Young Key Populations

Data availability and data issues

95% “The analysis carried out by the Commission shows that over 95% of all new HIV infections among young people occur among most-at-risk adolescents.” Report of the Commission on AIDS in Asia. Redefining AIDS in Asia: Crafting an Effective Response (2008), p. 146.

HIV-related risk in populations What do we need to know to prioritize populations for the AIDS response? HIV-related risk in populations Sexual risk: levels and frequency of unprotected vaginal and anal sex Injection risk: sharing of needles HIV and STI prevalence of sub-populations Sizes of higher risk and vulnerable sub-populations Geographic location of risk populations

Main data collection components of HIV/STI surveillance systems Size estimates of key populations Reported HIV and AIDS cases HSS - HIV sentinel surveillance (facility-based) BSS/IBBS - Bio-behavioral surveys in key populations (or general population) STI Surveillance Additional strategic information sources: Mapping of sub-populations Special surveys Program M&E, other…

What is different about surveying young key populations at higher risk (YKAPs)? The ethical considerations needed to include minors in studies that ask questions that relate to their sexual behavior, use of drugs and other risk behaviors

Ethical procedures for surveyed young populations Ethical review and approval: Weigh community benefit Ethics approval granted for a person of any age to participate Surveillance deemed as non-research activity by the Ethics Committee Surveillance does not require Ethics Committee Review Parental consent requirements: Parent/ guardian consent required Parent/ guardian consent waivered Consent from Dept. of Education or school principal sufficient Special adjustments for minors: Protection of respondents built into design and questionnaires Sensitive sexuality questions removed for very young students Strategies to ensure consent secured without coercion Referral to appropriate services. Adjustments for minors: Afghanistan(2009)-Protection of respondents was built into the questionnaire for MSM Indonesia-Sensitivity questions on sexuality were removed from the questionnaire for elementary school students Cambodia(2005)-survey was designed to balance protection of under-age respondents and community benefits Pakistan(2011)-strategies were put in place to ensure that consent is secured without coercion and that adolescents are referred to appropriate services. In a study conducted in PNG(2011), ethics approval was granted for a person of any age to participate. Parental consent: Parental consent was waivered for studies conducted in MSM in Afghanistan(2009) and in sex workers in Vanuatu(2011). Indonesia(2011)-Consent from department of education and school principal for in-school youth and parental/guardian consent for out-of-school youth was required for participation. Maldives-parental consent was required for IDUs, FSWs and MSM under 18 years for their inclusion. Surveillance as non-research: Lao PDR(2009)-IBBS conducted in MSM and BSS conducted in service women were deemed as non-research activity by the ethics committee. Thailand(2010)-Assessment protocol of a survey was determined a surveillance activity by CDC, which, consequently did not require an IRB review. Only 9 out of 47 studies reviewed described ethical procedures specific for minors: Afghanistan, Cambodia, Indonesia, Lao PDR, Maldives, Pakistan, PNG, Thailand, Vanuatu

Data need for young key populations To understand how HIV affects young key populations… Surveys have to include enough of young key populations to yield meaningful results Reports of surveys have to include the age disaggregated data and results

We need age disaggregated data to know the epidemic among young key populations…and do we have it? Bangladesh, China, India, Myanmar, Sri Lanka Myanmar Bangladesh, India, Myanmar, Sri Lanka, Thailand Bangladesh, Cambodia, China, India, Indonesia, Myanmar, Sri Lanka, Thailand, Viet Nam Source: Prepared by www.aidsdatahub.org based on National HIV Sentinel Surveys and www.aidsinfoonline.org

Apart from the data reported in global AIDS reporting, availability of age disaggregated behavioural data for FSW is limited Afghanistan, China, Fiji, Indonesia, Japan, Lao PDR, Malaysia, Mongolia, Pakistan, PNG, Philippines, Viet Nam Cambodia, Fiji, Mongolia, Nepal, Pakistan, Afghanistan, Cambodia, Fiji, India, Indonesia, Lao PDR, Mongolia, Nepal, Pakistan, PNG, Timor Leste, Viet Nam Afghanistan, Cambodia, China, Fiji, India, Indonesia, Japan, Lao PDR, Malaysia, Mongolia, Nepal, Pakistan, PNG, Philippines, Republic of Korea, Singapore, Timor -Leste, Thailand, Viet Nam Source: Prepared by www.aidsdatahub.org based on Behavioral Surveillance Surveys; Integrated Biological and Behavioral Surveys; and www.aidsinfoonline.org

The same is true for MSM and both epidemic and behavioural data for young MSM is scarce, especially from survey reports Afghanistan, Bangladesh, Cambodia, China, Fiji, India, Indonesia, Japan, Lao PDR, Malaysia, Mongolia, Myanmar , Nepal, PNG, Philippines , Rep. of Korea, Singapore, Thailand, Timor-Leste, Viet Nam Afghanistan, Cambodia, India, Indonesia, Lao PDR, Mongolia, Nepal, PNG, Timor-Leste, Viet Nam Afghanistan, Bangladesh, Cambodia, China, Indonesia, Japan, Malaysia, Mongolia, Myanmar , Nepal, PNG, Philippines , Rep. of Korea, Thailand, Viet Nam Source: Prepared by www.aidsdatahub.org based on National HIV Sentinel Surveys; Bio-Behavioural Surveys; www.aidsinfoonline.org

Only one out of 6 countries that conducted HIV sentinel surveillance surveys among PWID reported age disaggregated data in survey reports Bangladesh, China, India, Myanmar Myanmar China, India, Viet Nam Bangladesh, India, Myanmar, Thailand Bangladesh, China, India, Myanmar, Thailand, Viet Nam Source: Prepared by www.aidsdatahub.org based on National HIV Sentinel Surveys and www.aidsinfoonline.org

Less than 10% of countries that conducted behavioural surveys among PWID reported age disaggregated data in survey reports Afghanistan, China, Indonesia, Malaysia, Nepal, Pakistan, Philippines, Thailand, Viet Nam Afghanistan, China, Malaysia, Nepal, Pakistan, Philippines, Thailand, Viet Nam Afghanistan, India, Indonesia, Nepal, Pakistan, Afghanistan, China, India, Indonesia, Japan, Malaysia, Nepal, Pakistan, Philippines, Thailand, Viet Nam Nepal Source: Prepared by www.aidsdatahub.org based on Behavioral Surveillance Surveys; Integrated Biological and Behavioral Surveys; and www.aidsinfoonline.org

There has been progress but only around half the countries in the region reported key indicators for young key populations (YKP) in GARP 2013 reports Countries that reported YKP indicators in 2012 Global Reporting Countries that reported YKP indicators in 2013 Global Reporting GARP= Global AIDS Response Progress Reports Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org

Only 20 of 31 country HIV surveillance systems include key populations – half or less have a reasonable proportion of young key populations represented 38 UNAIDS country - 3 high income countries [Brunei, Japan, Singapore] - 2 Korea [RoK and DPRK]- 2 [Australia and New Zealand] = 38 -3-2-2 = 38-7 = 31 countries  Total 11 countries in the region - 10 Pacific island countries (excluding PNG & Fiji) and Bhutan - are not included in the assessment of HIV surveys. Generally 15 or 18+ except for SLK 10-50y in HSS and IBBS Maldives 13-49 for FSW, 10-55 for MSM and 17-49 for PWID Countries able to ID YKAP proportions & YKAP represent >=30%: FSW AFG, KHM, CHN, IDN, LAO, MLS, MDV, MMR, NPL, PAK, PNG, SLK, THL, VNM AFG, KHM, CHN, LAO, MDV, MMR, NPL, PAK, THL, VNM MSW PAK, PNG, THL; PAK, THL MSM KHM, CHN, IDN, LAO, MDV, MNG, MMR, NPL, PHL, SLK, THL, VNM KHM, CHN, IDN, LAO, MDV, MNG, MMR, NPL, PHL, THL, VNM TG IDN, LAO, MLS, PAK; LAO, PAK PWID AFG, CHN, IDN, MLS, MDV, MMR, NPL, PAK, PHL, VNM MDV, MMR, NPL, PHL Source: Prepared by www.aidsdatahub.org based on National HIV Sentinel Surveillance and HIV Prevalence Reports ; Global AIDS Response Progress Reports- Country Reports (2012) ; UNGASS Progress Reports (2010).

The same is true for behavioral surveillance 38 UNAIDS country - 3 high income countries [Brunei, Japan, Singapore] - 2 Korea [RoK and DPRK]- 2 [Australia and New Zealand] = 38 -3-2-2 = 38-7 = 31 countries  Total 12 countries - 10 Pacific island countries (excluding PNG & Fiji), Bhutan and China - are not included in the assessment of behavioral surveys Generally 15 or 18+ except for IBBS Maldives 13-49 for FSW, 10-55 for MSM and 17-49 for PWID; and Malaysia in BSS 14-<60 y FSW, MSW, TG and 17-65 PWID Countries able to ID YKAP proportions: FSW AFG, KHM, IND, IDN, LAO, MLS, MDV, MMR, NPL, PAK, PNG, SLK, THL, VNM AFG, KHM, LAO, MDV, NPL, PAK, PNG, THL, VNM MSW MLS, PAK, PNG, THL; PAK, THL MSM KHM, IND, IDN, LAO, MDV, MNG, MMR, NPL, PHL, PNG, SLK, THL, VNM KHM, IDN, LAO, MDV, MNG, MMR, NPL, PHL, PNG, SLK, THL, VNM TG IDN, LAO, MLS, PAK; LAO, PAK PWID AFG, IND, IDN, MLS, MDV, MMR, NPL, PAK, PHL, SLK, VNM MDV, NPL, PHL Source: Prepared by www.aidsdatahub.org based on National Behavioral Surveillance Reports ; Global AIDS Response Progress Reports- Country Reports (2012) ; UNGASS Progress Reports (2010).

HIV prevalence surveys Age of inclusion of YKAPs in surveys of key populations, based on available data from survey reports HIV prevalence surveys 9-14yrs : Maldives (FSW 13, MSM 10); Pakistan (MSW 13); PNG (FSW 14, MSW 9) 15+yrs : Cambodia (FSW 15, MSM 18); Lao (MSM, TG 15); Maldives (PWID 17); Myanmar (FSW, MSM, PWID 15); Nepal (FSW, MSM, PWID 16); Pakistan (FSW, Hijra 15); Viet Nam (FSW, MSM, PWID 16) 18+yrs : Afghanistan (FSW, PWID 18); India (FSW, MSM, TG, PWID 18); Pakistan (PWID 18); Malaysia (FSW, MSM, TG 18, PWID 20) Behavioral surveys 9-14yrs : Maldives (FSW 13, MSM 10); Pakistan (MSW 13); PNG (FSW 14, MSW 9 ) 15+yrs : Bangladesh (FSW, MSW, MSM, TG, PWID 15); Cambodia (FSW 15, MSM 18); Lao (FSW, MSM, TG 15); Maldives (PWID 17); Myanmar (FSW, PWID 15); Nepal (FSW, MSM, PWID 16); Pakistan (FSW, Hijra 15); Sri Lanka (FSW, MSM 16, PWID 17); Timor Leste (FSW, MSM 16) Maldives – The research team included the respondents (IDUs, FSWs and MSM) under l8 with informed consent from the parents/guardians for their inclusion in the study. Pakistan – HIV/AIDS Surveillance Project (HASP) proposed lower age limit of 13 years in SGS round 4 and has put the strategies in place to ensure that consent is secured without coercion and that adolescents are referred to appropriate services PNG - Ethics approval was granted (from PNG Institute of Medical Research Internal Review Board, the Research Advisory Committee of PNG National AIDS Council, the Medical Research Advisory Committee of PNG and the Human Research Ethics Committee of the University of New South Wales, Australia) for a person of any age to participate in the study; however, at the time of the survey being finalized for use on a PDA (personal digital assistant) , it was decided that no person under the age of 9 could reliably use the PDA, therefore 9 was arbitrarily selected as the age minimum. Malaysia – the study (BSS 2004) hasn’t mentioned about the ethical consideration on the inclusion of young respondents but it mentioned that neither name nor any other identifier was collected to protect the participants’ confidentiality. In this BSS 2004, the age of inclusion of the respondents were FSW, MSW, TG – 14 yrs and PWID 17 yrs. Source: Prepared by www.aidsdatahub.org based on National HIV Sentinel Surveillance, HIV Prevalence Surveys and Behavioral Surveys; Global AIDS Response Progress Reports- Country Reports (2012) ; UNGASS Progress Reports (2010).

Available information on Size Estimates of young key populations is extremely limited! For Bangladesh, EVA includes street children, children of sex workers, children living in the slum, Adolescents/young people who are on Yaba, Adolescents who live in Tea Garden, Adolescents who live in hostels or madrasa For Pakistan, EVA includes all adolescents not found to be living on the streets 24/7, engaged in commercial sexual exchange or injecting drugs, e.g. working on the streets (beggar, hawker, etc.), or on the streets, during the day or working in the automobile workshops or carpet weaving factories. They are still considered to be especially vulnerable to HIV due to lack of parental monitoring, disposable income, low literacy rates and other factors. SE Bangladesh 31,101 FSW; 1,932 MSW; 3,888 MSM; 6,096 PWID in 20 districts. Ethical considerations to not violate rights and informed consent of participants directly. Behavior survey 600 FSW and 400 of other key pops. The IDU 10-18 y only 10% of those surveyed, others are FSW & TG 33%, DU 26%, MSM/MSW 37% SE Pakistan 1,735 FSW; Total 7,101 SW in Karachi, Larkana, Quetta, Faisalabad, Lahore, Mardan and Peshawar; Behavioral survey 2345 total – 1173 street-based adolescents, 586 each from auto workshops, carpet weaving factories

HIV prevalence and epidemiology

690,000 young people (15-24) are living with HIV in 2012, 15% of adults (15+) living with HIV in Asia and the Pacific 320,000 young female (15-24) 370,000 young male (15-24) Source: Prepared by www.aidsdatahub.org based on UNAIDS estimates 2012

Estimated HIV prevalence among young people (15-24), 2012   Young females (15-24) (%) Young males (15-24) (%) Afghanistan <0.1 Bangladesh Bhutan 0.1 Cambodia 0.2 Fiji India Indonesia 0.5 0.4 Lao PDR Malaysia Maldives Myanmar Nepal Pakistan Papua New Guinea Philippines Sri Lanka Thailand 0.3 Viet Nam Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org

Young sex workers are getting infected with HIV! HIV prevalence among sex workers by age group, countries where the data is available from 2007- 2012 Countries with HIV prevalence > 5% among SW < 25 years * FSW only ** FSW and MSW *** FSW and TG SW Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org

Young MSM are getting infected with HIV! HIV prevalence among MSM by age group, countries where the data is available from 2009- 2012 Countries with HIV prevalence < 5% among MSM < 25 years Countries with HIV prevalence > 5% among MSM< 25 years Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org

Young PWID are getting infected with HIV! HIV prevalence among PWID by age group, countries where the data is available from 2010- 2012 Countries with HIV prevalence < 5% among PWID < 25 years Countries with HIV prevalence > 5% among PWID < 25 years Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org

Risk behaviours

Percentage of young people (15-24) who had sex before the age of 15, countries where data is available, 2006-2011 Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org

People do start risk behaviors when they are young … ≥ 25 yr Source: Prepared by www.aidsdatahub.org based on National Behavioral Surveillance Reports ; Global AIDS Response Progress Reports- Country Reports (2012) ; UNGASS Progress Reports (2010).

Condom use among young MSM is generally lower than their older counterparts Condom use at last anal sex among MSM by age group, countries where the data is available, 2007-2012 Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org

Low level of condom use among PWID including young PWID! Condom use at last sex among PWID by age group, countries where the data is available, 2007-2012 Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org

Young PWID’s risk behaviors compare to that of older counterparts % of PWID reported using sterile injection equipment at last injection by age group, countries where data is available, 2007-2012 Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org

Condom use at last sex among sex workers by age group, countries where the data is available, 2007-2012 * FSW only ** FSW and MSW *** FSW and TG SW Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org

Vulnerability and HIV knowledge

Percentage of MSM with comprehensive HIV knowledge, by age group, countries where data is available, 2005-2009 * Manipur Source: Prepared by www.aidsdatahub.org based on UNGASS Country Progress Reports 2006,2008 & 2010

Percentage of PWID with comprehensive HIV knowledge, by age group, countries where data is available, 2007-2009 * Manipur ** Kathmandu Source: Prepared by www.aidsdatahub.org based on UNGASS Country Progress Reports 2006,2008 & 2010

Percentage of sex workers with comprehensive HIV knowledge, by age group, countries where data is available, 2007-2009 * Manipur Source: Prepared by www.aidsdatahub.org based on UNGASS Country Progress Reports 2006,2008 & 2010

National response

As compare to their older counterparts, less young key populations are being reached by prevention programmes less accessible to HIV testing services and approximately 2/3 of young key populations do not know their HIV status

Less young MSM are being reached by prevention programmes as compare to their older counterparts, 2008-2012 Green filled down-bar shows prevention coverage among young MSM is higher than their older counterparts Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org

Lower prevention coverage among young sex workers under 25 years, 2007-2012 * FSW only ** FSW and MSW *** FSW and TG SW Green filled down-bar shows prevention coverage among young sex workers is higher than their older counterparts Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org

Approximately 2/3 of young MSM surveyed in the region do not know their HIV status…. Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org

Only 1/4 of young PWID in the region know their HIV status Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org

Less than 40% of young sex workers know their HIV status * FSW only ** FSW and MSW *** FSW and TG SW Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org

slides compiled by www.aidsdatahub.org THANK YOU slides compiled by www.aidsdatahub.org Data shown in this slide set are comprehensive to the extent they are available from country reports. Please inform us if you know of sources where more recent data can be used. Please acknowledge www.aidsdatahub.org if slides are lifted directly from this site