Senior Specialist, HIV (Adolescents) 20th International AIDS Conference Melbourne, Australia. 21st July 2014 The realities of adolescent key populations: what is the evidence? Susan Kasedde, DrPH Senior Specialist, HIV (Adolescents) UNICEF, NYHQ #EndAdolescentAIDS #ShowYourLove

Outline What we know about adolescent key populations Opportunities for programme and future research Outline

What Do We Know? Adolescent key populations: adolescents who sell sex, transgender adolescents, adolescent MSM and adolescents who use drugs. In all regions, these adolescents face an increased risk of infection with HIV. They are highly stigmatized and face exclusion from services (preventive care, protection, treatment, care and support) due to the illegality of their behaviours or sexual orientation. One of the realities is that the data on adolescent key populations is extremely limited. Many of the behaviours that these young people engage in, are criminalized, making not only service access and delivery challenging but also making research in these populations very difficult to conduct. Ethical guidelines in research make it particularly difficult to enroll very young adolescents in research making it even more difficult to get good insight into the experience of these younger key populations to inform design of programmes. So we do not have a good understanding of the number of adolescent key populations at national or global level. But from surveys with limited coverage, from our programme experience and from data gathered from older respondents, we know that there are many adolescents among key populations. Fortunately, we do know what works to prevent HIV infection, illness and death so we can act to address HJIV in adolescent key populations but in many ways, our greatest barriers are leadership and political will to change and confront the complex structural challenges that underlie the adolescent epidemic and to some degree, the quality and amount of information available to help us tailor an effective response to adolescents in particular. In each context. Still, some countries have attempted to conduct research to generate estimates of population sizes, estimates of HIV prevalence and other behavioural data and this has been enormously helpful in providing insight into their reality. A 2008 report by the Commission on AIDS in Asia estimated that over 90% of new HIV infections in young people were concentrated among young key populations, underscoring the exceptional level of risk in these populations. The CDC has reported recently that one out of every four new HIV infections each year occurs in adolescents and young adults (aged 13 – 24) and seven out of ten new HIV infections in adolescents (aged 13 – 19) in 2010 were among adolescent MSM (CDC. HIV Among Youth in the US: protecting a generation, in CDC vital signs. November 2012). UNICEF has supported a number of studies with implementing partners in to help get better data on the realities of adolescent key populations in particular. One such study with the Institute of Public Health in Tirana, Albania, explored injection drug use in street-connected adolescents. The study was able to recruit 121 young males aged 15 – 24 (no young women would agree to participate) The study found: • 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. • 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. 4) A number of common issues emerge from the information that we have: 1) Underlying social and economic factors play a big role in contributing to vulnerability and reinforcing high risk behavior. The increasingly young age of injecting drug use in adolescents in eastern Europe and central Asia has been seen in particular among adolescents in communities hard hit by the effects of economic transition, such as increased unemployment. 2) Drug use and the sale of sex by children very often go hand in hand, each one of these in some way a coping strategy and the adolescents are as much at risk because of their own behavior as they are because of their partners’ behaviours and the behavior of their peers. 3) Social exclusion and discrimination both drive and exacerbate the vulnerability of adolescent key populations. They limit full participation, dignity and access to information and services. 4) Punitive laws hurt children – directly through withholding their freedom and rights to protection and indirectly through separation from appropriate care and support. 5) Low risk perception also affects the behavior and choices of adolescent key populations and this is a direct result of their access to information, support and services. 6) Experiences of physical and sexual violence and exploitation are common, also leading to long term effects including long term risk behaviours.

… Not just adolescents Part of the reality is that the effects of exclusion and neglect of the needs of key populations including adolescents, continue on to affect their children. A study across the different regions of the Russia Federation found that HIV + mothers are 20 – 150 times more likely to abandon children then HIV negative mothers and the number of abandoned children in one city (St Petersburg) doubled in two years Reasons for child abandonment include shame, helplessness, negative attitudes towards single mothers and disabled children, lack of family support, fear if violence, rejection. The result for many of these children is years in residential care, many of them, into adolescence. Often, because of the punitive approach to drug use and the sale of sex, adolescents themselves are incarcerated , often while they are pregnant or with very young babies, leading to incarceration of young babies too.

Opportunities for Programmes & Research Participation of adolescents, young people, community based organizations as critical resources to bridge the gap between programmes/services and vulnerable adolescents. Laws, policies and social norm change – engaging adolescents, civil society organizations and communities Strengthening data & evidence: Population size estimation and disaggregated data Implementation science to accelerate learning on effective service delivery Some priorities for implementation science: HTC models and linkage to services Use of mobile technology to enhance information access, data, service delivery and retention Bundling of prevention intervention Managing transition and prevention, SRH for perinatally and behaviourally infected adolescents Social Protection