2005 with UNICEF support. ATIS offers information about sexually transmitted diseases and HIV/AIDS, and provides counselling and testing services, access to contraceptives, and care and support for the most vulnerable adolescents. Located in one of Moldova’s most HIV/AIDS-affected towns (Balti), ATIS offers services to vulnerable adolescents and young people aged 10–25, not only from Balti but also from nearby villages and small towns.

MOLDOVA

TAMARA’S STORY In a courtyard in the town of Balti in Northern Moldova, Tamara and other young people are discussing what they have learned at a seminar they have just attended. Tamara came to ATIS when she was 17 years old. “I started doing drugs at the age of 15 and that’s how I got infected with HIV ... I went to see my family doctor and he only wanted to get rid of me.” Despite a law requiring medical staff to keep a diagnosis confidential, Tamara said the doctors were writing the code “20” (signifying that the patient is HIV positive) on her file, even on her prescriptions. “I felt depressed and had the feeling that nobody cared. Although I stopped taking drugs and my life changed for the better, I still felt rejected by people around me because of my HIV-positive status ...” In Moldova, people living with HIV and their families face discrimination. They are often unable to get a job, their children may not be accepted in preschools, and these circumstances force them to hide their status. Many of the youth and adolescents at risk avoid seeking health care because they are afraid of how they

will be treated. This has consequences for their health and affects their lives in other ways. Tamara is now a young mother and her son attends a local kindergarten. She is aware that, if the teachers and other parents knew that she were HIV positive, her child would face the same stigma – even though he is HIV negative. “We try to hide my HIV status, because people do not know a lot about HIV and they do not understand there is nothing to be afraid of,” she explains. Tamara’s life changed when she learned about the ATIS clinic. “One day a friend told me about a youth-friendly clinic where people like me can get help. I decided to go and it worked ... Here I feel safe, accepted and feel the comfort of not having to hide anything … the doctors treat me without judging me.” Asked how she would feel if the centre closed down, Tamara says it would be a real shock. “I cannot even imagine what I would do. If ATIS did not exist, I would have to travel to the

THE APPROACH specialized HIV centre in Chisinau each time I had a health problem,” she says. “It would cost me a lot, as I need medical examinations for myself and my child every three months or so, and here I don’t have to pay for anything, all the services are free.” Tamara comes to the centre every day, both for medical examinations and to attend seminars and support groups and socialise with other young people and the staff.

Moldova is classified as a country with low HIV prevalence. The HIV epidemic in Moldova is particularly concentrated among injecting drug users and their sexual partners. In 2008 the Ministry of Health, with UNICEF’s support, conducted a baseline study among 369 IDUs aged 12–24 and their sexual partners in Balti, Chisinau and Tiraspol2. The research confirmed that young IDUs are taking risks: they are sharing needles and they are less likely than older IDUs to use condoms with casual partners. Young injectors are reluctant to use health and harm-reduction services, and outreach activities are not managing to reach them.

MOLDOVA

DATA AT A GLANCE Research among 12–24-year-old IDUs in Balti, Chisinau and Tiraspol • 30% of respondents were under age 18. • 79% said they had obtained their injecting equipment from pharmacies and adolescents were significantly more likely to do so. • 85.3% said they had shared injecting equipment at least once in the previous month. • A majority of female IDUs had IDU sexual partners. • Younger IDUs seemed more likely to engage in higher risk sex with casual partners. • Injection patterns were found to be very sporadic – nearly 25% had not injected during the previous month.

“I started to hang out with those people who had it (heroin) permanently. Everyone was looking for it, I was looking for it, and we were together all the time and it appeared all the time and then it gets to a point when it is stupid to refuse. In any case, you are going to do it and you do it and you feel fine. And I did it time and time again.” Igor, young IDU

Surprisingly, sampled IDUs had similar education levels and occupations to their friends of the same age who did not inject drugs. This made it difficult to identify young IDUs as a specific group in the community. In addition, adolescents and young people in Moldova were found to inject drugs much less often than their peers in Albania, Romania and Serbia3 – nearly one-quarter had not injected during the previous month.

UNICEF undertook a qualitative study4 to clarify these unusual results5. Interviews in Balti with 31 current IDUs and 11 ex-injectors showed that young injectors tend to be initiated into injecting drugs by their peers.

“I saw for myself how these people were using, and they said to me, ‘Don’t even think about it.’ And I thought the opposite, ‘Why are they using and yet persuading me not to?’” Fyodor, young IDU

“I am in withdrawal, I need money. I met Vasya who has money and he wanted to try, and tells me he will give me money. Almost everyone would accept his money to get the drug for himself and for this guy. There are not many conscientious people who would say, ‘I would not get you the drug.’ ... As they say, ‘If it’s free, even the vinegar is sweet.’ So of course the drug addict will take the money and will give him the drug without thinking twice. When a person is a dependent drug user, he has no boundaries.” Anatoli, IDU

This contrasts with the situation in Albania, where older injectors were found to initiate new, younger injectors. The research confirmed that the Balti environment was unlikely to support interventions aimed at working with older IDUs to dissuade them from initiating younger, noninjecting drug users into injecting.

MOLDOVA

THE PROGRAMME Other factors, including a shift in the focus of law enforcement to mid-level dealers and producers, were found to contribute to an environment in which interventions such as Break the Cycle* would be unlikely to be effective. The research had significant implications for the types of programmes that were supported in Moldova. Findings showed that existing harm-reduction programmes have not been reaching younger IDUs who inject intermittently with their peers, nor are these types of services particularly relevant to them. Therefore, alternative entry points were needed.

Following discussions with service providers and NGOs, UNICEF, the Ministry of Health and other partners opted to: • build understanding of most-at-risk adolescents (MARA) and the actions required to produce a comprehensive response to their complex needs • advocate for national strategies, plans and monitoring systems to include MARA and especially vulnerable adolescents • strengthen capacity of existing YFHSs to provide high quality, targeted services for MARA • improve cross-sectoral communication and cooperation, and pilot high quality services and referrals to meet the needs of at-risk and vulnerable adolescents. 1. Building understanding and support for MARA

*Piloted in the U.K., Break the Cycle interventions promote to current IDUs that they not discuss, demonstrate or initiate injecting among or with non-injectors.

UNICEF began by introducing the concept of MARA and demonstrating the need for data and targeted responses. Key stakeholders and decision makers came together to identify an ap-

propriate national response. A National Action Plan for MARA was developed by the government, NGOs and young people from all sectors. The Plan identifies the key issues and sets out a range of actions required for a comprehensive HIV prevention response.

It was a new issue, and at the start of the programme we didn’t have data. Developing the MARA Action Plan gave ministries and civil society the time to absorb the issues. This process lasted a year but it meant people understood the issues and challenges MARA face. In the end they became allies of MARA. UNICEF Programme Specialist

2. Advocating for national strategies, plans and monitoring systems to include MARA UNICEF’s advocacy led to integration of MARA into the National AIDS Programme 2011–2015 (NAP)6. The NAP includes references to adolescents in its definition of at-risk populations (ie, IDUs, sex workers and men who have sex with men [MSM]) and, among its list of vulnerable populations, identifies children living/working on the streets, in conflict with the law and/or living in institutions. A joint UN/Ministry of Health working group is reviewing legislation to identify potential barriers to adolescents’ access to reproductive health services.

MOLDOVA

As a result of UNICEF advocacy, indicators related to MARA and other vulnerable adolescents are now included in the monitoring and evaluation (M&E) plan of the NAP. The National Health Management Centre routinely collects data on 15–18-year-olds. A monitoring system that was developed for YFHSs is also being integrated into the national M&E system. It includes indicators on at-risk and vulnerable adolescents reached through outreach activities and services provided in health facilities. 3. Strengthening the ability of youth-friendly health services to reach MARA For a number of years, UNICEF has worked with its partners to establish YFHSs as part of the broader adolescent development programme in Moldova. As a result, YFHSs are integrated into the health system and are included in Moldova’s health policies and youth strategy. UNICEF led development of a national concept for YFHSs, standards of quality, monitoring tools and training materials for profes-

sionals. The standards set out a minimum package of services to be delivered by YFHSs. They include a focus on equitable access to services and a chapter on providing services to MARA and vulnerable adolescents. A guide to implementing the standards, which includes advice on how to reach MARA, is under development. Key staff from YFHSs and reproductive health services have been trained in outreach, case management approaches and use of a referral mechanism for MARA. Supervision and monitoring systems are being developed and tested. Funding for YFHSs has also been secured, with the state’s Health Insurance Fund taking over their funding in 2008. Two new YFHS centres are being introduced in Transnistria with funding from local authorities, the Global Fund and UNICEF. Support groups for young drug users, adolescents living/working on the streets and young people living with HIV are in place. A national NGO of young people living with HIV, Positive Youth, has been established. Members actively participate in the development of policies and programmes related to HIV.

4. Improving cross-sectoral communication and cooperation Pilot projects have also been established in Balti, Chisinau and Tiraspol to determine how best to provide integrated services for MARA and other vulnerable adolescents using outreach activities, case management approaches and referrals. These are focused on identifying at-risk adolescents as early as possible and providing high quality services that respond to their needs.

Piloting a referral mechanism to ensure comprehensive services for most-at-risk adolescents in Balti Experience has shown that services for MARA and other vulnerable adolescents need to be cross-sectoral – addressing problems related to their health, education, experiences of violence and problems with the law. A referral system developed by UNICEF and local partners in Balti aims to improve the communication and cooperation between sectors and provide quality services that deal with adolescents’ complex needs.

“There are children who cannot even explain the problem they have. We work with children living in the streets, with the victims of domestic violence, males having sex with males, trafficked women and girls. We counsel adolescents giving birth and thinking of abandoning their babies.” Therapist, ATIS

Prior to establishment of the referral mechanism, cooperation between sectors in Balti was weak. Health professionals did not refer their clients to other services, nor did they consult with professionals from other sectors to provide a joint response. In Balti, the social assistance, health, education and police departments, prosecutor’s and probation offices, and civil society organizations agreed to work together to identify and refer vulnerable and at-risk adolescents to the services they need. They agreed that health professionals should provide direct referrals to other services and that a social assistant, acting as a case manager, would develop an intervention plan for adolescents, referring them to a range of services, periodically evaluating their progress and making adjustments as needed.

Methodological and support materials have been developed to support the referral system. These include: a map of social services describing education, health and social services in Balti and their contact details; a guide on working with vulnerable children; leaflets for professionals about the referral mechanism; and leaflets and posters for the general public to promote attendance at services. The YFHS standards and protocols help to ensure good communication between providers and contribute toward creating a “safety net” of services for vulnerable young people. Experience from the pilot clinics suggests that the referral system can succeed. Outreach workers are working with local authorities and social assistants to help street children go back to school, help undocumented adolescents get identity papers, and mediate contact between vulnerable families and social assistance services in the community.

MOLDOVA ÂŠ Lina Osoianu

THE WAY FORWARD UNICEFâ&#x20AC;&#x2122;s on-going support for MARA and vulnerable adolescents in Moldova will be guided by the activities outlined in the NAP. UNICEF will work with the Ministry of Health, with support from the Swiss Agency for Development and Cooperation, to develop a strategy for scaling up YFHS that ensures that services reach the most vulnerable young people and to identify ways to promote adolescent participation in this process. UNICEF will support the revision of pre-service and in-service curricula for health professionals to ensure a youth-friendly approach within health services, including primary health care.

UNICEF will continue to revise and adjust existing legislative and normative frameworks in order to remove barriers among most vulnerable adolescents to accessing youth friendly care and support. Also, a cost effectiveness analysis of YFHS will be carried out to help the Moldovan Government identify and implement appropriate financing for YFHS, to expand and to include outreach for most vulnerable adolescents in YFHS. UNICEF will continue to monitor and evaluate the pilot referral mechanism in Balti, with the aim of scaling up the model throughout the country, to better ensure supportive responses to the complex needs of adolescents in Moldova.

“I feel that there are many moments when people look down at me because I am a Roma.”

We work with IRFAN

in MONTENEGRO

Irfan, a 16-year-old Roma boy, first heard about HIV/AIDS, gender issues, and sexual and reproductive health in a UNICEF-supported youth workshop in Podgorica. Sexuality is strictly suppressed in his community. “We never talk about personal matters, especially not between girls and boys,” Irfan explains.

MONTENEGRO Silke Steinhilber

MONTENEGRO

IRFAN’S STORY Irfan has not been able to go to school since arriving in Montenegro in 2001. Only one in four children in Irfan’s community access primary education; only 18 per cent of them will complete it. Three-quarters of the community’s parents are illiterate. Irfan lives in Konik, a community of over 2,000 Roma, Ashkali and Egyptians (RAE) on the outskirts of Podgorica. Many here are refugees from Kosovo. The poverty rate of displaced RAE families is five times the national average. Irfan’s 10-member family is slightly better off than others. They rent a two-room apartment but struggle to pay the 150 euros monthly rent. Sometimes Irfan can work with his father in order to bring home a little money. “We boys are expected to help our fathers, while girls help their mothers with women’s work.” But girls are more likely than boys to have their movements restricted, to lack access to health services and education, to be unaware of their rights – indeed, to lack control over their own lives.

Every day, young people like Irfan face exclusion. They have limited opportunities to shape their own lives and they dream of living like other young people. “I dream of becoming a professional football player,” says Irfan, “but most of all, I would just like to have a real house, a job and a family.” Irfan’s minimal educational opportunities are further limited by his community’s lack of support for education and strongly gendered belief in the male as family provider. “I have no idea how I could provide for a family,” he says. Irfan has seen some of his friends engage in human and drug trafficking: “They were looking to make quick money and are now much better off than I am.” Some have resorted to sex work out of economic necessity. One in five young RAE men from Podgorica have reported having had sex with men, typically unprotected. Most had their first anal intercourse before age 18. Some of them reported that they had experienced forced sex.

Irfan attends youth workshops organized by a local NGO with UNICEF support. It was there he first heard about HIV/AIDS, gender issues such as violence and the limitations of traditional roles for girls, and sexual and reproductive health. He realized the need for such spaces where boys and girls can be together and speak freely. “The leaders here in Konik do not pay much attention to our needs as young people,” he says. “We would like to form a group and do our own youth leadership training now ... In the end, all that I want is equal rights, as a Roma and as a refugee.”

MONTENEGRO

THE APPROACH Overall, Montenegro has very low HIV prevalence. However, young Roma are extremely vulnerable to the rapid spread of HIV/AIDS in the region. Isolated from the wider community, discriminated against, poorly educated and unable to easily access health services, they lack both the knowledge to protect themselves and the confidence to demand better services. There is a great need for sexual and reproductive health services in Roma communities. Baseline research1 conducted in 2007–8 among a sample of Roma aged 15–24 in Podgorica and Niksic demonstrated their poor knowledge of HIV/AIDS. In a society with unequal gender relations, girls are particularly vulnerable. Domestic violence is widespread. Early and unprotected sex is very common and girls have little knowledge of how to protect themselves. One-quarter of girls surveyed reported that they had experienced forced sex and some of them reported having had an abortion or miscarriage. Based on these research findings, UNICEF engaged with national authorities and partners to develop targeted interventions for young Roma in Podgorica and Niksic. The approach encompassed: • laying systemic foundations through policy and service strengthening for long-term support to young Roma • providing targeted, community-based services that will help and encourage young Roma to make positive behaviour choices to protect themselves and their peers.

DATA AT A GLANCE Research among Roma aged 15–24 in Podgorica and Niksic • 29% of girls had first sex before age 15. 25% of these girls had had an abortion, and an alarming 30% had had a miscarriage. • Only 44% of boys and 22% of girls had ever been enrolled in school. • 50% of males, and only 5% of females, had used a condom with a casual partner at last sexual intercourse.

Evidence from the 2007–8 study that looked into the risks and vulnerabilities of young RAE for HIV and sexually transmitted infections (STIs) provided UNICEF and its partners (including the Institute of Public Health, Red Cross, youth NGOs and Roma NGOs) with clear parameters within which to design an effective programme.

MONTENEGRO

THE PROGRAMME Targeted interventions focused on young Roma aged 15–24 living in settlements in Podgorica and Niksic, and aimed to: • reduce risk behaviour among sexually active Roma • reduce the vulnerability of young Roma in settlements for displaced persons • increase their HIV-related knowledge and skills, and build their confidence • challenge prevailing social norms and attitudes toward violence and gender relations • improve their access to quality health services by strengthening national strategies, policies and standards. 1. Building foundations for sustained support – Gender advocacy For the UNICEF programme to be successful it had to address gender inequality, while reducing risk and vulnerability to HIV and other STIs. Gender-sensitive programming was new to many of the partners, so there were several challenges:

Building stakeholder support – Community advisory boards, each including a local doctor and youth and Roma leaders, ensured community participation and ownership. Community elders and parents had to be convinced to allow their girls to participate in research and attend discussion workshops. Personal visits to 120 Niksic families resulted in some 20 girls and 50 boys participating in the programme. Data collection – Young women were actively involved in the behavioural survey of 15–24-year-olds, the first baseline survey of RAE adolescents. Ensuing discussions about sexual health and HIV/AIDS prevention assisted planning of prevention measures for boys and men. However: • more women than men dropped out during the survey’s training phase • constricted living conditions and family controls impacted on the random selection of respondents and interview privacy • cultural attitudes (eg, prohibition on men who have sex with men [MSM]) may have produced biased responses.

Capacity building and empowerment – This was achieved through an HIV/AIDS analysis of Montenegro, a regional training package and briefings on developing gender-sensitive prevention programming for adolescents. Promoting community dialogue – Openness was the key, including provision of shared and female-only spaces to empower girls, weekly visits by doctors and peers, and open exchanges between policy makers and community representatives. Empowering RAE adolescents – Two young men were the first from Konik’s RAE community to attend secondary school. Young women have been empowered by open participation in the programme. There is increased awareness that girls lack role models, and of the effects of the community’s restrictive gender norms.

Discussion workshops In 2010, young Roma attended 56 workshops and about 500 were influenced through peer discussion on such topics as human rights, gender stereotypes, family violence, stigma and discrimination, access to youth-friendly social services, the right to education, and healthy lifestyles. Opening such topics to discussion was an important achievement. Female-only discussions allowed girls to speak openly about sensitive topics, while mixed discussions gave them the opportunity to voice their ideas in front of boys. (See Gender Case Study2.)

2. Integrating young Roma into national strategies UNICEF and partners advocated successfully for young Roma to be specifically targeted in national plans, strategies and monitoring systems. The National HIV/AIDS Strategy3 sets out the Government’s long-term commitment to young Roma. The national monitoring system for measuring the national response to HIV/AIDS and STIs now includes indicators on knowledge levels and condom use among young Roma. These are also included as indicators for monitoring the implementation of Global Fund programmes.

â&#x20AC;&#x153;We needed to promise that we would take the girls home, one-by-one, after the workshops; otherwise they would not be allowed to participate.â&#x20AC;? Workshop Organiser, Niksic

3. Changing legal systems to improve access to health services UNICEF has successfully advocated for better systemic recognition and response, not only to HIV/AIDS-related needs but also to the broader health needs of young Roma. As a result, the Government is committed to providing free, youth-friendly primary health services (YFHS) across the country, offering information on sexual and reproductive health and referrals. Young Roma have been involved in developing protocols and standards for YFHS appropriate to their needs and circumstances, and a set of rights-based principles for use in YFHS has been promulgated. As a result, access to YFHS will be increased. UNICEF and partners continue to advocate for staff training programmes to be systematized by the health, education and social protection systems. This is critical if quality services are to be provided to vulnerable adolescents over the long term.

4. Working with adolescents who live in settlements Participatory workshops were facilitated by UNICEF, with support and participation from representatives of the Institute of Public Health, the Ministries of Health, Education and Human and Minority Rights, professionals from primary health centres, NGO representatives and young Roma. Along with the workshops and peer-to-peer discussions, 350 home visits were conducted and resulted in an increased number of girls participating in the workshops. UNICEF, in partnership with the youth NGO Forum MNE and the Centre for Roma Initiative, supported continuous, intensive training in project development and report writing, NGO management, human rights, and education and health issues, for 30 RAE adolescents from Podgorica and Niksic, to enhance their knowledge and skills.

MONTENEGRO ÂŠ Silke Steinhilber

Roma adolescents and other youth NGO members have been trained to talk to their peers about HIV and reproductive health and inform them about YFHS. Some 500 young Roma have been reached through this approach, which has proved effective and popular with adolescents and their parents. In December 2010, young Roma helped to establish Montenegroâ&#x20AC;&#x2122;s first Roma youth NGOs (one in Podgorica and one in Niksic) as a means to strengthen community participation among young Roma boys and girls and address their issues of concern.

THE WAY FORWARD The programme has generated a new sense of solidarity, common purpose and nationalcommitment to issues affecting young Roma in Montenegro. A new NGO for Roma youth has been established to increase their participation in planning and implementing programmes, both within and beyond their own community. UNICEF will continue to support communitybased activities with adolescents and their parents, and strengthen the youth NGO and peer education programmes. The aim is to establish youth clubs in all municipalities to bring Roma youth together with their non-Roma peers.

There are many remaining challenges that need to be addressed, including reproductive health issues, violence, family support and child care, and enhancement of active participation by Roma youth, to name a few. As Montenegro moves towards EU accession, resources must be found and political support must be sustained to consolidate and build upon the programmeâ&#x20AC;&#x2122;s success.

“People see us as … I don’t know! They don’t see us. They look at us as criminals, knowing that we use drugs and therefore we are the worst criminals. I think that drug dependence is a disease and we need support, not to be excluded …”

We work with MARIA

in ROMANIA Maria struggles with drug addiction, hepatitis C and many other challenges. UNICEF and partners are working with marginalized young people like Maria to build trust and increase equitable access to community services throughout Romania.

ÂŠ Mugur Varzariu

ROMANIA

MARIA’S STORY Maria lives on the streets of Bucharest. She used to live with her aunt who sent her out to work or beg. Tired of this life, Maria ran away to live on the streets. At 17 years of age Maria has a twoyear-old child who lives in a State Care Placement Centre, but she never visits her. The Romanian Association Against AIDS (ARAS)1 found Maria at the city’s railway station a year ago. She was high from the heroin she had just injected and reluctant to use the services offered by ARAS as she was afraid she would be placed in state care. Maria had once lived in a state protection centre for street children but she felt isolated and vulnerable there – the older girls used to beat her and she could not access drugs, so she ran away. Eventually Maria began to trust the staff from ARAS and she started to visit their drop-in centre. ARAS helped her get her identity papers but it was a long and difficult process as she would only come to the centre occasionally – usually high on drugs. Eventu-

ally Maria agreed to undergo detoxification treatment (the only service available to minors) but after a month in hospital she learned that she has hepatitis C. Maria is back on the streets ... she wants to stay clean, but with all her friends using drugs and with no place to go her options are limited. She hopes to start substitution treatment when she turns 18.

THE APPROACH UNICEF Romania has focused in recent years on prevention among at-risk and especially vulnerable young injecting drug users (IDUs), female sex workers (FSWs) and men who have sex with men (MSM), in Bucharest, Iasi, Constanta and Timisoara. The work with local partners has centred upon a three-pronged strategic approach that includes: • building support for targeted HIV prevention for most-at-risk-adolescents (MARA) at national and community levels • improving the quality of health and social services • piloting interventions linked to drop-in centres, outreach activities, HIV testing and counseling (HTC), and medical and social services.

The following are some of the results from UNICEF and partner programming among MARA in Romania: • Baseline research conducted in 20082 confirmed high rates of risk behaviour. Especially striking was overlapping risk and vulnerability among IDU and FSW populations (see Data At-A-Glance). • Advocacy led to the inclusion of marginalized adolescents in the proposed 2011–2015 National AIDS Strategy. • Standards, protocols and a training curriculum were developed to ensure that services reached adolescents effectively. • Pharmacists and social service providers were trained to refer and work with MARA and other vulnerable adolescents. • A voucher system was developed to increase access to and use of health and social

ROMANIA

services, including child protection services. • Evaluation research conducted in 20103 showed that projects intended for MARA are considered to be efficient and relevant to the specific needs of these groups (IDUs, FSWs, MSM) both by beneficiaries and by those who have managed the projects on behalf of each of the eight organizations involved. Community-based services were effective in reaching over 1000 MARA and other vulnerable adolescents. Of these, 200 were tested for HIV and counselled. Pilot medical–social services served over 500 young clients. However, changes in the political environment led to delays in addressing laws that require parental consent for minors to access testing, counselling and other services. The political situation and economic crisis limited government involvement in the programme overall, thus hindering efforts to integrate MARA programming into national plans, budgets and systems. The programme has shown that government leadership is critical if programmes and interventions are to be sustained and taken to scale. During initial consultations with government and civil society, UNICEF and partners decided to investigate risk behaviours and the extent to which existing services were addressing the needs of young IDUs and FSWs. Recent data show that 15–24-yearolds account for almost 50% of new cases of HIV. The Faculty of Sociology and Social Work of the University of Bucharest conducted a baseline study during 2008 among 300 IDUs aged 10–24 in Bucharest, and 295 FSWs aged 10–24 in Bucharest, Constanta, Iasi and Timisoara2. The study showed that: • IDUs and FSWs are at high risk of HIV infection, and their level of risk increases as their age decreases. • adolescents do not use harm reduction services as often as older injectors

• younger FSWs are less likely than older FSWs to use condoms consistently with commercial and casual partners. The data also demonstrated the overlap between sex work and injecting drug use and confirmed that being Roma increases the likelihood of practicing risk behaviours.

DATA AT A GLANCE Research among FSWs and IDUs under age 24 • 6% of IDUs and 20% of FSWs surveyed were under age 18; over one-quarter (29% and 27% respectively) in each sample were Roma – 3 times more than in the general population. • Nearly one-quarter (22%) of FSWs surveyed said they inject drugs. • Younger IDUs, FSWs and respondents of Roma ethnicity had less knowledge about HIV transmission and available services than their older counterparts. • Adolescent IDUs were more likely to have shared equipment during the previous month than those over 18 (26% vs 19%), and less likely to have accessed outreach and/or needle-exchange services. • 41% of steady sexual partners of IDUs were injecting drug users. • 23% of FSWs had partners who inject drugs. • More than one-third of FSWs and 14% of IDUs did not have identity papers – reducing their access to health and social services.

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THE PROGRAMME There were some encouraging findings. One was that adolescents had lower rates of anal sex and injecting drug use than their adult counterparts. This suggests there is an opportunity for early health promotion interventions that would prevent initiation of risk behaviours. An assessment of existing services confirmed that Romania has a strong network of NGOs providing HIV prevention and harm reduction services which have good experience of working with IDUs. However, legal restrictions on providing services to adolescents without parental consent limit NGOs’ ability and willingness to openly provide appropriate services to them. Although UNICEF tried to advocate for a review of policies that would facilitate improved access to prevention, care and support services for younger populations, political instability made revision of laws impossible. In order to avoid problems with authorities, NGOs working with MARA in Romania, as in many other countries, tend to use unique codes for all beneficiaries, without asking for identity data and while adhering to principles of confidentiality.

Baseline data showing risks and the overlap between sex work and injecting drug use meant that comprehensive services had to be developed for both FSWs and IDUs. As a result, UNICEF and NGO partners focused on: • building support for targeted HIV prevention for MARA at national and community levels • improving the quality of medical and social services for adolescents • piloting interventions to increase adolescents’ access to services. Partners for the work have included: Ministry of Health; Ministry of Interior and Administration (National Antidrug Agency); Ministry of Labour, Family and Social Protection (National Authority for the Protection of Child Rights); General Directorates for Social Assistance and Child Protection; and eight NGO partners – the Romanian Harm Reduction Network (RHRN)4; Accept5; Aliat6; Integration7; ARAS1; Parada8; Samusocial9 and Sastipen10.

1. Building support for targeted HIV prevention UNICEF advocated with central and local authorities to build a better understanding of at-risk adolescents and create a supportive environment for HIV prevention and harm reduction interventions. As a result of UNICEF advocacy efforts, the draft National HIV/AIDS Strategy 2011â&#x20AC;&#x201C;2015 includes a chapter on MARA. Data from the baseline studies and lessons learned from programming were used to inform the chapter, which sets out actions to develop, and provides communication strategies and services tailored to at-risk adolescents. UNICEF facilitated regional advocacy meetings with government partners, the police, media, pharmacists, at-risk adults and adolescents, parents and service providers, to address HIV and harm reduction. Special sessions on the stigma

and discrimination experienced by MARA were included. Participants identified priorities and developed action plans based on the research findings and local capacity to respond. 2. Improving the quality of medical and social services National partners developed standards and protocols to help ensure equity and quality of HIV/STI services for young people, including at harm reduction drop-in centres and in needleexchange programmes, HIV counselling and testing, outreach and interventions for FSWs. Guidelines for outreach, drop-in centres and substitution treatment for IDUs and FSWs were adapted to include MARA. A capacity assessment of services for MARA was undertaken. The assessment reviewed

medical and social units, state institutions and NGOs. It found that both state and NGO services had been affected by the political and economic situation and the lack of funding. A training curriculum on providing services, including VCT, to at-risk adolescents was developed, and professionals from the health and child protection sectors were trained. A study on access to sterile injecting equipment and opioid substitution medication in pharmacies was developed and certified by the College of Pharmacists11. Attitudes, knowledge and practices of Bucharest pharmacists regarding injecting equipment and opioid substitution treatment were assessed. It was recommended that pharmacists be involved more explicitly in developing services for IDUs, that is, access to sterile injecting equipment and availability of drug substitution treatment, with prescriptions from physicians

Pharmacists were trained to support prevention and appropriate counseling and harm reduction approaches for adolescent IDUs. A manual and guidelines on harm reduction for pharmacists was developed. Both documents were certified by the College of Pharmacists – a training-of-trainers curriculum was developed and credited with 64 hours of continuous pharmaceutical education, thus ensuring its integration into the broader education system. A database was set up to monitor adolescent use of harm reduction and HIV prevention services provided by NGOs. Managed by RHRN, the database includes information on age, sex, services received (syringes, condoms, medical and social assistance), areas where clients live, and HIV/HVB/HCV test results. A coded system was established to protect the identity of clients. The database serves as an important advocacy tool that holds information on the number and typology of clients seen – providing tangible evidence that MARA do exist, highlighting the problems they are dealing with and showing which services they need. 3. Piloting interventions to increase adolescents’ access to services The work by UNICEF and partners brought government service providers from the health and social sectors together with representatives of eight NGOs to see how appropriate HIV prevention services, including harm reduction, could be provided to marginalized adolescents in four cities. Outreach activities supported by the Global Fund were adapted to respond to adolescent IDUs, FSWs and MSM in Bucharest, Iasi, Constanta and Timisoara. A new drop-in centre was set up in a Roma community, one of the poorest communities in Bucharest. The drop-in centre was developed in partnership with the United Nations Office on Drugs and Crime (UNODC.) The centre provides adolescents and vulnerable young people with

ROMANIA

specialized in addiction.

harm reduction services, medical assistance for emergency situations, and social services, including psychological counselling and support in obtaining identity papers and increasing school enrolment. In all, 507 clients were seen between January and June 2010, all of whom were adolescents. Another, pre-existing centre was adapted to better serve adolescents. Special emphasis was placed on reaching socially excluded adolescents, including those living and working on the streets. Services included social assistance and psychological support, access to treatment, and HIV, Hepatitis B and C counselling and testing. During 2010, drop-in centres and outreach activities reached 1072 young people aged 15–24. The services focused mainly on primary medical care of infected wounds due to injecting, general medical check-ups, and social services adapted to clients’ needs, including support to obtain ID papers. Clients were also referred to specialized medical services.

Monitoring data collected through the voucher system included:

Piloting the voucher referral system to increase equitable access to services

“The syringes were very useful because I didn’t have to use someone else’s, I didn’t have to beg for money to buy a syringe, the vial was mine and I didn’t share it with anybody and that helped me a great deal. I stopped picking paper off the ground to wipe my arm and get infected; instead I have gauze swabs, stuff like this.” 14-year-old IDU

Of all the young clients seen, 200 (153 female and 47 male) requested HIV counselling and testing, 28 of whom were under age 18. HIV tests were provided by partner NGOs.

UNICEF collaborated with medical and child protection services to pilot a voucher referral system aimed at increasing access by MARA to a range of health and social services. The voucher system was coordinated by ARAS and implemented by seven NGOs, in partnership with service providers at hospitals, clinics and child protection departments. When outreach workers or staff at drop-in centres identified a prospective referral client, the client was given a voucher to present to providers at relevant services. The voucher included information on the client’s age, sex, health issues and referral source. The system used outreach workers to accompany young clients to meet health and social services staff who were trained and sensitized to provide appropriate and friendly services to adolescents. By monitoring voucher use, programme implementers were able to identify barriers that MARA encountered in accessing services.

• routine project data from referring institutions and referral sites • data from client interviews conducted with MARA • data from interviews with service providers • results of quality-of-care “spot checks” undertaken at referral sites • case studies documenting project experience. ARAS analyzed vouchers from hospital and clinic service providers, confirming that more at-risk populations were accessing the services as a result of targeted interventions. Nevertheless, the voucher project encountered significant challenges. At the service level,clients lost their vouchers, which interrupted service provision. At the systems level, access to medical care remained limited since laws require that clients show identity papers and proof of medical insurance before services can be provided. Even when service providers were open to assisting MARA, they could not overlook the fundamental problem that their own medical costs would not be reimbursed if they treated at-risk adolescents who did not have identity or insurance documents. The voucher referral experience showed that, despite best efforts, legislative changes are needed to enable adolescents to access medical treatment (including HIV testing and counseling) without parental consent and without medical insurance.

UNICEF HIV Consultant

An evaluation of the MARA programme in Romania3 was carried out in 2010. A monitoring framework12 was used to assess results, including the relevance, effectiveness, efficiency and sustainability of harm reduction services for MARA, as well as referrals to specialised medical and social services. The evaluation showed the following: • All beneficiaries claimed that the support offered was useful and met their needs. Beneficiaries had good or very good opinions about service delivery conditions and the staff who provided these services (social workers, nurses, doctors, psychologists and outreach workers). • MARA knowledge about their own health and available services increased. Adolescents also reported that they felt empowered as a result of relationships formed with outreach workers and service providers at the drop-in centres. • From NGOs’ and other partners’ perspectives, without technical and financial support from the State, MARA project sustainability will be weak. If such projects were to stop, the short- and long-term effects would be extremely detrimental to

“Legislative barriers made it difficult for NGO staff to work with young clients under 18 years of age. “Considering this, more advocacy is needed to remove policy restrictions and parental consent requirements that restrict access to services.”

MARA and to the society as a whole, leading to increases in rates of HIV/AIDS, hepatitis B and C, and other STIs. Changes in the political environment, along with the economic crisis, have had a profound effect on programming for MARA, as implementation rates have been affected by events beyond the control of service providers and NGO programme managers. Changes in staff at the Ministry of Health and shifting political priorities delayed the adoption of the National AIDS Strategy 2008– 2013. This in turn hindered efforts to integrate MARA programming into national plans, budgets and systems. The fluid political situation also delayed the validation of standards and protocols for outreach, drop-in, and counselling and testing services which include a focus on MARA.

ROMANIA

THE WAY FORWARD Programming experience has shown that government leadership is critical if prevention interventions for MARA and vulnerable young people are to be sustained and taken to scale. UNICEF will continue to advocate that MARA be kept on the national HIV/AIDS agenda in Romania. As the epidemic evolves, political commitment and sustained support to the response to the epidemic will be essential.

Given the strength and long history of provision of community-based HIV prevention, care and treatment services by NGOs in Romania, UNICEF will continue working to strengthen partnerships between government and civil society organizations and to ensure the inclusion of adolescents in programming. MARA interventions have been ensured, at least in the short term, owing to inclusion of MARA as a target group within a programme funded through European Union Structural Funds, implemented by a consortium of NGOs and supported in part by UNICEF.

“Had it not been for these people from the Centre for Youth Integration, who knows where I would have ended up?”

We work with MIRELA

in SERBIA © Sladjana Stankovic

Mirela, a 17-year-old Roma, attends a drop-in centre for marginalized, “street-involved” children in Belgrade, Serbia. She has benefitted from the HIV and Hepatitis Prevention services provided by the Centre for Youth Integration (CYI)1, supported by the Youth of JAZAS2 organisation and UNICEF. Thanks to the motivational, educational and psychological support from the centre, Mirela has resolved not to adopt her family’s lifestyle.

ÂŠ Sladjana Stankovic

SERBIA

MIRELA’S STORY Mirela has learned to cope with challenges that would make even the strongest among us give up hope. She manages to support her entire family, including her mother, her older brother who is a heroin addict, and a sister who is a sex trafficking victim and also a drug user. Because of her family situation, Mirela is exposed daily to the risks of HIV, and hepatitis B and C infection. “You don’t see parents like mine every day, parents who don’t care,” Mirela says. “Had I not been smart myself, I would have ended up like my sister. She has been sleeping on the streets and sniffing glue since she was a kid. She started to work ‘down the street’ and sell her body when she was nine. The idea that she could get ill and die never occurred to her. Her first husband dragged her into the street to sleep with other men for money. Now, she has plenty of men. It breaks my heart to watch her walking, all doped up and other people touching her. Even while pregnant, she was doped every day.”

Now 16, Mirela’s sister Danijela is already the mother of a sixmonth-old baby and is pregnant again. Social workers have taken away the baby, since Mirela was the only one taking care of the child in their cottage in an unsanitary settlement in Belgrade. “When I was a little girl, I used to wash wind-shields at the traffic lights. Now, I do cleaning as well. That is how I make money to buy bread for the whole family,” Mirela says. Her older brother (19) also had two children taken into care by social workers. He beats Mirela every day, which is why she sometimes runs away and sleeps in the street, thus facing additional risks. “We were hungry, and I worked to make money for his children as well. Still, I’m never good enough. He washes wind-shields every day but only to buy drugs, and he beats me if there is no bread at home. My brother does not want to be helped,” she explains, tears falling down her cheeks. Her brother and sister reject any kind of professional assistance. Until recently, Mirela herself was constantly vulnerable to direct risks – to try drugs or get involved in trafficking.

Three years ago, when the CYI1 field activists found her, Mirela had lost faith in people, and was unwilling to communicate with outsiders. Only recently did she come to the drop-in centre for “street-involved” children, and she gradually became involved in the centre’s HIV and Hepatitis Prevention, Drop-In and Outreach services, initiated by CYI and supported by Youth of JAZAS2 organisation and UNICEF. Following a series of motivational and educational sessions, combined with psychological support provided by the education officers and psychologists at CYI, she gave up the idea of adopting her family’s lifestyle.

Mirela has no documents, not one paper that proves legally that she exists. She never had the chance to attend elementary school, or to use health care services. Getting a medical check-up meant taking money from the food budget. Naturally, she had medical treatment only when it was absolutely necessary. All she hopes for now is to get an ID card, with the help of CYI and UNICEF, and become a Serbian citizen, entitled to health care and work.

SERBIA

THE APPROACH Serbia has low HIV prevalence (0.1%); HIV affects mainly select, at-risk populations. In partnership with the Ministry of Health, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and other partners, UNICEF has worked to prevent new infections among excluded adolescents – “social ghosts” marginalized or stigmatised by society – including those who live and work on the streets, and adolescents who inject drugs (IDUs). Initial assessments confirmed a dearth of data on at-risk adolescents, a lack of ethical guidance for research and programming for adolescents, the absence of appropriate policies and legislation supporting programmes for minors, and weak provider skills for working with at-risk and vulnerable adolescents. Policy makers, researchers, and service providers (even those working with adult, most at-risk populations) had not recognised the need for a specific focus on adolescents. UNICEF and the Ministry of Health conducted baseline research among adolescents who live and work on the streets and those who inject drugs. This included a rapid assessment of 178 children aged 10–19 who were living and working on the streets in three cities in 2007–8. UNICEF also worked with research teams funded by the Global Fund to formally integrate adolescents and young people aged 15–24 into national data collection, bio-behavioural surveillance surveys (BBS) and interventions intended for most-at-risk populations. The research confirmed that risk behaviours start in adolescence and that adolescents living and working on the streets are especially vulnerable to HIV and other risks.

“We had to open their eyes and ears to [at-risk] adolescents.” UNICEF Programme Specialist

DATA AT A GLANCE Research among 178 at-risk 10–19-year-olds living and working on city streets • 70% had used marijuana, 40% had sniffed glue, • • • •

15% of boys and 12% of girls had injected heroin. 17% of boys and 57% of girls had sold sex. One-third of girls and 16% of boys had never attended school. One-third had come into contact with the police. Approximately one-third had lived in and run away from an institution.

Research among 248 15–24-year-old IDUs3 in Belgrade, Novi Sad and Nis5 • 50% of respondents were Roma, compared with 10% of all IDUs (10% of all IDUs in the three cities are Roma). • One-third started injecting drugs before age 18. • 35% had shared needles during the previous month. • Younger injectors were less likely than older injectors to use outreach and needle-exchange services (4.8% vs 24.7%) and more likely to obtain needles from acquaintances.

SERBIA

THE PROGRAMME Research findings were used to develop new programmes providing medical and social support to at-risk and vulnerable adolescents in Belgrade and Nis. UNICEF worked with the Serbian Government, the Global Fund and NGO partners to: • advocate for revised laws and strategies to support and protect at-risk and vulnerable adolescents • adapt laws to improve adolescents’ access to services • revise research, surveillance and monitoring systems to routinely include adolescents • strengthen the capacity of stakeholders to respond appropriately to the needs of at-risk and vulnerable adolescents • pilot interventions for at-risk and vulnerable adolescents who live/work on the streets, and adolescent IDUs – with a view to nationwide implementation.

1. Advocating for revised laws and strategies Analysis of existing HIV/AIDS policies and legislation showed that laws could be strengthened to provide more equitable access to services for adolescents. UNICEF therefore advocated intensively to revise legislation related to HIV/AIDS and adolescents and to integrate adolescents into the National AIDS Strategy4. This resulted in greater appreciation by policy makers and programme planners of the need to ensure ethical, rights-based approaches. Consequently: Most-at-risk and vulnerable adolescents are included as priority populations in the National HIV/AIDS Strategy 2011–2015. The strategy stresses the importance of early risk identification and reducing vulnerability (eg, by keeping children in school and providing appropriate community support services.)

Issues of concern to adolescents are incorporated within a developing legal framework to protect MARA (including laws on health protection, social protection, health insurance, mental health and substance use.) For example, UNICEF and partners advocated to increase the age at which health insurance coverage is provided to adolescents from 15 to 18 to increase opportunities for adolescents, especially those most at risk, to obtain proper health care. A Codex on Ethics in Research and a National Guide on HIV Programming Among Adolescents were developed and endorsed by the government. Methodological guidance for the health care of women, children and young people was strengthened to help providers to recognize early health-

related risks among adolescents, especially focusing on those most at risk. The guidance includes national accredited professional training packages on adolescent health, addressing HIV, reproductive health, tobacco, alcohol and drug use (including injecting drug use,) mental health, abuse and neglect, and nutrition. Standards for outreach services to vulnerable and at-risk adolescents await final approval. These complement standards to integrate HIV prevention into existing outreach services and drop-in centres for most-at-risk populations (including adolescents,) and promote a case management approach that ensures access and coordination across health and social service sectors.

2. Strengthening the capacity of key stakeholders Significant investment was made in training stakeholders. â&#x20AC;˘ In all, 247 young people, researchers, planners, and government and NGO service providers have been trained to develop and support gender-sensitive responses for at-risk and vulnerable adolescents. â&#x20AC;˘ Capacity building has strengthened provider skills to provide substance abuse services â&#x20AC;&#x201C; to assess risk, adhere to ethical guidelines and provide counselling to adolescents.

3. Piloting interventions for at-risk and vulnerable adolescents Since 2010 UNICEF and partners have supported HIV prevention interventions for adolescents 10–19 years old who live and/or work on the streets, and others who inject drugs. • Working with socially excluded 10–19-year-olds who live and work on the streets of Belgrade and Nis has revealed many of the challenges these adolescents face. Some are alcohol and drug users, some are sexually exploited and selling sex, some have parents who are drug users or sex workers. Such “social ghosts,” many of whom live without proper documentation, a social security number and adequate family support, are excluded from social, health and education services. UNICEF and partners have found that, in addition to addressing risk behaviours, standards for outreach need to ensure referrals to services and programmes that address citizenship, housing, health insurance, education and other important protection areas. • Working from CYI in Belgrade and the Children’s Help Centre in Nis, trained staff provide outreach services in the field, including risk assessment, referrals, information sharing, and educational activities where possible. They also introduce young people to drop-in centres where they can rest, eat, wash and change their clothes, attend creative and educational programmes, or spend the night in case of an emergency. The centres also provide more comprehensive and structured education on HIV, hepatitis B and C and STIs, prevention and treatment for substance use, health and medical services, referrals for HIV testing, condoms, social protection measures and assistance in obtaining identity documents.

“Interventions are based on principles of voluntarism, non-judgemental attitudes and participation ... providing a link to a better life, support for change, integration into society and hope for the future. However, without supportive health, education and social services the scope of outreach and drop-in services remains limited.” UNICEF Programme Specialist

SERBIA © Zoran Jovanovic Maccak

• The Veza NGO’s6 harm reduction programme in Belgrade provides a drop-in service and needle-exchange programme for IDUs of all ages, including those aged 15–21. Following new ethical and normative guidance on harm reduction programmes for those under 18, in addition to the Convention on the Rights of the Child, needle-exchange programmes in Serbia must be linked to a comprehensive package of services including drug cessation treatment. This innovative programme offers group education on HIV, hepatitis B and C and STIs; information on safe injecting and harm reduction; motivation to attend treatment; individual counselling; and assistance in navigating relationships with family members and the authorities. Referral services focus on general health and HIV testing and counselling, but assistance is also given to obtain identity documents, access health insurance and education opportunities, and find a job.

THE WAY FORWARD Programming by UNICEF and partners in Serbia has shown that intensive advocacy can strengthen and link social and health systems to better enable them to meet the needs of most-at-risk and vulnerable adolescents. Laws have been revised to remove barriers to services, and sustainable options for long-term funding have been secured. Equally importantly, interventions that touch the lives of adolescents in desperate need have begun to build trust among such clients and have generated important lessons for future expansion. The programme has recognised that these interventions cannot be developed in isolation – civil society and government must join forces; health and social services must work together. Now that political and other stakeholders have glimpsed the impact of this innovative programming on these young, disadvantaged and marginalized “social ghosts,” their continued support is critical if the work is to be scaled up and sustained.

â&#x20AC;&#x153;My mother was a drunkard and made me beg. When she died I was put in the orphanage in Cherkassy. I ran away from there because it was boring and the other boys harassed me.â&#x20AC;?

We work with VIKTOR

in UKRAINE Victor, a 14-year-old homeless orphan, has survived repeated trauma during his short life. As part of a community at high risk of HIV and other infections, he is relieved to have been tested and proven not to have the virus. Now he has the chance of an easier future as a healthy working adult.

ÂŠ Michal Novotny

UKRAINE

VIKTOR’S STORY Social workers first met 14-year-old Viktor at the scrap metal and glass dump in Kiev that is something like a home to him. The temporary shelter he’d shared there with other homeless adolescents had burned to the ground. “I was sleeping in the fridge at the time,” Viktor said. “I woke up because there was all this foam around me. Freon had leaked out of the fridge. There was a lot of smoke, everything was black ... I escaped through the roof before the firemen arrived.” This was his second lucky escape from a fire. Some years ago he saw his mother, an alcoholic, die after she fell asleep in bed with a burning cigarette. Viktor had awoken to find the house on fire; he tried but failed to rescue her. “My mother was a drunkard and made me beg. When she died I was put in the orphanage in Cherkassy. I ran away from there because it was boring and the other boys harassed me,” he said. Since then, he’s lived on the street. Viktor is an orphan. He knows

that his older brother, Lyosha, lives “somewhere in America … He probably doesn’t even know our mother died,” he says. Now, he has fallen in love with a girl called Angela. “She isn’t from our circle. She has a family and goes to her grandmother for vacation.” Viktor hopes to see her again later in the summer. At the drop-off facility where he hangs out, the workers give the homeless children food, allow them to watch TV and pay them a little money for odd jobs. A truck full of empty bottles arrives and Viktor is called over to count them. Viktor says he has no dreams, but adds that if someone gave him a million dollars he would buy an apartment and live there all by himself for a long time, because he is very tired.

HIV status is not the most important issue for street children such as Viktor. What specialists call “risky behaviour” is simply their way of life. Every child on the street must join a group in order to survive. To be accepted they must behave like the rest of the group, which usually means smoking, drinking, using drugs or sniffing glue. Offering sexual services in exchange for money is widespread. Street children like Viktor are acutely lonely. For many of them, sexual intercourse is like a friendly hug, and so they start their sexual lives early. It’s difficult to change long-established risky lifestyles in this environment, but it is possible to help these children and safeguard them against dangerous infections. That’s why, several times a week, social workers, representatives of NGOs and volunteers come out to plac-

es such as the metal and glass dump in search of the homeless. And after years of determined effort, they now find that children like Viktor are willing to share their experiences. The workers and volunteers talk with these children about the dangers of HIV, sexually transmitted infections (STIs) and other blood-borne diseases. They answer their questions and provide them with some basic necessities, food and condoms. They also distribute information about HIV, syphilis and other venereal diseases, and give them details of charity and social service organisations, hospitals and drop-in centres where they can go and which offer social and medical support, including HIV testing, free condoms, needle exchange and substance abuse counselling.

UKRAINE

THE APPROACH Ukraine has the highest HIV prevalence in Europe (an estimated 1.1% of adults aged 15–49 are living with HIVi.) The virus is mainly found amongst most-at-risk populations, and young people are bearing the brunt of the epidemic. UNICEF began its work with most-at-risk adolescents (MARA) by reviewing existing data1 from over 130 studies already conducted in Ukraine, including national and local surveys, bio-behavioral and sentinel surveillance data and other quantitative and qualitative2 studies3, to gain an initial understanding of which adolescents were at risk. Analysis of findings showed high levels of risk3.

DATA AT A GLANCE Findings from secondary analysis of previous research • Among sex workers, over 19% of 15–19-year-olds and 11% of 15–24-year-olds were living with HIV in 2006, as were 29% of youth who inject drugs (young IDUs) • In 2009, 18% of 15–24-year-olds living on the street were living with HIV. • 30% of adolescent IDUs surveyed had shared needles during the previous month. • 1 in 4 adolescent female IDUs reported selling sex; two-thirds of those had had unsafe sex (at last sex.) • 48% of adolescent female sex workers (FSWs) had had unsafe sex with clients during the previous month. • 1 in 4 adolescent males who had sex with males (MSM) had engaged in unsafe sex. • 22% of IDUs surveyed gave or sold their syringes to others after injecting with them. • 58% of IDUs said they injected with a pre-filled syringe (they did not know how it was pre-filled.)

UNICEF presented its research analysis to stakeholders through intensive regional and national planning processes set up to develop action plans and service models. UNICEF and partners agreed to focus on HIV prevention among adolescent IDUs, young FSWs and adolescents living and working on the streets – an extremely marginalised population among whom risk behaviours were assumed to be widespread. To guide programme planning among adolescents living and working on the street, baseline data were collected in four cities. The results4 were compelling.

DATA AT A GLANCE Research among street children aged 10–194 in Kiev, Donetsk, Dnipropetrovsk and Nikolayev5

• 16% had injected drugs; 45% of these started when under the age of 15 and injected at least weekly. • 61% had shared injecting equipment during the previous month. • 74% had engaged in vaginal sex, including 43% of 10–14-year-olds. • 10% of boys had had penetrative anal sex with men, 52% of these for remuneration. • Over half the girls had exchanged sex for money, food, drugs or other goods. • 18% of girls had been pregnant and 68% of those had had an abortion. • Respondents reported high levels of sexual assault, violence and police harassment.

UKRAINE

THE PROGRAMME The research confirmed that street-based adolescents are at significant risk of HIV through injecting drugs, sharing needles and unprotected sex (whether in personal or commercial exchanges, including male-to-male sex) – behaviours begun at an early age. These young people do not use available HIV prevention and other health services. Barriers to access include the need to have parental consent and documentation, and a lack of provider skills. The study also found high rates of sexual assault, violence, distrust of social services and other authorities, and harassment from the police. Child protection interventions appeared to have reinforced street children’s reluctance to have any contact with authorities.

The Ukrainian Government, UNICEF and partnersii agreed to: • revise legislation that keeps adolescents under 18 from accessing services • incorporate MARA into national strategies and work plans • improve the quality of HIV prevention services and their capacity to respond to at-risk and vulnerable adolescents • pilot interventions for adolescents living and working on the street, adolescent IDUs and adolescent FSWs • strengthen co-operation across the health and social service sectors, and build referral systems. UNICEF facilitated a strategic planning process, overseen by community advisory boards (representing health and social services) and including decision makers, service providers and adolescents to plan the programmatic approach to working with MARA. The boards were later institutionalised at the four intervention sites. Key programmatic approaches included:

1. Establishing a supportive legislative environment UNICEF commissioned a comprehensive review of policies and legislation to identify any legal barriers to adolescents’ access to health care (including HIV prevention) services. Legal experts made recommendations to align national legislation with international laws and policies. UNICEF successfully advocated for a change in the national AIDS law, reducing the age at which an adolescent can be tested for HIV without parental consent, from 18 to 14. The redrafted law was approved by parliament6.

2. Advocating for national strategies and plans to include HIV prevention for MARA A “bottom-up” approach was used to integrate MARA7 into national8 plans9, using UNICEF’s baseline research as the foundation. In response to the research data, local decision makers and stakeholders developed sub-national plans which aligned with the specific needs of adolescents in their cities. This process proved central to the programme’s success; it built an understanding of MARA and other vulnerable adolescents and their needs, and fostered a strong sense of local ownership in the programme. The Ukrainian Government allocated funding for implementation of the plans and made each city’s Coordination Council on HIV/ AIDS and TB responsible for monitoring them.

MARA were included as key target populations in the National HIV/AIDS Programme implementation plan. A National Strategic Action Plan on MARA and Children Affected by HIV, which builds on the sub-national plans, was endorsed by the National Coordination Council on HIV/AIDS and TB. A MARA Stakeholder Group was established within the Ukrainian Government to coordinate work with MARA and oversee the implementation of the Strategic Action Plan. MARA were also included in the National Road Map on Scaling-up Towards Universal Access to HIV/AIDS Prevention, Treatment, Care and Support in Ukraine by 2010. The target for national prevention was set at 60% for “risk groups” including MARA. Significantly, UNICEF also advocated successfully for Ukraine’s national monitoring and surveillance systems to disaggregate data on adolescents by age and gender. Ethical

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“They just take [us] and beat us ... all problems come from the police ... I do not know about any services. Why should I go? What if they will take me to the police station? ... I do not go to the hospital ... they do not talk to the dirty ... without any documents, no services ...” (Street youth, anonymous)

“Preparing the data in such a way and using them also convinced stakeholders of the importance of a sound evidence base for planning and programming and led to the decision within the National M&E Working Group of Ukraine to disaggregate data collected systematically by age (including those under age 18) in the future, so as to further strengthen the evidence base on MARA.” UNICEF MARA Consultant

guidelines on conducting research among minors were prepared, and national monitoring and evaluation (M&E) guidelines and the 2009 HIV surveillance studies included MARA. In addition, Ukraine’s report to the UN General Assembly Special Session (UNGASS) included indicators on 15–19-year-olds for the first time. 3. Improving the quality and capacity of services Service gaps and training needs were identified.10. A Trainer’s Tool Kit11 was developed, and staff from NGOs, health and social service departments and the police were trained to work with MARA. Protocols for service provision for young people have been approved. These include quality standards on equitable access to services for at-risk and vulnerable adolescents, cross-sectoral communication for effective referrals, and involving young people in service provision. Guidelines on identification and standardsbased service provision to MARA were developed and approved by the Ukrainian Government.

“Service providers did not know what the law said. They were afraid of giving condoms to adolescents. We had to train them and make sure they understood the legal frameworks they were working in so that service providers felt protected and able to provide services.” © G. Pirozzi

UNICEF MARA Consultant

4. Piloting targeted model interventions UNICEF worked with local stakeholders and through the sub-national strategic planning process to design and pilot five different model approaches targeted to three specific groups of adolescents: • FSWs and girls who have been sexually exploited • adolescents living and working on the street • adolescent drug users, including IDUs. Services included HIV testing and counseling (HTC) with follow-up care and support, sexual and reproductive health services, providing information and building life skills, helping

adolescents access available health and social services, reintegrating adolescents into society through enabling their participation in peer-topeer programmes, promoting their participation at community drop-in centre activities, and building their confidence through provision of care and support services. All these were facilitated through outreach, client management and referral systems.

dress the varied needs of adolescents. Thus, all these services found new ways of working together at local, regional and national levels to ensure that at-risk and vulnerable adolescents do not get lost to follow-up when being referred from one place to another.

The programme recognised that a multi-sectoral response is required since no single service provider can provide all the services that at-risk and vulnerable adolescents need. Case management was established to link one-stop-shops and drop-in centres at the pilot sites to health, education, and social protection sectors to ad-

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“Once trust has been established, the children feel free to speak openly about their situation, more willing to try out the services that are available, and ready to learn about HIV and other sexually transmitted infections.”

Kiev City – Street-based HIV prevention with MARA using multidisciplinary teams UNICEF worked with partnersiii to expand existing outreach services for adolescents living and working on the streets in Kiev. The approach involved multidisciplinary teams (MDTs) that promoted trustful relationships to address the complex needs of adolescents involved in substance abuse and commercial sex, as well as many coming from families in crisis situations. Three MDTs, each consisting of a social worker, a psychologist, medical and NGO outreach workers, and supported by a mobile clinic, conducted outreach among adolescents at “hotspots” three evenings per week to provide information, counselling and general support. Adolescents were informed about the programme and asked about their needs. HIV testing and counselling was provided in the mobile clinics and confidential referrals were given to the AIDS Centre and “trust rooms” for confirmatory tests, social and other medical services. Where possible, teams accompanied adolescents to the services. Basic necessities such as food, clothing and shelter were also provided.

UNICEF staff member

UNICEF successfully advocated for the pilot programme to be integrated into the Kiev City Plan on HIV. Funds for the activities were subsequently allocated through the state budget. Ethical standards were developed by the state social services to ensure consistency and quality in outreach activities for MARA. The AllUkrainian Network of People Living with HIV and AIDS, and several other NGO partners, expanded their programmes to accommodate the needs of HIV-positive adolescents. During the first 12 months of the programme, contact was made with 2488 street-based adolescents through outreach. Of these, 1131 received services, including services of the mobile clinic, STI testing, HIV counselling and testing, and information and education about HIV. Of these 1131 adolescents, 661 were boys and 470 were girls; a total of 685 were tested for HIV. Over 400 were referred for follow-up services, including legal, psychosocial, social assistance and other community-based services.

Important lessons have been learned. To take HIV testing to street-based adolescents, there must be well-defined ethical procedures and staff appropriately skilled to provide a range of support. Referral systems must have sufficient capacity for daytime follow-up if they are to be effective. The project also highlighted the need for legal regulations to support services for adolescents in the absence of available parents or guardians. It showed the need for round-the-clock support to meet the basic needs of adolescents living on the streets, including food, clothing, hygiene and shelter. The project showed that MDTs can support the complex needs of adolescents living on the street and that the physical presence of a provider or caring adult to escort clients when referred can make the difference in retaining them within services.

Donetsk â&#x20AC;&#x201C; Connecting adolescent drug users and IDUs with available services UNICEF supported a programme in Donetsk that used outreach activities and a referral system to promote reduced risk behaviour among adolescent IDUs and prevent drug injection amongst adolescent â&#x20AC;&#x153;pre-injectorsâ&#x20AC;? who are already using other drugs. The Donetsk Centre for Social Services had initially planned to support a peer outreach programme to reduce risk behaviours among adolescent IDUs. However, as plans for the pilot evolved it became apparent that the programme would have to expand its mandate. The intermixing between young IDUs and other drug users meant that it would be unrealistic to focus the programme solely on adolescent injectors.

A peer outreach team was established by two experienced outreach workers from NGOs with histories of working with IDUs. The team included former injectors from a local drug rehabilitation centre in the final stage of their rehabilitation. They worked alongside experienced harm reduction service providers. This participatory approach was effective, but the programme found that it had to give additional support to peer educators, helping them deal with the possibility of relapsing back into injecting as they returned to locations where others were doing so. At the same time, the Centre for Social Services set up the second part of the service - a drop-in referral centre called RESPECT. Outreach workers sent their clients to RESPECT which then assessed their needs and, with

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a focus on HIV risk behaviours, referred the adolescents to other services such as needle exchange programmes, the AIDS Centre, the Narcological Dispensary and youth-friendly health centres. A review of the programme showed that adolescent drug users wanted the service to respond to their basic needs for food, safety and hygiene before they could begin to engage in issues around HIV prevention. Programme managers decided to consider how RESPECTâ&#x20AC;&#x2122;s portfolio could be expanded to provide the services required. The review also found that it would be more effective if outreach workers could refer adolescents directly to services rather than channelling them through RESPECT. The Centre for Social Services responded by signing an agreement with the NGO Caritas, which has integrated services for adolescent IDUs and drug users into its Centre for Street Youth in the city. Outreach workers were then able to refer adolescent drug users directly to a drop-in centre that provides health, education and employment services in one place. Preliminary monitoring data suggested that the model worked well, and other cities expressed interest in replicating it at their own cost. During the first 12 months of the service, outreach workers reached 455 adolescents (286 boys and 169 girls). Of these, 109 were identified as IDUs and 177 said they used other psychoactive substances. All received HIV prevention counselling and consultations with social workers. Twenty received general health check-ups by medical workers, while 38 were referred to other services, including needle exchange and other youth-friendly services.

Odessa – HIV prevention and rehabilitation services for sexually exploited adolescent girls UNICEF worked with the Odessa NGO, ‘Faith, Hope, Love’ to pilot a new approach to providing social rehabilitation services to adolescent girls engaged in transactional sex.The programme aimed to take girls off the streets, providing them with a social and psychological rehabilitation course that included HIV risk reduction, livelihood skills and job orientation, to give them opportunities to be assimilated back into society. The programme made full use of the harm reduction services and referral networks that Faith, Hope, Love had already established – the innovation lay in providing a range of services in one, safe place along with comprehensive support through a rehabilitative course for two months.

Outreach workers established relationships with the girls and encouraged them to come to the centre where they could stay for two months. During their time at the centre the girls were offered medical help, life-skillsbased education, psychosocial support, vocational training, legal assistance, leisure activities and support to get back into school. UNICEF supported HIV/AIDS education and STI services within the programme. Fifty girls aged 12–18 stayed at the centre in its first 10 months of operation.

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The pilot programme confirmed the benefits of working with a well-established and respected NGO when dealing with sensitive issues like sexual exploitation and abuse. Faith, Hope, Love was able to use established partnerships and referral systems to increase the girls’ access to a wide range of services. On completing the course, 41 girls were referred to other services within a week. Outreach workers stayed in contact with the girls when they left the centre, providing follow-up support as needed. It became evident, however, that a more structured approach to providing follow-up services needs to be agreed. UNICEF is working with Faith, Hope, Love to develop standards which will give guidance on how to provide services to adolescent girls using this one-stop-shop approach.

Odessa – Integrating HIV prevention education and psychosocial support into state detoxification and rehabilitation services The NGO, ‘The Way Home’ has for many years provided support to adults and young people living and working on the streets of Odessa. With support from UNICEF, The Way Home expanded its regular programming and complemented state services with counselling, psychosocial support and HIV prevention services to adolescents attending the hospital. The programme included three primary goals: to reduce the number of adolescents dropping out of the state medical rehabilitation programme; to reduce HIV risk; and to reintegrate adolescents back into society and keep them off the streets upon their departure from the hospital.

The Way Home’s long and successful history of providing harm reduction and outreach services to IDUs proved invaluable. The NGO brought to the intervention experienced staff used to working with street children, a strong referral network and the capacity to provide follow-up services (such as a halfway house, support for education, employment support and legal advice,) which have been central to the success of the programme. The Odessa State Narcological Hospital collaborated and made two rooms available as “safe spaces.” MDTs from The Way Home attended each day to provide services to adolescent inpatient clients. The Way Home also provided a drop-in service for adolescents referred by the City AIDS Centre, Social Services Department and other NGOs.

UNICEF trained staff from The Way Home to use a case management approach to address the range of problems that make adolescents vulnerable to injecting drugs. In the first 11 months of the programme, 152 adolescents (12–18 years old) were reached. Of these, 56 (53 boys and 3 girls) received the services of the drug treatment and rehabilitation course, including HIV testing and legal services, offered by The Way Home. Notably, none of the 56 went back to the street! Fifteen returned to their families, 10 went into shelters run by The Way Home, five went back to their home countries, 20 went to a halfway house run by The Way Home, and six are working and renting a place to live. Another 119 were referred to various services for counselling, HIV and STI testing, and medical examination.

Nikolayev – Safety for sexually exploited adolescent girls In Nikolayev, UNICEF supported interventions in collaboration with the NGO UNITUS, and forged links between government health and social services, the police and the education sector to provide a safe space for adolescent girls exploited for sex. The programme was funded by UNICEF and the International HIV/AIDS Alliance.

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The programme aimed to pull adolescent girls out of risk situations by changing their behaviour, while adapting health and social services to their needs, making legal and life-skills-building services available to them, and advocating for changes to policies and legislation.

ments, enable emergency calls and provide telephone counselling. This part of the programme proved unexpectedly popular, with the mobile phone proving to be an efficient communication tool. The girls described their risk behaviour more openly and sought advice more proactively on the phone.

Service providers from UNITUS undertook outreach activities and ran a drop-in centre where the girls received counselling, HIV tests, social services, legal advice, harm reduction services, treatment for STIs, condoms, clean needles and syringes, pregnancy tests, products for personal hygiene and referrals to other services as required. Parallel to this, UNITUS worked with child protection services, the police and the education sector to ensure broader support for the girls.

Demand for the service exceeded expectations12. User satisfaction was high and uptake of services increased. When planning the intervention, UNITUS and partners calculated that they could serve about 50 users in the first half of the pilot year. By July, they were serving around 100 young users and in the first 11 months of the programme, 120 adolescent FSWs. At least 35 were referred to relevant services. Of those reached, most (60%) were 17 years old; 22% were 18 years old and 11% were 16 years old. Interestingly, 64% said they studied at various educational institutions and 57% still lived at home12. As a result of limited capacity, and despite needs and requests, UNITUS had to stop recruiting new users.

Mobile phones were used for regular communication between staff from the drop-in centre and the girls, 90% of whom were found to have mobile phones. This allowed staff to keep in contact with the girls, invite them to project events, remind them about appoint-

“The social workers use their own mobile phones to communicate with clients. The work phone of the community centre is publicized as a ‘hot-line’ but clients prefer to call the private phones of social workers. The personal mobile phone of our social worker is our ‘hotline’.” UNICEF staff member

Successful new partnerships were established. When the pilot project started, for example, UNITUS staff had to use their personal contacts with the police to make sure that law enforcement officers would not stop outreach workers from carrying out their duties. Improved collaboration helped the police understand the value of the services UNITUS provides. Police began to refer young women whom they would previously have picked up for engaging in sex work to the UNITUS outreach workers and the drop-in centre, or they called outreach workers to provide support to young women and girls on the spot.

5. Strengthening cross-sectoral cooperation and referral systems The programme in Ukraine recognised that no single service provider can provide all services required to meet the complex and varied needs of at-risk and vulnerable adolescents. Each of these pilots used a case management system to link one-stop-shops and dropin centres to other health, education, and social protection services. All those involved had to find new ways of working together at local, regional and national levels to ensure that atrisk and vulnerable adolescents did not get lost in the system when being referred from one place to another.

THE WAY FORWARD UNICEF is continuing to work with its national partners in Ukraine to scale up coverage and improve access to comprehensive services for MARA and other vulnerable adolescents. This will involve scaling up HIV service interventions during implementation of the National Strategic Action Plan on MARA and Children Affected by HIV. It will see services extending beyond health care to ensure that the socioeconomic and protection needs of at-risk and vulnerable adolescents, including reporting on and addressing violence, are met. UNICEF’s continued leadership on MARA programming in Ukraine includes: • continued policy and advocacy work, including, documentation of implementation results of the model interventions discussed above13 • publication of an important study that determined population size estimates of MARA in Ukraine14 • development of manuals for trainers aimed at preparing service providers and other specialists to address the primary, HIV prevention and psychosocial needs of MARA and other vulnerable adolescents. The manuals include approaches such as case management, motivational counselling, and HIV testing and counseling for MARA.

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ÂŠ G. Pirozzi

UNICEF advocates that state systems focus on MARA by working in partnership with adolescents, placing emphasis on child and human rights, identifying ways to involve adolescents living with HIV, and further institutionalising mechanisms to include MARA and other vulnerable adolescents in planning, implementing and monitoring programmes.

i. UNAIDS Report on the Global AIDS Epidemic 2010. ii. A broad array of national, regional and local govern ment and civil society partners. iii. Kiev City Social Services for Families, Children and Youth. the State health system and local NGOs, including the All-Ukrainian Network of People Living with HIV and AIDS, and the AIDS Foundation East-West.

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MARA PROGRAMME DEVELOPMENT PROCESS AND TOOLS The UNICEF Regional Office (RO) for Central and Eastern Europe Commonwealth of Independent States (CEE/CIS) provided leadership and overall coordination to government and civil society partners and to UNICEF country offices to support the multicountry programming described in this document. This included: • identifying technical resources and providing direct technical support to programme planners and service providers • advocating to build commitment to collect strategic information and develop targeted, evidence-based interventions for most-at-risk adolescents (MARA)

• documenting experiences and sharing lessons learned at regional and international level • mobilizing partners and additional resources for MARA programming . This section provides a look at the MARA programme development process from a regional perspective and features key findings and hyperlinks to many of the tools, guidelines and advocacy documents developed during the programme.

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BUILDING THE EVIDENCE BASE GOALS AND OBJECTIVES Responding to the lack of data on MARA and HIV/AIDS-related services, UNICEF RO contracted the London School of Hygiene and Tropical Medicine (LSHTM) to help country teams with data collection and analysis. Each country collected quantitative baseline data on priority at-risk or vulnerable adolescents. In some cases, qualitative studies were carried out to probe findings in greater depth. (See research reports by country in Reference Section.) In order to allow comparable analysis across countries, partners agreed on a common set of core indicators1 that were in line with existing HIV/AIDS indicators used for reporting on the implementation of the UN General Assembly Declaration of Commitment on HIV/AIDS (UNGASS).

UNICEF used the findings to advocate with government partners, civil society and funding agencies for targeted interventions for MARA and other vulnerable adolescents, aiming to ensure their inclusion in national AIDS strategies and national monitoring systems and their integration into country applications to the Global Fund. UNICEF found stakeholders far more willing to develop interventions for MARA once they understood evidence about their day-to-day realities. A research toolkit: Working Documents for Data Collection Amongst Most-at-Risk Adolescents2 was developed by UNICEF and LSHTM to build capacity of country and other regional teams to carry out research on MARA. The toolkit contains data collection tools, research guidance, core indicators, survey questionnaires, a summary of country findings and tools to guide development of monitoring and evaluation frameworks.

A TYPICAL MARA PROGRAMME DEVELOPMENT PROCESS Below is an outline of some of the key steps that national partners supported by the UNICEF Ukraine office undertook to develop programming for MARA. (These steps are not necessarily sequential and often occurred in parallel.) 1. Review existing data to get an initial understanding of adolescent risk behaviour and vulnerability 2. Use the findings to explain the concept of MARA to key decision makers and build support for targeted interventions 3. Agree with partners on what additional research is needed, for which groups and where 4. Establish community and regional advisory boards (CABs) consisting of stakeholders from health, education and social protection sectors, along with NGO leaders and adolescents to coordinate and oversee research, programme planning and implementation processes 5. Review legislation and identify barriers to service provision for minors; advocate for policies to be revised where necessary 6. Collect and analyze data on target populations; share and discuss the findings widely

7. Conduct a capacity needs assessment and stakeholder analysis to understand which services are already available and what kind of support is needed to enable them to serve MARA 8. Use data to develop regional, gender-sensitive sub-national plans -- including monitoring and evaluation frameworks -- for MARA with stakeholders to ensure MARA access to quality health, education and social support services 9. Implement sub-national plans 10. Build capacity and establish linkages among service providers through effective referral systems 11. Work with outreach workers and MARA to spread information and build demand for services among their peers 12. Advocate with regional advisory boards to have MARA formally integrated into national plans, strategies and monitoring systems, using data and local plans as advocacy tools 13. Use sub-national plans to develop a National Action Plan (NAP) and advocate for national surveillance systems and surveys to include age- and gender-disaggregated data on MARA

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ETHICAL CHALLENGES FOR RESEARCH AND PROGRAMMING AMONG MARA Researchers and programmers faced ethical challenges when working with at-risk and vulnerable adolescents. What procedures apply, for example, when an adolescent is breaking the law? What do researchers do when they uncover confidential information about the abuse of a minor? When are adolescents “competent” to decide, without parental consent, whether a proposed treatment is in their best interest? And how should researchers and programmers deal with adolescents who do not want their parents involved or whose parents cannot or will not provide consent? In every country, these were complex issues that always provoked intense discussions and required careful consideration of the best interests of the child, grounded in the context of their daily lives and keeping in mind national and local legislation.

UNICEF developed two guides to help country teams address the ethics of conducting research, and ethical and protection issues for HIV programming among MARA. Ethical Issues in Conducting Quantitative Research with Adolescents Engaging in HIV Risk Behaviour7, is grounded in the Convention on the Rights of the Child and includes: steps to follow for conducting research with MARA; guidance for ensuring respect, informed consent and confidentiality of adolescents. Ethical and Protection Issues in HIV Programming for Adolescents Engaging in HIV Risk Behaviour8 examines principles to guide programming including protection, informed consent and competence; HIV testing and counseling of MARA and other vulnerable adolescents; and offers ethically challenging scenarios with suggested steps involving specific MARA groups. In Serbia, these guidelines helped to ensure that research was conducted “in the best interest of the child.” Details were provided to parents where possible, psychologists were trained to support adolescent respondents and the questionnaires used language that adolescents felt comfortable with. A referral system was established to link adolescents to emergency health and protection services where necessary. And the national ethical committee ruled that minors could not be tested for HIV unless there are follow-up support services available and tailored to their needs.

A SUMMARY OF COUNTRY RESEARCH ON MARA AND HIV • Albania, BiH, Moldova, Romania and Serbia surveyed IDUs under the age of 24 to compare their behaviour and experiences with older injectors. Romania also surveyed young sex workers. In Ukraine, anyone encountering minors without parental care must inform the authorities, especially in cases of suspected abuse or exploitation. In practice, adolescents revealing information about their abusers can face harmful repercussions. There were fears that the police might use mapping data from research to conduct raids or forcibly remove adolescents from the streets. Local partners adapted the above guidelines to develop a study protocol and principles for research and programming that were approved by the national ethical board. This kept mapping data confidential and researchers were able to refer adolescents to appropriate services where necessary. In all cases, ethical guidance and procedures for research and/ or interventions with MARA should be adapted to local policy environments and approved by the relevant local and national authorities.

• BiH, Moldova, Montenegro, Serbia and Ukraine studied the risk behaviours of vulnerable adolescents: those living in institutions, those living and working on the streets and adolescent Roma. • Moldova and Ukraine undertook qualitative research to deepen their understanding of initial findings on adolescent drug users and sex workers. • Albania, Romania and Ukraine assessed the capacity of existing services to meet the needs of MARA . • Romania and Ukraine developed research frameworks to monitor the results of their interventions.

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where around one-third of IDUs surveyed were under 18, adolescents were more reluctant to obtain clean injecting equipment from exchange programmes, drop-in centres or outreach workers than adults (11% vs 29%). In Serbia, outreach workers or exchange programmes were far more common sources of needles and syringes among older users than younger users (25% vs. 5%); younger users were more likely to obtain needles from acquaintances and adolescents were less likely to have had an HIV test. (Busza, J., Ferencic, N., Nary, P. “Adolescents and

Cross-Country Issues Risk behaviours often start in adolescence. In a multi-country study of IDUs aged 15–24, up to 30% reported being under 15 when they first injected; the mean age in Albania was 15.6 years, in Moldova 17.5 years, in Romania 16 years and in Serbia 18.7 years. (Injecting Behavior

and Service use among Young IDU in Albania, Moldova, Romania and Serbia-Abstract-20123)

Young drug users have poorer access to harm reduction services and often take greater risks. Among Romanian IDUs surveyed, 26% of those under 18 had shared injecting equipment during the previous month, compared with fewer than 20% of those over 18. In Moldova,

Risk in Eastern Europe: Assessing Harm Reduction Needs.” Presentation to the International Harm Reduction Association Annual Conference, Bangkok, 20094)

Routine police harassment affects service provision and is a barrier to trust. Routine police harassment often discourages adolescents from contacting services. Female sex workers (FSWs ) in Romania reported the highest rates of police harassment (87%), followed by IDUs in Romania (76%), street children in Ukraine (74%), IDUs in Serbia (61%) and IDUs in Moldova (48%).(Police harassment of most-at-risk young people in Eastern Europe-Abstract-U.K. 20105)

Getting syringes from pharmacies, needle exchange programmes (NEPs) and outreach services reduces the risk of sharing needles, when compared with obtaining syringes on the street. IDUs in Moldova were 6.5 times more likely to share if they got syringes on the street rather than from pharmacies and/or NEPs. In Romania, IDUs who used a variety of sources, including the street, were three times more likely to share than IDUs who relied exclusively on pharmacies and/or NEPs. The figures were similar in Serbia. Police harassment increases the chances of needle sharing. At-risk adolescents and young adults report high levels of police harassment and detention. Half of all respondents in Albania and Serbia, 28.8% in Romania, and 13.8% in Moldova reported having been in prison or juvenile detention. Three-quarters of IDUs in Romania and half the IDUs in Moldova said they had been harassed by the police in the last year. In three of these four countries (Albania, Moldova and Romania) contact with the police or being incarcerated increased the odds of syringe sharing. IDUs in Moldova who had been incarcerated were 5.5 times more likely to share needles than IDUs who had not been incarcerated (Busza, Ferencic and Nary, cited above). In Romania, 22% of IDUs reporting police harassment or arrest during the past year had shared injecting equipment during the previous month, compared with 8.6% of IDUs who had not faced harassment or arrest. (Police harassment of most-at-risk young people in Eastern Europe-Abstract-U.K. 20105) The source of injecting equipment matters. Analysis of data from studies of young IDUs showed that the source of syringes is linked to injecting behaviour in three of the four countries included â&#x20AC;&#x201C; Moldova, Romania and Serbia.

Roma are represented disproportionately among at-risk populations. Baseline studies in Albania, Serbia and Romania showed that young Roma are more likely to be engaged in risk behaviours. In Romania, 27% of surveyed FSWs and 29% of IDUs self-identified as Roma, even though Roma account for only 2â&#x20AC;&#x201C;7% of the population. In Albania, Roma IDUs began injecting roughly two years earlier than non-Roma and were less likely to obtain clean injecting equipment from pharmacies. (Albania, Serbia, Romania Baseline Studies) Local drugs markets affect risk taking. Drug-taking patterns in Albania, Moldova and Serbia were assessed to help understand when and why young people choose to inject drugs. This information was needed to assess the potential of interventions like Break the Cycle which aims to prevent initiation of injecting amongst adolescents. The quality of heroin was poor in Moldova and Serbia, so users opted to inject the drug, and better in Albania, where users tended to smoke, sniff or inject it. A comparison of the three countries concluded that patterns of heroin use in Albania offered a window to implement Break the Cycle. This was not the case in Moldova and Serbia. (Break the Cycle: Opportunities and challenges for preventing initiation into injecting in Eastern Europe-U.K. -20106)

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ADVOCATING TO BUILD NATIONAL OWNERSHIP AND COMMITMENT Each country spent time and resources advocating for governments and civil society partners to include MARA in their plans, strategies, budgets, surveillance systems and monitoring frameworks. Most partners were unaware of problems related to MARA and HIV, reluctant to work with children or prejudiced by disapproval of the behaviours to be addressed. UNICEF brought together government, civil society, funding partners (including the Global Fund) and young people to explain the concepts around MARA and HIV and the need for targeted responses. Discussions focused on the newly-gathered data and their implications for the needs of MARA. Training helped ensure that partners had the skills to develop sustainable and gender sensitive responses. Ongoing advocacy resulted in intensified dialogue around MARA issues among all partners; increased media attention to MARA;

and a shift within some services originally designed for adult most-at-risk populations, toward greater attention to the needs of the younger cohorts of their beneficiaries. In seven countries MARA were included in national AIDS strategies. Several countries developed national action plans for MARA. BiH, Moldova, Serbia and Ukraine included MARA in their applications to the Global Fund to Fight AIDS, TB and Malaria. Advocacy also generated discussions on laws and policies affecting access to services and support for MARA. Laws were revised, lowering the age at which parental consent is required for HIV testing in BiH and Ukraine, and addressing drug-related issues in Albania, Moldova and Serbia. Advocacy around HIV issues also led to an increasing recognition of the needs of vulnerable adolescents by programmes dealing with child protection and juvenile justice.

UNICEF’s advocacy focused on: • convincing policy makers and service providers of the need for targeted prevention, care and support services and interventions for MARA • revising laws and policies that prevent the provision of services to MARA and other vulnerable adolescents • promoting inclusion of MARA in national AIDS strategies, monitoring plans and surveillance systems • changing the way health, education and social protection systems work together through strengthened referral systems • integrating service provider training activities into national training curricula • securing additional resources for MARA programming. MARA work in CEE/CIS has been recognized outside the Region. In Asia, UNICEF’s Asia–Pacific Shared Service Center developed a course on most-at-risk young people (MARYP,) “Understanding the Needs of Vulnerable and Most at Risk Adolescents and Young People in Concentrated and Low Prevalence HIV Epidemics: A Short Course for Policy Makers, Programmers and Providers in the Asia Pacific,”9 in partnership with the University of Melbourne. The United Nations Fund for Population Activities (UNFPA) developed a course: “Training-of-Trainers Course Providing Comprehensive Sexual and Reproductive Health Services for Mostat-Risk Adolescents and Young People.”10 And UNICEF’s Global Guidance Briefs on HIV Interventions for Young People11 include guidance based on experiences from UNICEF and partner programming for MARA.

UNICEF Regional Office for CEE/CIS developed advocacy documents highlighting programming challenges and calling for targeted responses. In particular, “Blame & Banishment - The underground HIV Epidemic affecting children in Eastern Europe and Central Asia,”12 was launched by UNICEF Executive Director Anthony Lake at the 2010 Vienna International AIDS Conference and helped to raise funds for Moldova, Ukraine, Kazakhstan, Uzbekistan, Georgia and Serbia. The advocacy process was labour-intensive and time consuming. Nevertheless, UNICEF and partner experience has affirmed that MARA programmes that lack the support and ownership of Government will have limited and short-lived success. MARA issues are politically hard to acknowledge and difficult to address through services and programmes. Governments and civil society organizations have limited funds, competing priorities and potentially prejudicial attitudes that cannot be ignored. The needs of MARA and other socially excluded adolescents will only be met if governments are committed to intervening to support them.

friendly” HIV prevention services, including HIV testing and counseling (HTC,) harm-reduction and psychosocial support services.

BUILDING SYSTEMS AND SERVICES FOR MARA AND OTHER VULNERABLE ADOLESCENTS In many countries of the Region, government health and social service systems tend to operate in isolation from each other, using different approaches and failing to pool their skills and facilities to serve the same populations. For example, there are limited referral mechanisms where social workers can refer adolescents to legal or psychological care. In most countries, there is also limited cooperation between civil society and government partners. Furthermore, organizations working on HIV with most-at-risk populations in the region tend to work primarily with adults. UNICEF was surprised at the low level of service providers’ and programme planners’ capacity and willingness to work with MARA. Capacity-building was incorporated into every element of programming for MARA at country and regional levels to enable policy makers, researchers, programme planners, service providers, young outreach workers and peer educators to provide “MARA-

A number of guidance documents, including a “Capacity Assessment Tool for Organizations working with Most-atRisk Adolescents”13, a “Manual on Programming to Prevent HIV in Most at-risk Adolescents”14 as well as tools to guide research (see reference section1,2,7,15) were developed to strengthen the capacity of programme managers and service providers from youth-friendly health centres, harm-reduction and outreach programmes to work with MARA and other socially excluded adolescents. Country teams were supported in analyzing strategic information and planning appropriate interventions to respond to the needs of MARA. Local plans were developed and coordination mechanisms, including community action boards (CABs,) were created to oversee their implementation. Cross-sectoral partnerships, referral systems and case management approaches were developed to help health, education and social welfare departments work more effectively together. UNICEF successfully advocated with government partners in Moldova, Serbia and Ukraine to change the structure of health and social welfare systems to provide more comprehensive services. Romania and Ukraine undertook intervention research to monitor service delivery and track progress. Programme assessments suggest that the interventions were successful in reaching and addressing MARA needs (see descriptions of all interventions in Country Experience in this document.) Despite this progress, much more will need to be done to ensure that the complex and varied needs of MARA and other vulnerable adolescents are fully met.

REGIONAL PERSPECTIVE

SOME KEY CONSIDERATIONS FOR WORKING WITH MARA • MARA risks and vulnerabilities overlap and are also related to other health issues and social and economic determinants. Interventions must therefore ensure that service providers respond to a wide range of risk behaviours and social vulnerabilities. For example, using “one-stop-shop” approaches and referral systems with case management can be effective approaches. • HIV prevention interventions among MARA cannot deal with public health “risk reduction” alone – programmes must take into account the other complex challenges adolescents face, including violence, substance abuse, social isolation, mental health and psychosocial problems and many other health, economic and social issues. • The tendency to “rescue” or remove children from the street, including through “street raids,” often by force, can have negative effects, driving such children into hiding, making them harder to reach with outreach services, and increasing their vulnerability to exploitation, abuse and HIV. • Children should only be removed from the street when they are willing, have a medical emergency or are in acute danger. Health and social services can be more effective when they build trust with at-risk and vulnerable adolescents and young people, reducing the risks in their environment, giving them access to services and seeking their views on the future.

LOOKING FORWARD Concerted advocacy and action is needed from all partners to ensure that quality services are available to vulnerable and at-risk adolescents at national scale. Policy reforms, programmatic shifts and a reallocation of resources to strengthen the ability of health and social protection systems to cater to MARA and other vulnerable adolescents are required to halt the further spread of the HIV epidemic. Reforms must aim to expand and grant equitable access to services for all, including adolescents engaging in risk behaviours who are currently excluded. And progress on HIV can only be increased and sustained if underpinned by social environments that advance equity, human and child rights, gender equality and social justice.

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REFERENCES

REGIONAL OVERVIEW

REFERENCES

ALBANIA 1. Behavioral Survey-HIV-STI among Most-at-Risk Adolescents in Tirana, Albania-2008 http://www.unicef.org/ceecis/Behavioural_survey_on_most_ at_risk_adolescents_Albania.pdf 2. “Injectingdrugusers in Albania-Factsheet-2008 http://www.unicef.org/ceecis/Albania_factsheet_(draft).pdf 3. Capacity Building Needs Assessment for Organizations Working with Most-at-Risk Adolescents-Albania-2009 http://www.unicef.org/ceecis/Albania_MARA_capacity_assessment.pdf

4. Don’t Forget About Us – Children Living with HIV/AIDS in Albania-2011 http://www.unicef.org/ceecis/Dont_forget_about_us_-_Children_with_HIV_AIDS_in_Albania.pdf 5. Descriptive Mapping of Drug Use Hot Spots in Albania-2009 http://www.unicef.org/ceecis/IDU_hot_spots_(SA_2009).pdf 6. Break the Cycle Case Study – Albania-2010 http://www.unicef.org/ceecis/BTC_Case_Study_FINAL_ Ver_4.0.pdf 7. Aksion Plus NGO http://www.aksionplus.net/aboutus.html

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REFERENCES

MOLDOVA 1. Youth-friendly Health Center ATIS http://aids.md/aids/index.php?cmd=item&id=217 2. Assessment of Risk of HIV infection among Most-atRisk Adolescents-Moldova-2009 http://www.unicef.org/ceecis/2008_002_Eng_Risk_Assessment_MARA.pdf

BOSNIA & HERZEGOVINA 1. HIV Risk Behaviors Among Injecting Drug Users-Bosnia & Herzegovina-2007 http://www.unicef.org/ceecis/BBS_Among_IDUs_in_BiH.pdf 2. Female Injecting Drug Users-Qualitative Study-Bosnia & Herzegovina-2009 http://www.unicef.org/ceecis/Report_of_the_Qualitative_ Study_female_IDUs_2009.pdf 3. Review of Legislation, Policies and Practices for adolescent access to HIV-related information and health services-Bosnia & Herzegovina-2007 http://www.unicef.org/ceecis/Legal_Analysis_final_Eng_ June_2008%281%29.pdf 4. Guidelines for Voluntary Testing & Counseling for HIV-Bosnia and Herzegovina-2009-(in Bosnian) http://www.unicef.org/ceecis/VCCT_in_BiH_latin.pdf

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3. Injecting Behavior and Service Use among Young IDU in Albania, Moldova, Romania and Serbia, Busza et. al, (Abstract) 2012 http://www.unicef.org/ceecis/4-country_study_IDU_ Study_4_countries-abstract-Busza_et_al.pdf 4. International Journal of Drug Policy – Narrating the social relations of initiating injecting drug use: Transitions in self and society-Moldova-2011 http://www.unicef.org/ceecis/IJDP-2011-Initiation-narratives-proofs.pdf 5. Social Science & Medicine – “Back then” and “nowadays”: Social transition narratives in accounts of injecting drug use in an East European setting-Moldova-2012 http://www.unicef.org/ceecis/SSM-2012-Transition_Narratives-%2874%29-425-433.pdf 6. National Programme on Prevention and Control of HIV/ AIDS and STI (NAP), Government of the Republic of Moldova, (English) http://aids.md/aids/index.php?cmd=item&id=120

MONTENEGRO 1. Knowledge and Behavior of the Roma, Ashkali and Egyptian Youth Living in Collective Centers in Relation to HIV/ AIDS Montenegro, 2008 http://www.unicef.org/ceecis/MARA_MNE_Final_Re port_%282008%29.pdf 2. Addressing Gender Issues among Vulnerable Roma, Ashkali and Egyptian Adolescents through HIV PreventionMontenegro-2010 http://www.unicef.org/ceecis/Montenegro_Gender_Case_ Study_October_9_2010.pdf 3. National AIDS Strategy-Montenegro– 2010 to 2014–Awaiting Government Ratification http://www.unicef.org/ceecis/National_HIV_AIDS_Startegy_2010_to_2014_%28Montenegro%29.pdf

ROMANIA 1. ARAS NGO http://www.arasnet.ro/ 2. Research Report on Most-at-Risk Adolescents-Romania-2009 http://www.unicef.org/ceecis/MARA_EN.pdf 3. Evaluation of Programs for Most-at-Risk Adolescents-Romania-2010 http://www.unicef.org/ceecis/MARA_evaluation_report.pdf

4. Romanian Harm Reduction Network http://www.rhrn.ro/ 5. Accept NGO http://accept.ong.ro/foramoregayromania.html 6. Aliat NGO http://www.aliatong.ro/ 7. Integration NGO http://www.integration.org.ro/ 8. Parada NGO http://srap-project.eu/partners/foundatia-parada/ 9. Samusocial NGO http://www.samusocial.ro/ 10. Sastipen NGO http://www.sastipen.ro/ 11. Drug Users Access to Sterile Injecting Equipment and Opiate Substitution Medication-Romania-2011 http://www.unicef.org/ceecis/IDUs_Access_to_needles.pdf 12. M&E Prevention Intervention Framework for most-at-risk adolescents-Romania-2010 http://www.unicef.org/ceecis/Romania_Voucher_MonEv_ framework.pdf

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REFERENCES

UKRAINE

SERBIA 1. CYI NGO http://www.cim.org.rs/ 2. JAZAS NGO http://www.jazas.net/eng/index.html 3. Prevalence and risk of HIV among injecting drug users â&#x20AC;&#x201C;Serbia-2009 http://www.unicef.org/ceecis/IDU_MARA_Research_Serbia.pdf 4. Strategy on HIV infection and AIDS-Serbia-2011-2015 http://www.unicef.org/ceecis/NATIONAL_HIV-AIDS_STRATEGY_ENG.pdf 5. Questionnaire For Survey among Intravenous Drug Users-Serbia-2009 http://www.unicef.org/ceecis/Serbia_-_QUESTIONNAIRE_FOR_ IDUs_final.pdf 6. Veza NGO http://www.ngoveza.org.rs/lang/en/activities

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1. Review of evidence on HIV/AIDS and most-at-risk adolescents and young people-Ukraine-2008 www.unicef.org/ceecis/Desk_review_report_2008-ENG_ (1).zip 2. Risk and Protective Factors in the Initiation of Injecting Drug Use, Olexander Yaremenko Ukrainian Institute for Social Research, Kyiv, 2006 http://www.unicef.org/ukraine/3_HIV_injecting_drug_users_en.pdf 3. Children and Young People Living or Working on the Streets: The Missing Face of the HIV Epidemic in Ukraine, UNICEF Ukraine, Kyiv, 2006 http://www.unicef.org/ukraine/4_Street_children_and_ young_people_en.pdf 4. Most-at-Risk Adolescents-The Evidence Base for Increasing the HIV Response in Ukraine, Ukrainian Institute for Social Research after Olexander Yaremenko, UNICEF, Ukraine 2008 http://www.unicef.org/ukraine/MARA_Report_eng_web. pdf 5. Street-based adolescents at high risk of HIV-JECHUkraine-2010 http://www.unicef.org/ceecis/jech.2009.097469.full.pdf

6. Law of Ukraineâ&#x20AC;&#x201C;AIDS Prevention-Ukraine-2009 http://www.unicef.org/ceecis/HIV_Law_ Ukraine_12_23_2010_Eng.pdf 7. Law of Ukraine-HIV prevention, treatment, care and support to HIV-positive people and patients with AIDSUkraine-2009-2013 http://www.unicef.org/ceecis/The_State_HIV-AIDS_Program_for_2009-2013_narrative_EN.pdf 8. Law of Ukraine-HIV prevention, treatment, care and support to HIV positive people and patients with AIDS-Organizational Activities-Ukraine-2009-2013 http://www.unicef.org/ceecis/The_State_HIV-AIDS_Programme_Annex_1_Ukraine_%281%29.pdf 9. Law of Ukraine-HIV prevention, treatment, care and support to HIV positive people and patients with AIDS-Prevention among vulnerable groups-Ukraine-2009-2013 http://www.unicef.org/ceecis/The_State_HIV-AIDS_Programme_Annex_2_Ukraine%281%29.pdf 10. Capacity Building Needs Assessment Tool-Ukraine-2007 http://www.unicef.org/ceecis/CapacityNeedsAssessment_instrument_Engl.pdf 11. Stakeholder Analysis Toolkit-Services for most-at-risk children and adolescents-Ukraine-2009 www.unicef.org/ceecis/Stakeholdersanalysis_tools_Engl.zip

12. Adolescent Female Sex Workers-Targeted Intervention Model-Ukraine-2010 http://www.unicef.org/ceecis/InterventionReport_Mykolayv_ FINAL_eng_.pdf 13. HIV prevention among most-at-risk adolescents: implementation results of the targeted models, Ukrainian Institute for Social Research after Olexander Yaremenko, UNICEF, Ukraine, 2011 http://www.unicef.org/ukraine/Case_Study_EN_FINAL_ block.pdf 14. Population Size Estimate (PSE) of Most-at-Risk Children and Youth in the 10-19 Age Group, Ukrainian Institute for Social Research after Olexander Yaremenko, UNICEF, Ukraine, 2011 http://www.unicef.org/ukraine/Ocinka_chiselnosti_ditey_eng. pdf

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5. Police harassment of most-at-risk young people in Eastern Europe-Abstract-U.K. 2010 http://www.unicef.org/ceecis/Vienna_Conf_AbstractPolice_Harassment_2010_Busza_et_al%281%29.pdf 6. Break the Cycle: opportunities and challenges for preventing initiation into injecting in Eastern EuropeU.K.-2010 http://www.unicef.org/ceecis/Neil_Hunt_IHRA_2010.pdf

REGIONAL OVERVIEW 1. Core indicators for Programs intended for Most-At-Risk Adolescents (including UNGASS)-UNICEF-Geneva-2008 http://www.unicef.org/ceecis/Core_indicators_for_MARA_Programme.pdf 2. Research Toolkit for programs with most-at-risk adolescents and young people-UNICEF-LSHTM-London-2009 www.unicef.org/ceecis/Research_Toolkit_PDFs.rar 3. Injecting Behavior and Service Use among Young IDU in Albania, Moldova, Romania and Serbia-Abstract-2012 http://www.unicef.org/ceecis/4-country_study_IDU_Study_4_ countries-abstract-Busza_et_al.pdf 4. Adolescents and Risk in Eastern Europe, Assessing Harm Reduction Needs, Bangkok-2009 http://www.unicef.org/ceecis/Busza_et._al._Bangkok_IHRA_ Presentation_Session_C-18.pdf

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7. Ethical guidance for conducting quantitative research with adolescents engaging in HIV risk behaviourUNICEF-Geneva-2008 http://www.unicef.org/ceecis/Ethical_Guidance_for_Research_Among_MARA_-_Working_Document.pdf 8. Ethical and protection issues in HIV programming for adolescents engaging in HIV risk behaviour-UNICEFGeneva-2008 http://www.unicef.org/ceecis/Ethical-Protection_Guidance_for_MARA_Programming_-_Working_Doc.pdf 9. Course Summary-Understanding the Focus on MARYP in Concentrated and Low Prevalence HIV EpidemicsBangkok-2011 http://www.unicef.org/ceecis/Bangkok_MARYP_ Course_Summary-07_May_2010.pdf 10. Providing Comprehensive Sexual & Reproductive Health Services for Most-at-Risk Adolescents and Young Peopleâ&#x20AC;&#x201C;Training of Trainers Course CurriculumUNFPA-Istanbul-2012 http://www.unicef.org/ceecis/UNFPA_MARA-YP_ToT_ Training_Module_2011_FINALMay2012.pdf

REFERENCES

11. Inter-Agency Task Team on HIV and Young People-Guidance Briefs-UNICEF-New York-2008 www.unicef.org/ceecis/IATT_GUIDANCE_BRIEFS_PDFs_--_NOV_2008.rar 12. Blame and Banishment â&#x20AC;&#x201C; The underground HIV epidemic affecting children in Eastern Europe and Central Asia, UNICEF Regional Office for CEECIS, Geneva, 2010 http://www.unicef.org/ceecis/hiv_aids_15001.html 13. Capacity Assessment Tools for Organizations working with Most-at-Risk Adolescents-UNICEF-Geneva-2008 http://www.unicef.org/ceecis/Capacity_assessment_toolkit. pdf 14. Manual on Programming to prevent HIV in most at-risk adolescents-UNICEF-Geneva-2008 http://www.unicef.org/ceecis/Final_MARA_Guidance-1.pdf 15. Consultation Report-Strategic Information and HIV Prevention among Most-at-Risk Adolescents-UNICEF-Geneva-2009 http://www.unicef.org/ceecis/MARA_Consultation_REPORT_--_Final_v3.pdf 16. Development and Evaluation of the Drug Use Screening Tool for Young People-Kent, U.K. http://www.unicef.org/ceecis/DUST_report_Neil_Hunt_UK_ Drug_Use_Screening_Tool.pdf

All documents linked to Experiences from the Field also available at: http://www.unicef.org/ceecis/hiv_aids_19993.html

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United Nations Children’s Fund (UNICEF) Regional Office for CEE/CIS Palais des Nations CH – 1211 Geneva 10 Switzerland