1. Young Key Populations

2. Data availability and data issues

3. 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.

4. 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

5. 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…

6. 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

7. 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

8. 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

9. 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 based on National HIV Sentinel Surveys and

10. 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 based on Behavioral Surveillance Surveys; Integrated Biological and Behavioral Surveys; and

11. 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 based on National HIV Sentinel Surveys; Bio-Behavioural Surveys;

12. 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 based on National HIV Sentinel Surveys and

13. 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 based on Behavioral Surveillance Surveys; Integrated Biological and Behavioral Surveys; and

14. 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 based on

15. 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] = = 38-7 = 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 for FSW, for MSM and 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 based on National HIV Sentinel Surveillance and HIV Prevalence Reports ; Global AIDS Response Progress Reports- Country Reports (2012) ; UNGASS Progress Reports (2010).

16. 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] = = 38-7 = 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 for FSW, for MSM and for PWID; and Malaysia in BSS 14-<60 y FSW, MSW, TG and 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 based on National Behavioral Surveillance Reports ; Global AIDS Response Progress Reports- Country Reports (2012) ; UNGASS Progress Reports (2010).

17. 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 based on National HIV Sentinel Surveillance, HIV Prevalence Surveys and Behavioral Surveys; Global AIDS Response Progress Reports- Country Reports (2012) ; UNGASS Progress Reports (2010).

18. 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 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

19. HIV prevalence and epidemiology

20. 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 based on UNAIDS estimates 2012

21. 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 based on

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

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

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

25. Risk behaviours

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

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

28. 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,
Source: Prepared by based on

29. 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,
Source: Prepared by based on

30. 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,
Source: Prepared by based on

31. Condom use at last sex among sex workers by age group, countries where the data is available,
* FSW only
** FSW and MSW
*** FSW and TG SW
Source: Prepared by based on

32. Vulnerability and HIV knowledge

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

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

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

36. National response

37. 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

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

39. 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 based on

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

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

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

43. slides compiled by www.aidsdatahub.org
THANK YOU
slides compiled by
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 if slides are lifted directly from this site