Towards a common understanding of MARA/MARYP in the context of HIV/AIDS

1. Consultation on Strategic Information and HIV Prevention among Most-at-Risk Adolescents Geneva, 2-4th September YOUNG PEOPLE ADOLESCENTS Towards a common understanding of MARA/MARYP in the context of HIV/AIDS YOUTH RISK VULNERABILITY MOST-AT-RISK MARA MARPs MARYP EVAs Bruce Dick Department of child and Adolescent Health and Development WHO Geneva

2. Overview • Understanding adolescents • Why bother to give special attention to adolescents? • What do adolescents need for their health and development? • Understanding "most-at-risk" • What do we mean by most-at-risk, and which populations are most-at-risk? • DO we really need to focus on adolescents within these most-at-risk populations? • Understanding vulnerability • Preventing HIV in MARAs: why do we need to understand vulnerability? • What makes adolescents vulnerable to becoming MARAs?

3. Adolescents, youth, young people … who are we talking about? • Defining a period between childhood and adulthood • Adolescents: 10-19 years • Youth: 15-24 years (national variations) • Young People: 10-24 years (adolescents plus youth) • Age is only one factor that defines this period (eg. marital status, economic independence) • It is important to focus on the group of the population that is MOST different from children and adults

4. … SO, what's so special about adolescents? • A period of rapid development and change: • Physical: their bodies and brains, their physical and cognitive abilities • Psychological: how they think about themselves and others; how they deal with and express their emotions; future orientation • Social: their relationships and roles, expectations (of themselves and by others), opportunities, moving towards family formation, economic security, and citizenship

5. OK … but why is that important for HIV prevention, care and treatment? • Because these changes have implications for: • How they understand information and what influences them • How they think about the future and make decisions in the present • How they perceive risk in a period of experimentation and first-time experiences • Sexual behaviour during this period of development: relationships, sexual debut, sexual identity …

6. What do adolescents need for their health and development?

7. Many individuals, groups and systems meet young people's needs for health and development Social values Service providers Peers Family Family Adolescent Community leaders Policies

8. Common Determinants for different behaviours (risk and protective factors) Risk & Protective factors for adolescents Early Sex Substance Use Depression A positive relationship with parents Conflict in the family A positive school environment Friends who are negative role models A positive relationship with adults in the community Having spiritual beliefs Engaging in other risky behaviours *”Broadening the Horizon” Evidence from 52 countries: http://www.who.int/child_adolescent_health/documents/en/

9. OK … so what do we mean by "most-at-risk of HIV" Behaviours that put people most-at-risk of HIV transmission include: • Having penetrative sex (vaginal or anal) with multiple partners, without using a condom • Injecting drugs, using equipment that has been shared

10. SO, what do we mean by most-at-risk groups? • there are some groups/individuals who almost by definition adopt (or are forced to adopt) these behaviours: • Female or male sex workers • Injecting drugs users • Men who have sex with men • the risk of HIV transmission is increased because: • The behaviours are often illegal • The behaviours often cause these individuals/groups to be marginalized • The behaviours often co-exist (eg. sex work and drug use)

11. Of course there are other groups who could be considered "most-at-risk" • Anyone who has sex or is forced to have sex with someone who is/is likely to be HIV positive is at risk if they don't use a condom… for example: • People who have sex with sex workers • The HIV negative partner in discordant couples (e.g. the wives of men who have sex with sex workers) • Adolescent girls who have sex with older men in high prevalence settings

12. Most-at-risk groups are at the centre of HIV transmission in concentrated epidemics Hyperendemic Generalized Concentrated

13. Need to remember that most-at-risk groups are also epidemiologically important in generalized epidemics Multi-partner sex, paid sex, STIs and HSV-2 infection are as important to HIV transmission in advanced as in early HIV epidemics. Even in high prevalence settings, prevention among people with high rates of partner change, such as female sex workers and their male clients, is likely to reduce transmission overall. Chen L et al. Sexual risk factors for HIV infection in early and advanced HIV epidemics in sub-Saharan Africa: systematic overview of 68 epidemiological studies. PLoS ONE 2(10): e1001, 2007.

14. (N) (91,546) (118,279) (11,381) (76,315) (23,269) (74,263) 100 80 Percent new infections 60 40 20 0 Swaziland Lesotho Mozambique Uganda Zambia Kenya Incidence by Modes of Transmission MARPs MARPs Other Partners of clients of female sex workers Clients of female sex workers Injecting drug users Men having sex with men Casual heterosexual sex Partners (Casual heterosexual sex) Low risk heterosexual Sources: Draft results from Know your Epidemic project – acknowledgements Cate Hankins, UNAIDS

15. OK … but why focus on young people in most-at-risk populations? A significant percentage of most-at-risk populations are under 25 years Percent of female sex workers who are adolescents or under the age of 25 years AIDS in Asia: Face the Facts – WAP Report 2004 http://www.mapnetwork.org/docs/MAP_AIDSinAsia2004.pdf

16. … and these young people are at high risk of becoming infected with HIV: sex workers and injecting drug users AIDS in Asia: Face the Facts – WAP Report 2004 http://www.mapnetwork.org/docs/MAP_AIDSinAsia2004.pdf

17. … and young people may not be well targeted in the programmes that are implemented for most-at-risk groups Young MSM CDC (2009): HIV/AIDS and young men who have sex with men http://www.cdc.gov/healthyyouth/sexualbehaviors/pdf/hiv_factsheet_ymsm.pdf

18. Age is therefore an important factor in developing and implementing interventions for most-at-risk populations, because: • Adolescents' phase of development (e.g. knowledge, skills, concern (or not) about the future, peer influence) • Less likely to identify themselves as a member of an "at-risk group" (e.g. injecting drug user or sex worker) • Less likely to be fixed in their behaviour (eg. exploratory injecting drug use) • More easily exploited and abused • Less likely to have access to, or to use services (awareness, consent, resources) Implications for interventions: the content of services may not need to be so different from other MARPs, but how they are delivered will likely need to be different

19. In principle, preventing HIV in MARAs is simple • Do not become a sex worker or an injecting drug user (primary prevention) • Stop being a sex worker or an injecting drug user (secondary prevention) • If you are a sex worker or a man who has sex with men, use a condom consistently and correctly (risk reduction) • If you are an injecting drug user, use clean needles and syringes (harm reduction) BUT in reality it is clearly not so simple! … so we need to understand not just the behaviours, but why some adolescents do or do not adopt these behaviours

20. These factors give rise to the concept of vulnerability … vulnerability results from societal factors that effect adversely one's ability to exert control over one's own health … these societal factors increase and perpetuate the vulnerability of certain individuals and sections of society more than others … Based on: UNAIDS (1998), Expanding the global response to HIV/AIDS through focused action. Reducing Risk and Vulnerability: definitions, rationale and pathways

21. Many levels to consider: a pathway for gender inequality creating vulnerability to transactional sex Geeta Rao Gupta et al, The Lancet, Volume 372, Issue 9640, Pages 764 - 775, 30 August 2008

22. Many factors make adolescents vulnerable to becoming MARAs?

23. Examples of vulnerable adolescents, sometimes called "especially vulnerable adolescents" (EVAs) • Adolescents living on the streets • Adolescents living in prisons/correctional facilities • Adolescents living where there is easy access to drugs (in their family or community) • Adolescents living in families where there is physical and/or sexual abuse • Adolescents living in extreme poverty • Adolescents who are trafficked • Adolescents living with disabilities • And many others … It is important to understand why they are vulnerable and how this increases the likelihood that they will become MARA … this has implications for what we measure and what we need to do

24. It is important to understand the factors that make adolescents vulnerable so that we can be clear about: • What needs to be done to prevent people from becoming MARAs • Where to target interventions in order to reach MARAs • What prevents MARAs from accessing information and services that will decrease HIV transmission

25. Male and female adolescents who are engaged in behaviours that put them at high risk of HIV (eg. injecting drugs with shared needles/syringes, having unprotected sex with many partners) As for the general population and EVAs, plus: Interventions to reduce harm and change behaviour to decrease risk Differences between the general population of adolescents, vulnerable adolescents, and MARA General Population of Adolescents MARAs Adolescents with individual characteristics or environmental factors that make it more likely that they will adopt high risk behaviours As for the general population, plus: Structural interventions (e.g. education) Individual interventions to mitigate vulnerability (e.g. counseling and protection) Especially Vulnerable Adolescents The general population of adolescents … some will become vulnerable and some will adopt behaviours that will put them at high risk of HIV Interventions: information, skills, services

26. "Combination prevention" for most at risk adolescents

27. MARA require much more attention in concentrated epidemics Percentage of new HIV infections that can be prevented among young people and allocation of resources for young people by Joint UN Workplan Source: Draft UNAIDS Training Manual for Design and Costing of HIV Programmes in Asia

28. THANK YOU