MENA HIV/AIDS UnitMay 29, 2005 UNDP Youth Policies and Strategies in the Context of the MDGs George Ionita Regional HIV Advisor UNICEF MENA

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 Harvard Study: Young People’s Sexual Reproductive Health and Rights Unicef-UNFPA-UNAIDS-IFRC-WHO Started in 2003 Almost completed June 2005, Cairo, League of Arab States

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 Harvard Study: Methodology Desk-based review of published & unpublished literature Telephone interviews (N = 33) with key experts across region and internationally Face to Face interviews by research assistants in Egypt Lebanon, Jordan, and Tunisia (N = 29) Collection of data in above countries survey to UNFPA, UNICEF, IFRC country offices

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 The “youth bulge” Unique demographic moment: unprecedented numbers of young people 10 to 24 Arab region (roughly 1/3 of population) What are some of the implications of the “youth bulge” for young men and women and families? How have young people themselves experienced these changes? Problem: very little research on Arab youth (other than from sectoral perspective)

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 Considerable Unmet Need in the Region Rapid social change: –urbanization; –rising unemployment; –breakdown of social networks; –exposure to global media; –migration; –rising educational levels; –widening generation gaps; –changing gender roles etc. Rising age of marriage Few policies/services dedicated to age group Youth centres tend to exclude girls for various reasons

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 Need for Positive Youth Development Approach Need to integrate various interventions for youth within broad approach Need for positive approach (not seeing youth as deviant or politically dangerous): Youth are part of the Solution, not a Problem Importance of understanding perspective of young people Arab Human Development Report: high desire for emigration among young people – need to address their concerns

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 Social Context Protective factors: Strong family solidarity but in flux Intra-regional shared heritage Rising levels of education Increasing age at marriage Greater communication/access to electronic media Religious values that in some instances positively promote youth development and SRH

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 Economic Context Sharp class differences in vulnerability and outcomes (e.g. education; high risk behaviour in terms of HIV/AIDS) Rising unemployment among youth Higher costs of living/housing Higher material aspirations (media etc.) Above - Reasons for deferral of marriage (little research except for Egypt)

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 Political Context Conflict creates vulnerability: –Palestine (first intifada led to earlier marriage), –Sudan (HIV/AIDS driven by civil war) and –Iraq (violence against young women increased) Reluctance to address sensitive issues/ risk behaviors by both government and NGOs Political participation of youth limited, particularly young women

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 Marriage Patterns: Rising age at marriage for both males and females Early marriage still a problem in pockets of all societies High incidence of consanguineous marriages Higher numbers of unmarried women in 30s Resurgence of forms of non-conventional marriage

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 Maternal Mortality Maternal deaths concentrated in –Djibouti, Egypt, Morocco, Sudan, Yemen, Risks among young high, but number of deaths may not be known (few studies on age group) Early marriage a factor Anaemia in pregnancy high across region No data on relationship between induced abortion and maternal mortality

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 Unwanted Pregnancy and Abortion Young girls who marry early face strong pressure to bear children Unsafe induced abortion known to occur with often severe health consequences but little data on age group Survey of suicides in Algeria (1980s) showed 30% were unmarried and pregnant

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 Female Genital Mutilation (FGM) and Violence FGM in four countries: –Djibouti, Egypt, Sudan, Yemen and –Also reported in Iraq, Oman, Saudi Arabia, Sexual violence, abuse and incest reported, but little reliable data “Honour killings” reported across region, but much more data in some countries

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 Reproductive Morbidity Giza study: –Prevalence of reproductive tract infections 45% among year olds, 55% among year olds –Genital prolapse was 24% for year olds in Giza study Vasico-vaginal fistulae and prolapse in Yemen and Sudan (early marriage and poor nutrition) Poverty, lack of access to water, and inadequate IUD screening

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 Sexually Transmitted Infections WHO: 600,000 new infections per year but underreporting (esp. women and youth) Most reported: –trichomoniasis, gonorrhoea and syphillis Around 74,000 STIs in 5 countries reported 2002 Study in Morocco: 40% of reported STIs among young adults 15 – 29 years

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 Type 1: Consistently low rates but no consistent testing of high risk groups:  Egypt, Syria, Jordan, possibly Saudi Arabia and Iraq Type 2: Accumulating levels of infection; some rapid increase in identified high risk groups:  Algeria, Iran, Libya, Morocco, Tunisia, Lebanon, Oman, Bahrain, Kuwait, Yemen and possibly UAE and Qatar Type 3: High levels of HIV in general population, although solid epidemiological data are lacking:  Djibouti, Sudan and possibly Somalia HIV Epidemic Levels in the MENA/EM Region

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 HIV/AIDS and Youth Very little data on AIDS related knowledge and behaviour Wide reports of premarital sexual activity at least in urban areas but little research Main modes of transmission: Heterosexual and IDU Most women develop AIDS at younger age (25 – 29) than men (35 – 39) Globally: Married young women more at risk for HIV than sexually active un-married young women

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 Human Immune Deficiency Virus Acquired Immune Deficiency Syndrome HIV/AIDS: WHAT DOES IT MEAN?

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 People Living with HIV: 1980s:100, : 39,400,000 (36-44 million) Damascus, May , Joint WHO-UNESCO-UNICEF Workshop on School Health, Peer ED

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 Orphans: 1990: 1,000, : 11,000, : 25,000,000

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 Regional HIV/AIDS statistics and features, end of 2004 * The proportion of adults (15 to 49 years of age) living with HIV/AIDS in 2004, using 2004 population numbers ** Hetero: heterosexual transmission – IDU: transmission through injecting drug use – MSM: sexual transmission among men who have sex with men Sub-Saharan Africa Caribbean Eastern Europe&Central Asia North America Latin America South and South-East Asia North Africa & Middle East Western and Central Europe Australia & New Zealand East Asia & Pacific TOTAL late ’70s early ’80s late ’80s late ’70s early ’80s late ’70s early ’80s early ’90s late ’70s early ’80s late ’70s early ’80s late ’70s early ’80s 25.4 million million 1.0 million 1.7 million 7.1 million million 39.4 million 7.4% 2.3% 0.8% 0.6% 0.3% 0.2% 0.1% 1.1% 57% 49% 34% 25% 36% 30% 48% 25% 21% 22% 47% Hetero Hetero, IDU IDU, Hetero, MSM MSM, IDU, Hetero Hetero, MSM IDU MSM, IDU MSM, IDU, Hetero MSM Epidemic started Adults & children living with HIV/AIDS Adult prevalenc e rate * % of HIV- positive adults who are women Main mode(s) of transmission for those living with HIV/AIDS ** Adults & children newly infected with HIV 3.1 million million

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 outside region Source: UNAIDS/WHO July – 39% 5 – 15% 1 – 5% 0.5 – 1.0% 0.1 – 0.5% 0.0 – 0.1% not available HIV prevalence in adults, end % % + 60% + 160% + 30% + 40% + 20% Recent trends in HIV infection, 1996–2001 The global view of HIV, end 2001

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 HIV in High Risk Groups- ad hoc surveys, reports-#1 3% in 139 FSW; 2% of sex workers in Oran and 9% in Tamanrasset, 1.7% STD clinic in Oran (2000) Bahrain 0.3% in 291 IDUs (2000) 28% in bar girls, >50% in street FSWs ( ) 0.86% in 815 MSM (2001) 571 new HIV infections, 98% IDUs, (2000) 0 in 945 prisoners Qatar 2.3% in 217 FSW (2001) 0.22% in 458 FSW (registered)(2001) 0.59% in MSM;12% in FSW; 12% in STD patients (1998) 5% in 2240 STD patients (1999) 7% in FSW (2001); 1.8% in 248 STD patients (2000) 5% in 135 arrested IDUs (1999); 8.3% in 60 IDUs (2000) 0.14% in 2102 IDUs (1997) *FSW = Female Sex Workers *IDU = Injecting Drug Users *MSM = *STD = Sexually Transmitted Disease 12% in IDUs (in- treatment) up to 69%(in one prison) (2001) North: 10% in tea sellers, 4% in sex workers, 4% among refugees South: 17% in VCCT centers

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 HIV in General Population Algeria 0.4% in ANC; 0.9% at ANC sites in south (Tamanrasset) Bahrain 0.2% in 627 ANC (1998) Djibouti 2.9% general population (2002) Egypt 0.06% in blood donors, 0.6% TB patients (2000) Libya Jordan 0 ANC (1999);0.03% blood donors (1999); 0.36% in 281 TB patients (2000) Morocco 1.5% ANC (2000) Tunisia Yemen Oman Syria Kuwait Qatar 0.7% in 11,070 low risk persons (1998); 0.04% up to 0.28% in blood donors( ); sex ratio:4:1(M:F) in 1995 to 2:1 in % TB patients (2000) 0 in 2,464 blood donors 0 in 108 ANC ; 0.03% in blood donors (2000).0015% in blood donors 1.7% in 275,307 screened (2000) *ANC = Ante Natal Clinics Sudan 2.5% general population (2000)

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 Do Services Meet Needs?: HEALTH Respondents report service providers often judgemental, young people not welcomed Few scaled up programs: –Egypt Ministry of Health HIV Hot-Line –Oman Ministry of Health HIV Hotline + Outreach to High Risk Groups –Morocco NGO services

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 Do Services Meet Needs?: EDUCATION Lack of life skills and sexuality education programs Gender disparities in access/outcomes Generational differences in education Rural migrants to university often at risk E.g. Tunisia “Double Protection” Project in Tunisian university dormitories

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 Quantitative Research Exists DHS, PAPFAM and Gulf Family Health among others BUT lack of consistent data across region makes comparisons difficult Lack of dis-aggregation or secondary analysis of surveys for relevance to youth Certain questions never asked Limited info on unmarried Need more youth development surveys (PAPFAM Youth Module good opportunity but optional and new)

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 Till Recently little population based data on youth because: 1) Preoccupation fertility/family planning (so only ever married women) 2) It is sensitive to interview unmarried 3) Adolescent policy received little attention

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 Qualitative Research Gaps Perceptions of young people (of services, social norms etc.) Perceptions of adults re youth Reproductive Sexual Health (service providers, parents etc.) High quality and in-depth research (many KAP) Key linkages between development/social trends and RSH (much anecdotal)

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 CONCLUSIONS Lack of access to public Sexual Reproductive Health –Information, –Education, –Counseling and –Services for young people – married and unmarried Knowledge gaps huge –e.g. Need for understanding of this stage of life-cycle in cultural context Most programs small-scale and not sufficiently evaluated How to build on protective factors?

George Ionita MENA HIV/AIDSUNDP Youth Policies and MDG, Bahrain, May 28-29, 2005 Moscow Ballet, Jerash Art Festival 2004 Photo by Dr. George Ionita