Preview: National committee donor toolkit A regional approach
UNICEF supports adolescents and influences policy-makers in Central and Eastern Europe and the Commonwealth of Independent States
ABOUT THIS PREVIEW The UNICEF CEE/CIS Regional Office is breaking new ground to produce the first ever National committee donor toolkit with a regional focus. The toolkit will focus on three themes: Early Childhood Development, Health, and Most-at-Risk Adolescents, making the case for cross-regional investment in cross-cutting issues. All three kits will be available in May 2011.
Introduction A programme has charted a new course for UNICEF by supporting adolescents who are at risk of HIV, while influencing policy-makers across seven CEE/CIS countries. The programme for the Prevention of HIV among Most-at-Risk Adolescents (MARA) in Ukraine and South Eastern Europe (2006-2010) not only helped adolescents affected by HIV, it also highlighted the bigger challenges they face, and guided policy makers on the best response. The programme was launched in 2006 with one clear goal: to ensure that MARA were included in national AIDS strategies in seven countries: Albania, Bosnia and Herzegovina, Moldova, Montenegro, Romania, Serbia and Ukraine. That goal has not only been achieved, but surpassed. As well as influencing policy, the programme has improved the lives of many thousands of adolescents and contributed to a critical shift in perceptions. No group of countries has ever carried out such a programme in any other region. Its contribution to regional and global knowledge on HIV prevention among at-risk and vulnerable adolescents has already been immense. But now funding from Irish Aid, which covered the first four years of the programme, has come to an end.
This Preview sets out the ‘headlines’ from the forthcoming toolkit on Most-at-Risk Adolescents (MARA). It provides a snapshot of our results in this area, and a glimpse into the lives of those we have reached. Our goal is to stimulate feedback from National committees as we prepare the full toolkits, and all comments are welcome.
We need Euro 2 million, over two years, to scale up successful programmes and develop new ones to reach more adolescents in eight countries in East and South-Eastern Europe and Central Asia. Background In 2006, against the backdrop of the world’s fastest growing HIV epidemic, UNICEF’s CEE/CIS Regional Office set out to make the case for HIV prevention programmes for adolescents at risk. At the time, there were no programmes for such adolescents in the seven programme countries at all. But the needs were enormous, given the threat posed by HIV to this age group. The HIV epidemic in CEE/CIS is driven by an explosive mix of injecting drug use and, more recently, sexual transmission. Its spread goes hand in hand with social exclusion. And adolescents who are already shut out of society because of their poverty, ethnicity or because of family breakdown are the most likely to fall prey to HIV infection.
THE SOCIAL GHOSTS “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…” Maria, aged 17, a young mother and drug user, Romania
Desperation and loss of hope are leading growing numbers of adolescents into sex work and drug abuse, creating a vicious cycle of risk and vulnerability to HIV. Around 20 per cent of all female sex workers in Ukraine, for example, are under the age of 19. In this region, injecting drug use starts early. A multicountry study of injecting drug users aged 15-24 found that up to 30 per cent were less than 15 years old when they first injected drugs. The risks often overlap. A study of injecting drug users and female sex workers under the age of 24 in Romania found that nearly a quarter of the sex workers were also injecting drug users. In Ukraine, a quarter of adolescent girls who injected drugs also reported selling sex. These are uncomfortable truths in a region where, just one generation ago, drug abuse and sex work were uncommon and HIV was unknown. Very often, the response from policy-makers, health services and from the general public is to punish drug users and deny them humane care and support, to blame HIVinfected adolescents and to exclude them still further. There has been little or no hard evidence to counter such prejudice or to guide policy-makers on an effective response. As a result, many vulnerable adolescents have become ‘social ghosts’ on the fringes of society.
About the programme The programme for the Prevention of HIV among Most-at-Risk Adolescents in Ukraine and South Eastern Europe (2006-2010) is based on ‘action research’. In other words, it builds and supports services to help adolescents while, at the same time, gathering the evidence that will convince policy makers to change their policies and their thinking. Adolescents have been encouraged to take part in the whole process, sharing their stories and their views on what works, and what does not in HIV prevention programming. Very importantly, the programme has enhanced UNICEF’s role as a key player in policy dialogue. We now have hard evidence to help us persuade policy makers to think about at-risk adolescents when they think about HIV prevention. The UNICEF Regional Office provided leadership and overall coordination to country teams, consisting of UNICEF Country Offices working in partnership with government and civil society organizations. The country teams collected baseline data to get a true picture of the situation, before carrying out qualitative studies to look more closely at the specific risks and vulnerabilities faced by adolescents. They then worked to transform these research findings into better HIV prevention programmes for adolescents. In all seven countries, country teams worked with the UNICEF Regional Office and the London School of Hygiene and Tropical Medicine to develop and monitor programmes that were based on the research evidence. Working across a group of countries made it easier to spot common trends and successes, so that lessons could be shared with other countries in the region and beyond. At the same time, UNICEF reviewed laws and policies, and advocated
KEY STATISTICS The CEE/CIS region has the fastest growing epidemic of HIV and AIDS in the world, with especially rapid increases in parts of Central Asia. Adult HIV prevalence was estimated at 0.8 per cent in 2010, double that reported a decade ago. 90 per cent of HIV cases to date have been reported from the Russian Federation and Ukraine, where HIV prevalence rates are above 1 per cent; Ukraine has the highest HIV prevalence rate in all of Europe. The number of infected girls and women is high and rising, increasing the risk of mother to child transmission. Women account for between 17 per cent and 47 per cent of adult HIV cases across the region, and most of those infected are of reproductive age. An estimated 3.7 million people currently inject drugs in the region, and around onein four are thought to be HIV-infected.
for an end to legislative barriers, such as rules on parental consent, that stop adolescents accessing HIV prevention services. Our ultimate goal was to ensure that at-risk and vulnerable adolescents were included in national AIDS strategies.
capacity and attitudes of service providers. • Research institutions now have the skills and tools to design and carry out ethically sound research amongst adolescents, with more than 80 researchers trained to do so and a research tool kit in place. Building capacity Key results • More than 200 policy makers and service providers have been Changing laws and policies trained to develop gender-sensitive • All seven countries now include programmes, policies and strategies adolescents in their national AIDS in Albania, Bosnia and Herzegostrategies (present or planned). vina, Moldova, Romania, Serbia and • National Action Plans for MostUkraine. at-Risk Adolescents have been • Over 2,300 programme managers developed in Albania, Moldova and and service providers now have the Ukraine. skills to work with most-at-risk and • Laws on the age at which parenvulnerable adolescents. tal consent is required for HIV test• The Drug Use Screening Tool ing have been revised in Bosnia and (DUST), developed in the UK to Herzegovina and Ukraine. help service providers assess subBuilding the evidence stance use and the need for refer• UNICEF and its partners have rals is being adapted for Serbia, carried out 25 studies on adolescent with 38 service providers trained in risk, vulnerabilities and access to its use with adolescents. services across the seven countries. Support for innovative projects • These countries now have, for Albania the first time, disaggregated data - Break the Cycle: a programme to on the location of adolescents at prevent the initiation of drug injecrisk, an understanding of their daily tion among young people at risk. realities, their access to (and use Bosnia and Herzegovina of) HIV prevention services, and the - Communication to boost
KEY RESEARCH FINDINGS • Injecting drug use starts early in this region, with up to 30 per cent of young users in some countries aged 15 years or younger when they first inject. • Young drug users have poorer access to harm reduction services – and they tend to take greater risks. • Routine police harassment undermines trust between adolescents and authorities of all kinds, and increases the odds of taking risks. • Roma are over-represented among the adolescents at greatest risk of HIV infection.
MARIA’S STORY Maria began to visit Atis, a youth-friendly health centre in Balti, Moldova, when she was 17 years old, having been failed by traditional health services.
“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. I felt depressed and had the feeling that nobody cared... Since then I thought it would be better to hide my HIV status...” “One day a friend told me about a youth-friendly clinic where people like me can get help. I decided to go and it really helped... now I come to the centre every day, for medical examinations, and also to attend support groups and to socialise with other young people and the staff. Here I feel safe, accepted and feel the comfort of not having to hide anything.”
WHY THIS MATTERS TO NATIONAL COMMITTEES
Changing perceptions Very importantly, the programme has helped to tackle the blanket stereotype of drug-crazed teenagers who get what they deserve. What has emerged is a picture of adolescents who are as individual and unique as anyone else in society. Here is the sex worker who also goes to school each day, the drug user who supports younger brothers and sisters, the HIV positive girl who is a mother, and the so-called ‘street child’ with a mobile phone. The programme has helped to show policy-makers and others the real and often fragile adolescents behind the image, and it has given those adolescents a voice. The way forward The groundwork has been laid, and UNICEF is now ready to roll this programme out to reach more children and countries in the CEE/CIS region, particularly in Central Asia where the needs are clear and vast. UNICEF itself is providing some funding to carry the work forward in Kazakhstan, Moldova, Russia, Serbia and Ukraine, as are the governments of Austria, Germany and Liechtenstein. To reach its full potential, however, the programme requires an additional Euro 2 million.
To share comments or find out more, please contact: Nina Ferencic, Senior Regional Advisor on HIV and AIDS Telephone: +41 22 090 5540 Email: nferencic@unicef.org Visit the UNICEF CEE/CIS AIDS 2010 Microsite for: Blame and Banishment, a cutting edge publication on the underground HIV epidemic affecting children in the region; human interest stories; videos by Ukrainian teenagers living with HIV; a photo essay and more.
Full URL:http://www.unicef.org/ceecis/hiv_aids_14900.html
• This is outside the normal UNICEF mould. It is a unique cross-regional programme that is changing policies and perceptions on vulnerable adolescents, with HIV as the entry point. • By shedding light on the complexity of their lives, and by listening to them, the programme has given at-risk adolescents a face and a voice. • The work has pushed policy-makers and others out of their comfort zone, but has shown them the vulnerable adolescents behind the stereotyped image of the drug user or sex worker. • The programme has already influenced policies and could, with future funding, change the shape of government responses to adolescents at risk by demonstrating what works in HIV prevention, and how HIV is linked to vulnerability and social exclusion. TOTAL FUNDING REQUIRED UNICEF needs an additional Euro 2 million, over 2 years, to scale up and develop new programming in eight countries in Central Asia and Eastern and South-Eastern Europe. THE FUNDING WILL BE USED TO: • build and strengthen the evidence base (research) • support advocacy to strengthen and revise policies • develop, implement, scale up, monitor and evaluate essential packages of interventions that are tailored to the needs of vulnerable adolescents • monitor and evaluate programmes.
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knowledge of HIV among adolescents in institutions and reduce stigma in the community. Moldova - Strengthening youth-friendly health services for injecting drug users and other vulnerable adolescents. - Piloting a referral mechanism to ensure that vulnerable adolescents, including injecting drug users, have access to comprehensive services. Montenegro - Communication and social mobilisation to reduce social exclusion, improve health and raise awareness of human rights among young Roma. Romania - Strengthening outreach and harm reduction services to reach most-atrisk adolescents, including injecting drug users and sex workers. - Piloting a voucher referral system to increase access to services. Serbia - Drop-in centre and outreach services for adolescents living and working on the street. - Needle exchange programmes for young injecting drug users. Ukraine - Providing tailored services for adolescent female sex workers. - Integrating HIV prevention services into rehabilitation services for adolescent sex workers and girls who are sexually exploited. - Expanding existing outreach services, taking HIV testing and referral services to adolescents living and working on the street. - Reaching adolescent drug users and connecting them to available services. - Integrating HIV prevention education and psychosocial support for adolescents into state medical detoxification and rehabilitation services.