Regional Interagency Working Group on Young People and HIV/AIDS, MENA

1. Regional Interagency Working Group on Young People and HIV/AIDS, MENA Hala Abou-Taleb UNAIDS Inter-Country Programme Development Adviser Inter-Country Team Middle East and North Africa UNFPA HIV/AIDS Regional Meeting 20-24 June 2004, Cairo

2. First Regional UNAIDS andCosponsors Meeting November, 2001 • Young People identified as a regional priority • UNFPA, UNICEF, and UNESCO convene an Interagency Working Group on young people & HIV/AIDS

3. First IAWGYP MeetingMENA,Cairo, December 2002 • Facilitated by UNAIDS inter-Country Team UNAIDS Cosponsors, and partners including, Arab Scouts Movement, IFRCRC, FHI, USAID, CEDPA • Mapping exercise of interventions and available regional resources • Identified priority areas of interventions

4. First IAWGYP MeetingMENA,Cairo, December 2002 (Contn’) • Two Task Regional task Forces Recommended: • Data Collection • Peer Education

5. Regional Task Force on Data Collection • Facilitated, coordinated, and technically supported by UNAIDS ICT, MENA • Objective of the Data Collection Task force: • Collection of strategic information on young people vulnerability and risk and content analysis of YP programmes in the area of SH, RH and RR • Joint Regional UNICEF and UNFPA Strategic Planning and Coordination

6. UNFPA Technical research Team based in AUB, Beirut conducted a data inventory on KAP studies • UNICEF Regional research team • Two task force meetings during 2003 in Beirut and Amman • Outline of the regional assessment identified • Data reviewed and discussed • First draft report discussed with UNICEF Adolescents Focal points, UNAIDS ICT, MENA, and regional partners, on 13th June 2004

7. Situation Analysis and Recommendations Review of Young People’s Sexual and Reproductive Health and Rights in the Arab States and IranSponsors: UNICEF, UNAIDS, UNFPA Bonnie L. Shepard & Jocelyn DeJong For presentation at UNFPA regional meetings on HIV/AIDS and Young People June-July, 2004

8. Objectives of the Review • Strengthen the knowledge base on YPSRH • including gender issues, program and policy context • Provide recommendations and arguments for national YPSRH and gender policies and programs based on • international frameworks and evidence • regional data • Identify gaps in the knowledge base

9. Methodology • Desk-based review of published and unpublished literature • Policy analysis of YPSRH frameworks in international human rights treaties, and comments to countries from treaty bodies • Telephone interviews with key country, regional, and international informants • In-person interviews and data collection by research assistants in Lebanon, Jordan, Egypt and Tunisia • Email survey to UNFPA, UNICEF, IFRC

10. Products of Review • Executive Summary • Review of human rights frameworks and YPSRH • Review of international YPSRH program evidence on effective practices • Situation analysis, including data table • Recommendations -- Policy, Programs, & Research • Country policy reviews from treaty body data • Bibliiography, including thematic “key resources” • Stand-alone policy report -- advocacy tool

11. Situation Analysis Jocelyn L. DeJong University of Manchester

12. Considerable Social Change and Unmet Need • One third of region is 10-24 years old • Rising age at marriage & educational levels • Rapid social change: urbanization; rising unemployment; breakdown of social networks; exposure to global media; migration; widening generation gaps; changing gender roles, etc. • Few policies/services dedicated to age group • Almost no scaled-up SRH programs • Youth ministries/agencies weak and underfunded

13. Need for Positive Youth Development Approach • Arab HDR: high desire for emigration among young people – need to address their concerns • Need to integrate Sexual and Reproductive (SRH) with youth health and development • Need for positive assets-building approach • Focusing on protective factors and strengths • Seeing youth as part of solutions, not deviant or politically dangerous • Enabling participation of young people in policy-making and programs

14. 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?

15. Political Context • Conflict creates vulnerability: e.g. Palestine (early marriage), Sudan (HIV/AIDS),Iraq (violence against young women), and refugees in several countries • Nascent SRH movement • Political reluctance to support HIV-related research and programs for highly vulnerable groups: CSWs, MSMs, IDUs, street children • Political participation of youth limited

16. Social Context Protective factors: • Strong family solidarity • Intra-regional shared heritage • Increasing age at marriage prevents too early childbearing • Rising levels of education • Greater communication/access to electronic media • Religious values that in some instances positively promote SRH

17. Risk Factors for Young People’s Sexual and Reproductive Health • Pockets of early marriage in most countries • Rising marriage age -- risks from pre-marital sexual activity • Gender inequities wide and persistent • FGM/C in four countries • Strong stratification in households by gender and age • Physical and sexual violence reported, but unstudied • Substance abuse in some countries • Stigma attached to unmarried sex

18. Highly vulnerable groups --SRH issues unstudied • CSWs -- from within and outside of region • street children • MSM • young married girls under age 18 • labor migrants -- male and female • refugees • young people in conflict situations • women involved in summer or temporary marriages, and their children

19. Marriage Patterns: SRH Implications • Rising age at marriage for both males and females • Early marriage still a problem in pockets of all societies • Declining but still high incidence of consanguineous marriages • Higher numbers of unmarried women • Resurgence of forms of non-conventional marriage

21. Maternal Mortality • Maternal deaths concentrated in Yemen, Djibouti, Morocco, Egypt and Sudan • Early marriage and stunting in childhood are factors • Anemia in pregnancy high across region • No data on relationship between induced abortion and maternal mortality

22. Unwanted Pregnancy and Abortion • Very little data on unmet need for FP in this age group • Young girls who marry early face strong pressure to bear children • Unsafe induced abortion known to occur with often severe health consequences • Survey of suicides in Algeria (1980s) showed 30% were unmarried and pregnant

23. Reproductive Morbidity • Giza study: prevalence of reproductive tract infections was 45% - 55% among 14-19 and 20-24 year olds • Genital prolapse was 24% for 14-19 year olds • Vasico-vaginal fistulae and prolapse in Yemen and Sudan (early marriage and poor nutrition) • Poverty, lack of access to water, and inadequate IUD screening all factors

24. STIs • WHO: 600,000 infections per year but underreporting (esp. women and youth) • Most reported: trichomoniasis, gonorrhoea and syphillis • Around 74,000 STIs 5 cos. reported 2002 • Study in Morocco: 40% of reported STIs among young adults 15 – 29 years

25. HIV Epidemic Levels in the MENA/EM Region 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 Source: World Bank/WHO/UNAIDS 2002: 13

26. HIV/AIDS and Young People • Very little data on HIV/AIDS related knowledge, attitudes, and behaviour • Widespread reports of premarital sexual activity at least in urban areas but little research • Estimated new HIV infections 2000: 83000 • Main modes of transmission: Heterosexual, IDU • Most women develop AIDS at younger age (25 – 29) than men (35 – 39) • Some vulnerable groups mainly young: CSWs, IDUs, street children, labor migrants, (MSM?)

27. Substance Abuse • % of IDUs among total regional AIDS cases from 2% in 1999 to 9% in 2002. • Libya: IDU is main HIV transmission mode • Iran: 1.2-1.6 million drug users • 12 – 16% are intravenous drug users (IDUs) • 10% start before 15 years old • Many IDUs young and in prison, where HIV infection rate is 8% • Government has faced problem with harm reduction

28. FGM and Violence • FGM in four countries: Egypt, Sudan, Yemen and Djibouti • Physical and sexual violence, abuse and incest reported, but little reliable data • “Honour killings” reported across region, but much more data in some countries

29. Do Services Meet Needs?: HEALTH • Respondents report widespread lack of adequate SRH services for married & unmarried • Existing programs small-scale and poorly evaluated • Service providers judgmental with unmarried young people • Few scaled up programs • E.g. Iran Premarital Counselling • E.g. Egypt MOH&P AIDS Hot-Line • Few programs for vulnerable groups

30. Do Services Meet Needs?: EDUCATION • Gender disparities in access/outcomes • young married girls denied access to education and employment • In 3 countries, girls less access than boys to secondary level (Yemen, Morocco, Iraq) • Rural migrants to university often particularly vulnerable to SRH risks • Lack of life skills, health, and SRH education programs for in-school and out-of-school

31. CONCLUSIONS • Lack of access to public SRH 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?

32. Recommendations Bonnie L. Shepard & Jocelyn L. DeJong

33. Overarching principles • Young people’s participation • Representation, participation in decisions • Positive youth development approach • Comprehensive multisectoral designs • Community and parent involvement • Convention on the Rights of the Child framework • Evidence-informed programming • Context – disaggregated data • Evidence from global experience • MONITORING AND EVALUATION!!!!

34. “Youth-friendly” approaches • Train for empathetic, non-judgmental interactions • For adult and peer educators and providers • Emphasize privacy and confidentiality • Attend to young people’s preferences • Respond to young people’s particular barriers to access • Physical, financial, gender-based, administrative, legal, psychological, social • Facilitate active participation of young people

35. Advocacy always necessary • Gain political and administrative support • Policy dialogue with and involvement of decisionmakers and gatekeepers • Fill knowledge gaps to demonstrate need • Evaluate pilot programs to demonstrate success, and advocate for scale-up • Involve young people, parents, and community in needs assessments • question-asking exercises useful to break the silence, demonstrate information needs

36. Program Recommendations • Youth-serving agencies are urged to give priority in SRH & HIV programs to: • young people in pockets of high poverty • Marginalized vulnerable groups (street children, CSWs, MSMs, IDUs, imprisoned) • SRH education and counseling where young people are congregated in large numbers (schools, military, youth organizations, etc.)

37. Program Recommendations • Education (by adults and peers) in SRH and gender where young people are congregated in large numbers • Schools and universities • Sports programs • Military • Youth development programs & groups (scouts, vocational training, etc.) • Religious youth programs and organizations

38. Media and Entertainment Education • Entertainment education-- apt for breaking silence, dialogue, and peer education • Create or reproduce high quality media education products for SRH education programs • Other cultural events that stimulate discussion • Media-based strategies • Sustainable Partnerships with media outlets or shows • Analysis of outlets/shows young people listen to • Social marketing and “friendly” pharmacies to promote condoms

39. Recommendations for SRH service delivery -- general population • Pre-marital counseling programs (Iran) • Telephone hot lines as in Egypt MOH • Internet-based chat counseling • Pharmacy programs, with social marketing • Peer education models • Networks of trained youth-friendly health providers, mainly in private sector

40. Additional Recommendations for HIV prevention • Peer education, access to condoms and services, and VCT with vulnerable groups • Harm reduction programs for IDUs • Military health services include RSH • Destigmatize HIV+ & vulnerable groups. • RTI and STI VCT (including HIV) in primary care facilities

41. Not recommended highly • Youth centers • Unless transformed into an outreach program • One-shot media campaigns • Clinic-based SRH services

42. Policy recommendations • Strengthen resources and roles of youth ministries • Multisectoral coordination • Mechanisms for young people’s participation • Build capacity of National AIDS programs to work with young people • Consider CEDAW and CRC country comments for recommended policy changes • Especially increased attention to YPSRHR!! • Legal frameworks to re violence against women

43. Policy Recommendations • Education • Increased investment in secondary education, especially where below 80% • Eliminate discrimination against girls (3-4 countries) • Enable participation of married girls • Promote sports programs for girls

44. SRH policies • Reduce early and forced marriages • legal framework plus enforcement mechanisms • 3-pronged approach to eliminating FGM/C • Legal measures with enforcement • Media campaigns reaching diverse audiences • Community-based campaigns to delink FGM from marriagability • Reduce abortion rates and unsafe abortion • Removing criminal penalties • Widespread access to SRH education and contraception to reduce rates • Address sexual and physical violence and sexual harassment

45. Recommendations for Research

46. Research Context • Lack of political support for RSH researchers • Sensitivity of most topics/questions • Reluctance to study unmarried • Greater valuation of quantitative studies • Impediments to multidisciplinary research on RSH

47. Quantitative Research • Exists DHS, PAPFAM and Gulf Family Health among others • BUT lack of consistent data across region makes comparisons difficult • Lack of disaggregation 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 but optional and new)

48. Qualitative Research • Encourage research on perceptions of young people (of services, social norms etc.) • Encourage research on perceptions of adults re youth RSH (service providers, parents etc.) • Encourage in-depth research (many KAP) • Need better understanding of linkage between development/social trends and RSH (much anecdotal)

49. Dissemination • Need more translation into Arabic, Farsi, French for dissemination in region • Encourage more publication in international published literature • How to make existing data relevant to policy-makers and service-providers?