1. 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 Funded by the Open Society Youth Initiative Neil Hunt, Damon Barrett, Adam Fletcher

2. Overview 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 2

3. Project goals 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

4. Why Under-18s? 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 4

5. 5 ‘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 The acid test OF our policies is the quality of responses for children like ‘Chao’

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

7. United Nations Convention on the Rights of the Child (1989) 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.

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

9. Core services for People Who Inject Drugs (PWID) 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 9

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

11. UNGASS indicators 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+) HOW USEFUL FOR UNDER-18S? VIRTUALLY USELESS

12. Our understanding of the problem is often little more use than a chocolate teapot 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 12

13. Risk and protective factors: recurring themes 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

14. Philippines (an example) 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 ZAMBOANGA GENERAL SANTOS

15. Youth: Male Injecting Drug Users Integrated HIV Behavioral and Serological Survey (IHBSS) (DoH, 2009) 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%

16. Mateo et al. "HIV/AIDS in the Philippines." “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

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

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 Guidance for practice is difficult to find, often outdated, and unhelpful 18 As an example: Global Fund programming guidance ‘Harm reduction for people who use drugs’ (2011) omits any mention of under-18s

19. Recommendation 5.4 “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 19

20. Core services for People Who Inject Drugs (PWID) 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 20

21. Legal, policy and ethical problems 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

22. 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 23 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. Effective interventions? 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

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

26. UK: OST, opioid detox, naltrexone, alcohol/benzodiazepine withdrawal Pharmacological management: Should be in line with the recommendations in the National Service Framework for Children, Young People and Maternity Services (2004). Is only one component of addressing substance-related needs. Should be based on a holistic assessment of the child or young person’s needs and tailored to those needs, not delivered as a ‘one model fits all’ programme. Could reduce self-harm and suicidal behaviour. Should be delivered alongside specific psychosocial interventions to provide comprehensive care for substance misuse. Should be delivered alongside mental health services for those children and young people with mental health needs. Should be delivered in the context of a clear clinical governance framework. National Treatment Agency (2009) Guidance for the pharmacological management of substance misuse among young people. Department of Health. National Treatment Agency (2009) Guidance for the pharmacological management of substance misuse among young people in secure environments [online]. London

27. New South Wales, Australia: Needle and Syringe Programs (NSP) “Depending on the age of the child, a clinical decision may be required to determine that it is appropriate to provide injecting equipment. It is essential that advice be provided regarding drug and alcohol and other support services prior to provision of injecting equipment.” The following actions must be undertaken: –attempt to engage the child to assess the level of risk (including risk of exposure to blood borne virus) –assess whether the provision of clean equipment is appropriate –assess the extent of any other risks faced by the child and provide appropriate support, advice or other interventions –prior to providing equipment NSP staff must provide the child with information on alcohol and other drugs support services available to the child –make a report to the Department of Community Services.

28. Recommendations 1.Standardise the way we monitor the number of children and adolescents who inject drugs internationally 2.“Know our epidemic” and how it differs from that of adults in order to “know our response” 3.Make guidance accessible, specific and relevant 4.Collaborate internationally to produce enabling legal and policy frameworks that respect child rights 5.Listen to children and adolescents who inject and demonstrate clearly how what they tell us informs our responses 6.Learn from existing good practice and collaborate internationally to fill the many, urgent gaps 28

29. Further information Neil.Hunt@lshtm.ac.uk Damon.Barrett@ihra.net Adam.Fletcher@lshtm.ac.uk www.ihra.net