HIV and Viral Hepatitis Prevention: Addressing the Needs of Young People Who Inject Drugs

1. HIV and Viral Hepatitis Prevention:Addressing the Needs of Young People Who Inject Drugs Prevention Networking Group Viral Hepatitis Work Group Youth Program February 6, 2008

2. Webinar/Call Etiquette • Mute your phone line • Press *6 to mute • Press #6 to unmute • Questions • There will be dedicated time for questions • Please wait until the Q & A sections to ask Questions • Please identify yourself when asking question/comment • Written Questions • Participants using Microsoft Live Meeting may have the ability to submit written questions during the webinar • Please feel free to use this feature if you would like

3. Jurisdictions Registered for Call NH VT WA ME ND NY MT MA MN OR WI SD RI MI ID CT WY PA NJ OH IA NE IN DE NV IL CO WV UT KY VA MD KS MO CA NC TN DC OK AZ AR SC NM GA AL MS AK TX LA FL U.S. Virgin Islands HI 44 Jurisdictions Close to 100 Participants

4. Overview • Focus on Young People who Inject Drugs • HIV, Hepatitis and Youth Development and Programs • Opportunity to interrupt disease transmission • Invisible population • Venue to Talk with Our Peers

5. Webinar Objectives • Provide information to health department HIV and viral hepatitis programs on working with marginalized youth, particularly young people who inject drugs. • Discuss interventions that address the complex and unique HIV and viral hepatitis prevention needs of young people who inject drugs. • Identify specific strategies that health department HIV and hepatitis programs can employ to increase or enhance prevention services for young people who inject drugs.

6. Webinar Agenda • Welcome & Overview • Ann Shindo • Adult Viral Hepatitis Prevention Coordinator, Oregon • Engaging Marginalized Youth • Jerry Fest • JTFest Consulting: Training & Development, Oregon • Making Space for Young Injection Drug Users • Eliza Wheeler • Program Manager, Cambridge Cares About AIDS, Massachusetts • Ed Debortoli • Massachusetts Department of Public Health • UFO Study – University of California San Francisco • Kim Page-Shafer • Principal Investigator • Facilitated Discussion

7. Overview of Issues Facing Youth • Adolescence ~ highly pathologized • Adolescence ~ characterized by • More abstract cognitive functions • Self-growth and identification through peer-based relationships • Adolescence ~ highly volatile period for youth who have experienced trauma

8. High-Risk Youth Youth who experience trauma (including homelessness) are at susceptible to high-risk sex and drug behaviors that put them in the public health intervention realm – why we’re here today!

9. Specific Issues Drug & Sex behavior of concern: • 60% ~ some substance use • 6% ~ injectable substances use • 85% ~ sexually active (Baron, 1999; Forst & Crim, 1994; Greene, Ennett, & Ringwalt, 1997; Pires & Silber, 1996; Solorio, et. al., 2008)

10. Specific Issues Bottom Line: • Homeless, marginally housed high-risk youth are at greater risk of HIV, viral hepatitis, and STDs in comparison to housed youth. • Higher incidents of hunger, rape, survival sex and drug use ~ increases the likelihood of BBP transmission. (Kipke et al., 1992 & 1997)

11. Specific Issues Public Health Focus: • Safe syringe access and disposal programs • NEX, pharmacy sales, syringe drop kiosks • Many jurisdictions have age limits – OR = no prescription required for persons age 18 years and older Oregon Revised Statutes (§§ 475.525, 1987)

12. Where Does PH Begin? • Greater understanding of the target population • Identification of evidence-based programs that work to address youths’ needs in culturally competent, age-appropriate fashion

13. Where Do We Need To Go • Development of appropriate youth services; • Acquisition of funding for primary prevention activities targeting youth (instead of serostatus-based funding algorithms); • Evaluation criteria that consider appropriate developmental benchmarks not just head counts; Others?

15. Youth Risk Behavior Surveillance System Housed or In-School Youth Report • 71% of all deaths among youth 10 – 24 years old due to: • Motor-vehicle crashes • Unintended accidents • Homicide • Suicide (MMWR, 2006)

16. Youth Risk Behavior Surveillance System Drug, including alcohol, behavior of concern: Within 30 days YBRS youth report: • 9.9% driven while intoxicated • 43.3% consumed alcohol • 20.2% consumed marijuana/pot • 2.1% ever used a needle for drug-use (MMWR, 2006)

17. Youth Risk Behavior Surveillance System Sexual behavior of concern: • 46.8% ~ had engaged in sexual intercourse • 37.2% ~ had not used condoms @ last sexual intercourse • 7.5% ~ have been forced to have sex when didn’t want to (MMWR, 2006)

18. Engaging Marginalized Youth A brief overview of issues and strategies to consider when intervening in the lives of difficult-to-serve young people Presented by Jerry Fest

19. Introduction • Background: Homeless, Street-dependent youth • Training/Consultation: Positive Youth Development Agenda • Discuss some of the general issues related to working with marginalized youth • Provide an overview of the Positive Youth Development (PYD) approach • Relate PYD to Harm Reduction principles

20. General Issues: #1 • Marginalization is external and internal “I may be nothin’ more than a sleazy little street walking whore, but by God at least I’m honest about it.” - Street Culture: an epistemology of street-dependent youth

21. General Issues: #2 • The impact of concepts of time “I like living hour to hour. I just don’t get this week to week shit.” - Street Culture: an epistemology of street-dependent youth

22. General Issues: #3 • Relevance of prevention rationale “The streets aren’t under your feet, they’re under your scalp.” - Street Culture: an epistemology of street-dependent youth

23. PYD: The Beginning … • “The starting point is the belief that all youth have innate resilience” • - Bonnie Benard • Werner, E. and Smith, R. (1982, 1989). Vulnerable but Invincible: A Longitudinal Study of Resilient Children and Youth. New York: Adams, Bannister, and Cox. • Werner, E. and Smith, R. (1992). Overcoming the Odds: High-Risk Children from Birth to Adulthood. New York: Cornell University Press. • Benard, B. (2002). "The Foundations of the Resiliency Framework: From Research to Practice". In Resiliency in Action: Practical Ideas for Overcoming Risks and Building Strengths in Youth, Families, and Communities. San Diego, Calif.: Resiliency in Action. Also available at c

24. The other 30-50% • Why do some young people demonstrate resilient behavior, while others do not? • An individual’s capacity for resilience is affected by internal and external factors • Environmental factors can foster or inhibit a young person’s capacity for resilience.

25. Risk Factors Abuse/neglect, Family conflict, Poor family support, Substance use/abuse, Poor or unstable housing or homelessness, Extreme economic or social deprivation, Community deterioration or disorganization, Community violence and/or gangs, Inadequate education and recreational opportunities, Mental or physical health issues, Learning disabilities, Early unplanned pregnancy, Cultural and/or linguistic isolation … to name a few … • Risk Factors inhibit resilience

26. Protective Factors • Protective Factors foster resilience • Caring/Supportive Relationships • High Expectations • Meaningful Participation

27. Caring/Supportive Relationships • Caring • Someone is interested in the fact that I exist • Supportive • I can count on someone as a resource • Relationship(S) • Multiple • Defined • Appropriate

28. High Expectations • What “High Expectations” is not: • Positive Thinking • Goals, Measurements, Benchmarks, etc. • High Expectations are beliefs • Messages from people and environments about who a young person is and what they are capable of doing • High Expectations reflect what you really believe about a young person

29. Meaningful Participation • Anything that directly affects them • Choices, decisions, actions, environments, etc. • Must be legitimate • Does not mean that youth have all the power and can do anything they want • Does mean young people as legitimate stakeholders; participation is real and valued

30. Research base of PYD • All people are innately resilient • The human capacity to face, overcome, and even be strengthened by adversity • External factors affect resilience • Risk Factors inhibit resilience • Protective Factors foster resilience • Caring/Supportive Relationships • High Expectations • Meaningful Participation

31. PYD Defined • Youth Development as a concept: • A process by which all people seek ways to meet their basic physical and social needs and build competencies • Youth Development as a practice: • An approach to working with young people that fosters their innate resilience and supports their developmental process

32. A Framework for PYD … • PYD is implemented, that is, Protective Factors are created, through an approach best remembered with the acronym (s)OS • (services) • Opportunities & Supports

33. (s): (services) • Services are not PYD • They are sometimes a necessary foundation for PYD • To or For • Anything that can be defined as being done toor for another is by definition a service

34. Opportunities & Supports • Opportunities without supports • A setup for negative youth experiences • Supports without Opportunities • Staff directed activity • Opportunities AND related Supports • Create a framework for Protective Factors

35. Opportunities • By • Things that are done by young people • Requires voluntary participation and internal motivation • Requires honesty on the part of adults

36. Supports • With • Things that are done with young people in support of their opportunities • People, resources, information, guidance • How do you teach someone to drive?

37. The Essence of PYD • An approach to working with young people designed to foster their innate resilience by exposing them to Protective Factors. • Protective Factors are created by minimizing the things you dotoor foryoung people (services)and maximizing the things they do with your support (opportunities & supports).

38. PYD and Harm Reduction • PYD is an approach, not a model • PYD is not what you do, it is the way you do it • As an approach, PYD is compatible with many strengths-based models • Motivational interviewing • Stages of Change • &, particularly with drug-affected populations, Harm Reduction

39. Principles of Harm Reduction • Be nonjudgmental, avoid labeling • Avoid being parental/authoritarian, meet the client where they are • Value the client's information, emphasize client's strengths • Avoid having preconceived goals, provide guidance and consultation • Provide support, build rapport/trust • See small changes as success, emphasize personal responsibility for outcomes • In other words, Harm Reduction: • Works through relationship, demonstrates high expectations, and allows for meaningful participation • Is present focused and relevant to a young person’s current needs, reality, and environment

40. THANK YOU! “If we take people as we find them, we may make them worse, but if we treat them as though they are what they should be, we help them to become what they are capable of becoming.” - Johann Wolfgang von Goethe

41. Making Space for Young Injection Drug Users: Identifying Opportunities and Challenges Presented by Eliza Wheeler Cambridge Cares about AIDS Data from the YIDU Study, designed and implemented by CCA and the Institute for Community Health Participant statements taken from video documentary of YIDUs who access the Cambridge NEP

42. HIV/AIDS and IDUs • As of 2005, 30% (N=4,773) of PLWHA in Massachusetts had a history of IDU • 6% (N=899) were exposed to HIV through heterosexual sex with an IDU partner • From 1996 to 2005, the proportion of deaths among people diagnosed with AIDS represented by those who had a history of IDU rose from 42% to 55%. *Massachusetts HIV/AIDS Surveillance Program

43. HIV and young people, MA • From 2003 to 2005, 7% (N=201) of HIV diagnoses in Massachusetts were among 13 and 24 year olds. • Of all HIV infections among 13-24 year olds (2003-2005), 9% identified IDU as mode of exposure. *Massachusetts HIV/AIDS Surveillance Program

44. HCV and young people, MA • From 2002 to 2006, rates of newly diagnosed reported HCV infection in 15 to 25 year-olds in Massachusetts rose from 16 to 44 per 100,000 population. • 1,054 (14%) of cases in 2006 were 15 to 25 years of age. *Massachusetts Hepatitis Surveillance Program Onofrey SL, Church DR, Heisey-Grove DM, Briggs P, Bertrand TE, DeMaria A Jr.

45. Opioid-related data: 2005 • 43,450 treatment admissions for heroin** • 71% of these individuals reported IDU** • 544 opioid-related deaths** • 11,750 opioid-related ED visits* • 17,104 opioid-related acute care inpatient hospital discharges* • According to 2004-2005 data, 150,000 MA residents reported needing, but not receiving treatment for illicit drug use within the year*** *MDPH Bureau of Substance Abuse Services **MDPH Center for Health Information, Statistics, Research and Evaluation ***SAMHSA State Estimates of Substance Use from the 2004-2005 National Surveys on Drug Use and Health, February 2007

46. 18-25 year olds who enrolled in the NEP in FY05/FY06: There is low rate of seropositivity at the time of enrollment, but many do not know their status. • Less than 1% HIV positive, but over 20% didn’t know their status • Only 9% HCV positive, but nearly 30% didn’t know their status Approximately half report sharing injection equipment, either sometimes or always. • Approximately 50% report NEVER sharing syringes, over 40% report NEVER sharing cookers/cotton

47. Continued… Many already have a history of accessing drug treatment programs. • 67% have already been in treatment of some kind. Nearly two-thirds report never or sometimes using condoms. • Over 30% NEVER, approximately 30% SOMETIMES. Many have experienced overdose, or witnessed another person overdose. • 22% their own experience, approximately 50% had witnessed another person.

48. Why did we do the YIDU study? • Beginning in 2003, needle exchange staff noticed a significant increase in the number of young people (18-25) that were enrolling in the program. • This trend mirrored media reports and drug treatment data showing an increase in heroin and OxyContin use among young people in the state. • Between 2005-2006, 18-25 year olds accounted for over HALF of new enrollees into the program. • We wanted to respond to this trend by gathering more information to advocate for services or develop new interventions for this population.

49. Who was interviewed? • 150 Young Injection Drug Users (18-25 years old) who were enrolled in the needle exchange program, between September 2005 and July 2006. • 51% males and 48% females • 96% White • 75% completed 12th grade or higher • 38% employed in a part or full-time job • 38% had no health insurance • 80% were housed (NOT homeless) • Residents of 46 different Massachusetts towns responded to the survey.

50. Average ages of first use: