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Children and young people, injecting and HIV Under-18 and overlooked

Children and young people, injecting and HIV Under-18 and overlooked. Young People and Injecting Drug Use: Overcoming barriers to HIV Prevention and Harmonizing National Laws with the UN Convention on the Rights of the Child 11.00-12.30, 26th July, 2012 Session Room 4

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Children and young people, injecting and HIV Under-18 and overlooked

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  1. Children and young people, injecting and HIVUnder-18 and overlooked Young People and Injecting Drug Use: Overcoming barriers to HIV Prevention and Harmonizing National Laws with the UN Convention on the Rights of the Child 11.00-12.30, 26th July, 2012 Session Room 4 Funded by the Open Society Youth Initiative Neil Hunt, Damon Barrett, Adam Fletcher

  2. Project goals Methods Convention on the Rights of the Child (1989) The size and nature of the problem Guidance, policy and legal framework Best practice Overview

  3. Provide a global overview of: • Prevalence of injecting among under 18s/minors • What is injected • Age of initiation into drug use/injecting • HIV incidence/prevalence and other harms • Examine legal frameworks regarding injecting and services for young people • Collate and analyse best practice guidelines • Highlight data gaps and priorities for further research/action Project goals

  4. The ‘age of majority’ in most countries i.e. attainment of adult status (CRC 1989) Where HIV prevention services are available to children/adolescents, restrictive age-related conditions are often applied HIV prevention services for people who inject drugs (PWID) often exclude young people But review not rigidly restricted to under-18s Why Under-18s?

  5. The acid test OF our policies is the quality of responses for children like ‘Chao’ ‘Chao’, aged 12 Addicted since age 10 Started injecting heroin after his parents were jailed for drug trafficking Lived alone from the age of 8, after his grandparents died Caught by the police in Chenzhou buying needles for a dealer Now in rehab wing of Chenzhou Mental Hospital

  6. Search of • Academic literature • Publications by international agencies • Guidelines • Grey literature Methods

  7. Article 33 States Parties shall take all appropriate measures, including legislative, administrative, social and educational measures, to protect children from the illicit use of narcotic drugs and psychotropic substances as defined in the relevant international treaties, and to prevent the use of children in the illicit production and trafficking of such substances. YOUTH RISE AND IHRA 2009. Drugs, Harm Reduction and the UN Convention on the Rights of the Child: Common themes and universal rights. Youth RISE and International Harm Reduction Association. United Nations Convention on the Rights of the Child (1989)

  8. What exactlyare “all appropriate measures...to protect children?”

  9. Needle and syringe programmes (NSP) Opioid substitution therapy (OST) and other drug dependence treatment Voluntary HIV counselling and testing (VCT) Antiretroviral therapy (ART) Prevention and treatment of sexually transmitted infections Condom distribution programmes, information and education for PWID and their sexual partners Vaccination, diagnosis and treatment of viral hepatitis Prevention, diagnosis and treatment of tuberculosis Core services for People Who Inject Drugs (PWID)

  10. Our data is shot through with holes Not only a shortage of data but... • Intermittent • Inconsistent • Incoherent What did we learn from the review?

  11. Indicator 8. Percentage of most-at-risk populations (MARPs) that have received an HIV test in the last 12 months and who know their results • Indicator 9. Percentage of most-at-risk populations reached with HIV prevention Programmes • Indicator 14. Percentage of most-at-risk populations who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission • Indicator 20. Percentage of injecting drug users reporting the use of a condom the last time they had sexual intercourse • Indicator 21. Percentage of injecting drug users reporting the use of sterile injecting equipment the last time they injected • Indicator 23. Percentage of most-at-risk populations who are HIV infected Reporting required disaggregated by sex and age (<25/25+) UNGASS indicators HOW USEFUL FOR UNDER-18S? VIRTUALLY USELESS

  12. Not only are we bad at counting young PWID but... • What are they injecting? • From what age? • With what harms? • What risk and protective factors apply? • Structural/environmental • Vulnerable group • Individual factors Our understanding of the problem is often little more use than a chocolate teapot

  13. Structural/environmental factors • Repressive drug control policies • Medical/police corruption • No identity papers, no access • Exclusionary health service costs • Vulnerable groups • Orphaned/street children and those in state care • Involved in criminal justice system • Sex workers • Ethnic minorities • Individual factors • Mental health problems • Learning difficulties • Physical and sexual abuse Risk and protective factors: recurring themes

  14. Archipelago of 7,107 islands 3 main geographical divisions: Luzon, Visayas, and Mindanao 98 million people plus 12.5m Filipinos overseas Median age: 22.7 Ethnically diverse Philippines (an example)  ZAMBOANGA  GENERAL SANTOS

  15. Male, aged 15-24, injected drugs in past 6 months • Cebu, General Santos, Zamboanga (N = 494, 5% ♀) • 468 males (15-24): 12.8% <18 • Male injecting initiation: 11-24 (18) • Shared last injection: 67% • Received free needles: 23% <18; 27% 18-24 • Never had HIV test: <18 = 100%; 18-24 = 97% Youth: Male Injecting Drug Users Integrated HIV Behavioral and Serological Survey (IHBSS) (DoH, 2009)

  16. “In various national and international forums, HIV experts are baffled as to why HIV prevalence has remained low, despite the obvious presence of almost all the ingredients for explosive HIV spread.” Aids Education and Prevention. 16(3): 43-52. 2004 Mateo et al. "HIV/AIDS in the Philippines."

  17. IHBSS data – CEBU (People Who Inject Drugs) 2007 = 00.4% 2009 = 00.6% 2011 = 53.8% 2012 Philippine National AIDS Council UNGASS report HIV experts no longer baffled...

  18. As an example: Global Fund programming guidance ‘Harm reduction for people who use drugs’ (2011) omits any mention of under-18s Guidance for practice is difficult to find, often outdated, and unhelpful

  19. “Young people who use drugs must also have legal and safe access to HIV and health services.” Global Commission on HIV & the Law (2012) Risk, Rights and Health. New York: United Nations Development Programme Recommendation 5.4

  20. Needle and syringe programmes (NSP) Opioid substitution therapy (OST) and other drug dependence treatment Voluntary HIV counselling and testing (VCT) Antiretroviral therapy (ART) Prevention and treatment of sexually transmitted infections Condom distribution programmes, information and education for PWID and their sexual partners Vaccination, diagnosis and treatment of viral hepatitis Prevention, diagnosis and treatment of tuberculosis Core services for People Who Inject Drugs (PWID)

  21. Repressive laws • Death penalty, extra-judicial killing, compulsory drug detention and rehabilitation centres, registering/reporting ‘addicts’, arbitrary arrests, detention, evidence-planting and fabrication of cases by police • Arbitrary exclusion of under-18s from services • Mandatory reporting/registering with authorities • Parental consent required (groups with no-one in loco parentis excluded e.g. orphaned street children) • Consent – little recognition of evolving capacity and the “mature minor” principle Legal, policy and ethical problems

  22. If anyone using Ganja, Smack and Tablets are seen inside 21 ward it is okay to 'beat them up' if you are resident of 21 ward. 21 ward committee Mikhabahal - Pimpabahal, Lalitpur. Nepal

  23. We need to listen better to what young people have to say Taras, 17, cries after Denis, 12, who was not able to find a vein to inject him a self-made drug based on ephedrine, known as ‘baltoushka’. Photographed in an abandoned house where they lived in Odessa, Ukraine, on 16 June 2006. Taras died of an overdose in 2008. Denis’ whereabouts are unknown. BLAME AND BANISHMENT The underground HIV epidemic affecting children in Eastern Europe and Central Asia. UNICEF 2010 What would Taras and Denis have SAID THEY NEEDED, FROM WHOM, HOW, WHERE AND WHEN?

  24. How far can we generalise from an adult evidence-base? • Pharmacotherapies • Psychosocial interventions • Novel psychoactives : e.g. Desomorphine (krokodil), synthetic cathinones • How best to address structural/environmental, group, individual factors? • And more specifically... • Resource poor settings • Narcology/medicalised models • Nascent/evolving social services • Lack of integration: within state-run services & across the state/NGO divide • Legal and cultural obstacles Effective interventions?

  25. Good practice examples point to ways that child protection, harm reduction and youth development can be reconciled

  26. Standardise the way we monitor the number of children and adolescents who inject drugs internationally • “Know our epidemic” and how it differs from that of adults in order to “know our response” • Make guidance accessible, specific and relevant • Collaborate internationally to produce enabling legal and policy frameworks that respect child rights • Listen to children and adolescents who inject and demonstrate clearly how what they tell us informs our responses • Learn from existing good practice and collaborate internationally to fill the many, urgent gaps Recommendations

  27. Further informationNeil.Hunt@lshtm.ac.ukDamon.Barrett@ihra.netAdam.Fletcher@lshtm.ac.ukwww.ihra.net

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