HIV Prevention for At-Risk Youth

EXPERIENCES
FROM THE FIELD:
HIV PREVENTION AMONG
MOST AT RISK ADOLESCENTS
in Central and Eastern Europe and the
Commonwealth of Independent States

FOREWORD
The countries of Central and Eastern Europe and the Commonwealth
of Independent States (CEE/CIS) have the fastest growing HIV epi-
demic in the world. The number of people living with HIV has almost
tripled since 2000 and there are currently over 1.4 million people living
with HIV in CEE/CIS1
.
The HIV epidemic is affecting ever younger, vulnerable adolescents in
CEE/CIS, and yet it is masked by official overall HIV prevalence rates
that are, for the most part, relatively low. Still, within these countries,
we are seeing sub-groups of young people with infection rates on a par
with the worst-affected populations in sub-Saharan Africa.
The spread of HIV in this region goes hand in hand with the social
exclusion of those who are most vulnerable. Those who are most likely
to become infected with HIV are those who are already shut out of
society or denied services because of their poverty, ethnicity and be-
haviours that put them at risk, or who are made vulnerable because of
family breakdown, violence, social exclusion or conflict with the law.
The experiences of UNICEF, working together with government and
civil society partners, have increased our understanding of the needs
and vulnerabilities of most-at-risk adolescents. Much of what we know
about adolescents and HIV in the CEE/CIS region has emerged from
programming in numerous countries of Eastern Europe. Those fea-
tured in this publication, including Albania, Bosnia and Herzegovina
(BiH), Moldova, Montenegro, Romania, Serbia and Ukraine, have
been working with those adolescent boys and girls who inject drugs or
engage in transactional sex, young males who have sex with males,
street-connected adolescents and those coming from disadvantaged
socio-economic or ethnic backgrounds.
Tragically our work is deepening our understanding that a growing
number of adolescents are being drawn into sex work and drug abuse
as a way to cope with or escape from family problems, poverty, vio-
lence and a sense of isolation, creating vicious cycles of risk and
vulnerability to HIV.
These adolescents, who are most vulnerable to HIV infection, are
also the least likely to know the risks or how to avoid them, least
likely to have access to services that they need, and least likely to be
adequately protected by regulations, policies and laws.
UNICEF believes that the experiences in this publication represent
an important source of information that can motivate global learning
and continued work to prevent HIV infection and provide care and
support to those who are already affected by HIV. This in turn can
help to pull most-at-risk and vulnerable adolescents back into socie-
ties, giving them a “second chance” and supporting them in the full
realization of their rights. Some of the photographs in this document
may cause discomfort among readers. Nevertheless, they portray
the realities of the lives of these young people. True equity means
reaching out, protecting and caring for all, including those who have
been excluded and pushed to the margins of society. This publica-
tion is a call for change in policies, services and programmes to pro-
tect their rights and reduce their vulnerabilities.
Marie-Pierre Poirier
UNICEF Regional Director
CEE/CIS
1
http://www.unaids.org/en/regionscountries/regions/easterneuropeandcentralasia/
i

ACKNOWLEDGEMENTS
UNICEF Regional Office for Central and Eastern Europe/Com-
monwealth of Independent States (CEE/CIS) would like to ac-
knowledge the support received from many individuals who
helped make this documentation possible.
Regional Office for CEE/CIS: Paul Nary and Nina Ferencic, with
support from Marie-Christine Belgharbi, Nicola Bull, Jadranka
Mimica, Ruslan Malyuta, John Budd, Lely Djuhari, and Sharad
Agarwal. Special thanks to Marie-Pierre Poirier and Kirsi Madi
for their support and leadership.
Support for development of Country Experiences from: UNICEF
Country Offices; Albania: Alketa Zazo; Bosnia & Herzegovina:
Selena Bajraktarevic, Alma Herenda, Nineta Popovic; Moldova:
Angela Capcelea, Svetlana Stefanets, Sergiu Thomsa; Monte-
negro: Branka Kovacevic, Ana Zec, Jadranka Vucinic; Roma-
nia: Eugenia Apolzan; Serbia: Jelena Zajeganovic –Jakovljevic,
Jadranka Milanovic; Ukraine: Olena Sakovych, Sergiy Prokhorov.
Thanks to UNICEF Representatives and Deputy Representatives
for their support in finalizing the Country Stories: Albania: Detlef
Palm; BiH: Anne-Claire Dufay, Lesley Miller; Moldova: Alexandra
Yuster, Sandie Blanchet; Montenegro: Noala Skinner, Benjamin
Perks; Romania: Edmond McLoughney, Voichita Pop; Serbia:
Judita Reichenberg, Lesley Miller; Ukraine: Yukie Mokuo, Ritta
Poutiannen.
Photography: Albania: Rob Few; BiH: Edin Tuzlak, Amer Ka-
petanovic, Almin Zrno; Moldova: Corina Zara, Angela Munte-
anu, Lina Osolianu; Montenegro: Silke Steinhilber; Romania:
Mugur Varzariu; Serbia: Zoran Jovanovic Maccak, Sladjana
Stankovic; Ukraine: Michal Novotny, G. Pirozzi;
Content styling, creative direction and design:Laxmi Panicker-
Graber and bylines.ch
iii

INTRODUCTION
In recent years, UNICEF has worked together with national and
local authorities and civil society partners in a number of countries
in Eastern Europe and Central Asia to develop and implement
HIV prevention programmes intended to reduce risks and vul-
nerabilities among most-at-risk adolescents (MARA.) This docu-
ment presents programming experiences from seven countries:
Albania, Bosnia and Herzegovina (BiH), Moldova, Montenegro,
Romania, Serbia and Ukraine.
The overarching goal of these programmes has been to promote
HIV prevention among MARA and to ensure their integration into
national HIV/AIDS programme strategies and monitoring and
evaluation frameworks. Specific objectives included:
• Contributing to the evidence base on the risk profiles of MARA
and other vulnerable adolescents
• Advocating for protective policy environments
• Building capacity of government and civil society stakeholders
and service providers to support and provide MARA-oriented
services
• Piloting and monitoring interventions to reduce the risk and vul-
nerability of MARA to HIV.
Programmes began by targeting MARA who are at highest risk
of HIV infection, including: adolescent injecting drug users (IDU,)
adolescents selling sex1
, and males who have sex with males
(MSM,) to prevent risk behaviours (sharing needles and having
unprotected sex.) However, it soon became clear that these HIV
risks could not be addressed in isolation. Programmes had to
also respond to the circumstances that make adolescents vul-
nerable, including living and/or working on the streets, living in
institutions or in settlements for displaced persons.
1
The UN restricts its definition of “sex workers” to adults over 18 years of age and
affirms that the involvement of children (under the age of 18) in transactional sex/
sex work and other forms of sexual exploitation and abuse contravenes United Na-
tions conventions and international human rights law. Children under 18 years of
age who sell sex are victims who cannot be viewed as sex workers. Every reference
to “sex workers” in this report is used only as “short-hand” and should only be inter-
preted with the full understanding and in full agreement with the above definition.
v

INTRODUCTION
©AmerKapetanovic

ABOUT THIS DOCUMENT
The purpose of this document is to share experiences, including
the results of research, advocacy and interventions and to sup-
port programmers, policy makers and donors to carry out and
strengthen further programming among MARA and other vulner-
able adolescents in the CEE/CIS Region and beyond.
Country Experience
Country Experiences illustrate HIV Prevention programming for
MARA in seven Eastern European countries and include the per-
sonal stories and perspectives of most-at-risk adolescents and
young people themselves. Each Country Experience includes:
• Personal stories and photographs of MARA/young people
• Summaries of data, HIV Prevention programming processes
and results
• Hyperlinks to research reports, guidelines, case studies and
tools for programmes
Regional Perspective
The Regional Perspective section provides a “bigger picture” look
at the MARA programme development process, comparing coun-
try findings and experiences, and including hyperlinks to many of
the more universally-applicable tools, guidelines and advocacy
documents developed by the UNICEF Regional Office for CEE/
CIS. Please note:
All subjects of photos in this document granted consent to be photographed and
featured. UNICEF in no way endorses, supports or promotes the behaviours and
scenarios described and/or pictured in this document.
The resource documents referenced and hyperlinked throughout this publication
are intended to further inform work on MARA; their content does not necessarily
reflect UNICEF official policies or programming positions.
vii

TABLE OF CONTENTS
FOREWORD PAGE i
ACKNOWLEDGEMENTS PAGE iii
INTRODUCTION PAGE V
COUNTRY EXPERIENCE
ALBANIA PAGE 1
READ ABOUT THE ALBANIA COUNTRY EXPERIENCE AND THE STORY OF ARMAND, A YOUNG INJECTING DRUG USER (IDU)
FROM ALBANIA WHO IS TRYING TO “BREAK THE CYCLE” OF INITIATION OF INJECTING DRUG USE FROM OLDER TO YOUNGER
IDUs.
ix

TABLEOFCONTENTS
BOSNIA & HERZEGOVINA PAGE 11
READ ABOUT THE COUNTRY PROGRAMMING EXPERIENCE IN BOSNIA & HERZEGOVINA. AND READ ABOUT ANDREA AND LAM-
IJA, YOUNG INJECTING DRUG USING (IDU) WOMEN WHO SHARE THEIR STORIES OF DRUG USE, VIOLENCE AND STIGMA IN THE
HOPES THAT OTHERS LIKE THEM MIGHT FIND BETTER TREATMENT AND ACCEPTANCE IN THEIR COMMUNITIES.
MOLDOVA PAGE 25
READ ABOUT MOLDOVA’S PROGRAMME EXPERIENCE AND READ ABOUT TAMARA, A YOUNG HIV-POSITIVE MOTHER FROM MOL-
DOVA, WHO HAS OVERCOME FEAR AND FOUND A SOURCE OF STRENGTH AT A YOUTH-FRIENDLY HEALTH SERVICE (YFHS) IN
THE FACE OF STIGMA AND DISCRIMINATION AGAINST HER AND HER SON.
MONTENEGRO PAGE 37
READ ABOUT THE MONTENEGRO COUNTRY EXPERIENCE AND READ ABOUT IRFAN, A 16-YEAR OLD ROMA BOY FROM A CAMP
FOR INTERNALLY DISPLACED PERSONS (IDPs) IN MONTENEGRO, WHO STRUGGLES TO DEAL WITH SOCIAL EXCLUSION IN PUR-
SUIT OF HIS DREAMS.
x

ROMANIA PAGE 47
READ ABOUT THE ROMANIA COUNTRY EXPERIENCE AND READ ABOUT MARIA, A YOUNG INJECTING DRUG USER (IDU) FROM
ROMANIA WHO HAS FOUND TRUST AND HOPE IN COMMUNITY-BASED SERVICES (NGOs.) BUT WILL IT BE ENOUGH TO HELP
HER CHANGE HER LIFE?
SERBIA PAGE 59
READ ABOUT THE SERBIA COUNTRY EXPERIENCE AND READ ABOUT MIRELLA, A 17-YEAR OLD ROMA GIRL LIVING IN SERBIA
WHO HAS LEARNED TO COPE WITH CHALLENGES SUCH AS VIOLENCE AND POVERTY THAT WOULD MAKE EVEN THE STRONG-
EST AMONG US GIVE US HOPE.
UKRAINE PAGE 69
READ ABOUT THE UKRAINE COUNTRY EXPERIENCE AND READ ABOUT VIKTOR, A 14-YEAR OLD HOMELESS ORPHAN WHO,
AMONG OTHER STREET CHILDREN IN UKRAINE, HAS SUFFERED REPEATED TRAUMAS DURING HIS SHORT LIFE YET MAY HAVE
A CHANCE OF AN EASIER FUTURE.
xi

TABLEOFCONTENTS
REGIONAL PERSPECTIVE PAGE 89
READ ABOUT THE MARA PROGRAMME DEVELOPMENT PROCESS; A SUMMARY OF RESEARCH FINDINGS ACROSS EASTERN
EUROPEAN COUNTRIES; ETHICAL CHALLENGES OF RESEARCH AND PROGRAMMING WITH MARA; RESULTS OF ADVOCACY TO
CHANGE NATIONAL POLICIES AND STRATEGIES; AND CONSIDERATIONS AND LESSONS LEARNED FROM DEVELOPMENT OF IN-
TERVENTIONS AND SERVICES FOR MARA.
REFERENCES (ON-LINE) PAGE 101
xii

“I see great value in Break the Cycle. It has changed
the way I think and act. I see it changing others, too.”
We work with ARMAND
in ALBANIA
“I’ve been injecting for 10 years,” says 24-year-old
Armand, as he shares his story with a counsellor
at STOP AIDS, an NGO supported by UNICEF.
“A few years ago I started to get wounds on my feet
because I couldn’t find any veins ... People were
saying I would have to cut my feet off.” Armand now
works with STOP AIDS, promoting Break the Cycle,
an intervention designed to prevent adolescent drug
users from beginning to inject.

ALBANIA
ARMAND’S STORY
In Tirana’s extreme summer heat, Armand keeps his body com-
pletely covered. It’s only when he sits that his blistering legs might
be seen. “I have been living on the streets since I was 12 years
old,” he says. “Heroin has been a part of my life from a very early
age.”
Sharing needles is very common among Tirana’s heroin users.
Armand took his first injection at age 14, sharing a syringe with
strangers on a train. Armand is among thousands of injecting drug
users (IDUs) in Albania who risk contracting HIV. While Albania
has low HIV prevalence overall, concentrated epidemics occur
in specific geographical areas and among defined populations.
Drug injection is the second-highest means of HIV transmission
in Albania (after unsafe sex). The situation is ripe for the rapid
spread of HIV.
Several months ago, Armand met a fellow heroin user who is an
outreach worker for STOP AIDS. STOP AIDS offers free harm
reduction services such as syringe exchange, emphasizing the
necessity of safe injection to reduce risk. It also offers
confidential HIV testing and counselling. “STOP AIDS helped
heal my legs,” says Armand. “They also explained the risks of
sharing needles – the chance of contracting HIV.”
With his feet healed, Armand became a leading participant in
Break the Cycle. He and other counsellors and drug users from
STOP AIDS reach out to young people. He knows that young,
non-injecting drug users are particularly vulnerable to entering
the cycle of injection. “I see myself in some of the younger peo-
ple. I know what path they are walking down,” he says. “I don’t
encourage young people to try (injecting). I know that once you
start with the first hit, you won’t finish for a long time.”
“I feel really committed to engaging with other drug users,”
Armand says. Most days he goes to “hot spots”– common
meeting points for drug users – to explain the risks of HIV and
the services available at STOP AIDS, and to distribute clean
needles. “Armand has a real talent for this,” says his colleague
Kamani. ”When Armand talks to another drug user, he is able
to refer to their shared experience and that helps them relate
©RobFew
3

in a different way.” Advocating for HIV preven-
tion and behaviour change among fellow drug
users has helped Armand realize a new sense
of self-worth.
Since Break the Cycle began, Armand and
Kamani have noticed significant changes in at-
titudes among drug users. “I am impressed with
how quickly this message has spread. I know
people now who are afraid of sharing needles,”
Armand explains. Kamani is confident that 20
per cent of these users will themselves become
active in Break the Cycle and help their peers
avoid injection.
“By preventing young heroin users from inject-
ing, and by helping injectors to stop, we are
helping to slow the spread of HIV in Albania.”
©RobFew
4

THE APPROACH
Following discussions with government, NGOs and other part-
ners, UNICEF and key stakeholders prioritized work with adoles-
cent IDUs. Owing to a lack of data, the first priority was to build
an evidence base about adolescent and young IDUs to guide
development of an appropriate programme.
A 2008 baseline survey1
of injecting drug use in Tirana1
collected
data on 121 young males aged 15–24 in Tirana. The research,
carried out by the Institute of Public Health with UNICEF support,
painted an alarming picture of the extent to which adolescents
are putting themselves at risk of HIV transmission. Despite best
efforts, only young males were recruited for the survey, suggest-
ing that female injectors face important gender barriers, are ex-
tremely marginalized and remain hidden.
ALBANIA
©RobFew
5

Qualitative research was also carried out to clarify
the social dynamics and networks among adoles-
cents and young IDUs. The research confirmed
that young people are commonly introduced to in-
jecting heroin by older friends, siblings or sexual
partners. The study also found that girls are often
initiated into injecting by their boyfriends and that
harm reduction services typically do not reach
them.
A Service Capacity Assessment3
confirmed that
existing harm reduction service providers lack the
capacity and resources to target and address the
needs of adolescent IDUs or those at high risk of
initiating injecting.
Research among 15–24-year-old males
in Tirana (See data summary2
)
• 86% had shared needles in the previous
month and more than 50% injected every day.
• One-third of the sample group had tested for
HIV but none of the adolescents in the study
had done so.
• Up to 34% of IDUs were Roma adolescents.
• Condom use among respondents at last sex
was extremely low – 14% with regular
partners and 19% with casual partners.
• Over one-quarter (26%) of young IDUs
surveyed had never been to school and 30%
were homeless.
DATA AT A GLANCE
6

Having reviewed the research findings, UNICEF, government
partners and other stakeholders agreed to:
• advocate for most-at-risk adolescents (MARA) to be placed on
the national agenda and strengthen capacity of policymakers
to address them
• strengthen capacity and adapt existing HIV prevention and
harm reduction services to better respond to the needs
of adolescents
• prevent the transition to injecting among adolescent
“pre-injectors.”
1. Advocating for MARA to be placed on the national
HIV/AIDS agenda
From the beginning of programming with MARA, UNICEF had
to convince stakeholders that targeted, gender-sensitive inter-
ventions for MARA should be part of a long-term approach to
addressing HIV/AIDS in Albania.Results of ongoing advocacy
include a gender-sensitive National Action Plan for MARA, an-
nexed to the National HIV/AIDS Strategy 2011–2015. It defines
MARA as adolescents who inject drugs, adolescent boys who
have sex with males, adolescents who are trafficked and forced
to engage in transactional sex, and adolescents engaged in sex
work.
UNICEF advocacy also contributed to development of a new
HIV/AIDS law that includes a definition of MARA and sets out
principles for HIV prevention among most-at-risk populations, in-
cluding adolescents. The law also provides for harm reduction
services for young IDUs (although the age range is not yet speci-
fied) and protection services for HIV-infected children (Study:
“Don’t Forget About Us4
...”).
In addition, advocacy strengthened government commitment to
integrating outreach work for MARA into existing services. HIV
testing and primary health care centers will henceforth use the
skilled staff, tools and experiences resulting from the UNICEF
Programme to increase young people’s access to voluntary
counselling and testing.
THE PROGRAMME
ALBANIA
“For too long we have been content with providing
services for young people when in reality we have
mainly been reaching those who are aged 23 and
above. This programme put pressure on us and our
partners to think carefully about how we could help
those who are truly young – the adolescents ... be-
cause the problems are there.”
UNICEF Programme Specialist
©RobFew
7

2. Strengthening capacities to develop
appropriate responses
To identify service delivery gaps, NGOs were as-
sessed for their capacity to provide services to
at-risk and vulnerable adolescents. A Service
Capacity Assessment3
was used to identify the
training needs of 20 organizations. Training pro-
grammes were developed and UNAIDS integrat-
ed findings from the Assessment into its National
Technical Support Plan.
Given the complex social challenges that MARA
face, as highlighted by the qualitative research,
new partnerships were set up to link HIV pre-
vention interventions to child protection and
social welfare services. The Municipality of
Tirana established a special unit of social work-
ers to receive and refer MARA and their families
to a range of social protection services.
3. Developing and piloting Break the Cycle
in Tirana and Vlora
Research findings confirmed that a MARA pre-
injector population warranted special attention,
and revealed:
• a young injecting drug population with a risk
of rapid spread of HIV
• insufficient national capacity to scale up HIV
prevention interventions for IDUs as rapidly
as required
• evidence that transitions to injecting
frequently occur during adolescence.
An assessment of the drug-using environment5
also confirmed that there were several sub-
groups of users, each administering heroin in
different ways, through snorting, smoking or
injecting.
This suggested an opportunity to intervene to
prevent non-injectors from becoming injectors,
through Break the Cycle6
, an intervention origin-
aly developed in England.
InAlbania, Break the Cycle was delivered through
two NGOs: STOP AIDS, which provides needle/
syringe exchange services, and Aksion Plus7
,
which offers methadone substitution treatment.
Both work with IDUs to exert a positive influ-
ence on young non-injectors within their social
networks. The programme targets adolescents
who are already dependent on heroin and at high
risk of beginning to inject. IDUs who express a
willingness to be involved are taught about HIV/
AIDS and other health risks associated with in-
jecting drugs. They are also trained to share this
information with others, particularly adolescents,
and to provide them with information about where
they can access medical services and support.
8

The programme builds on the fact that many IDUs disapprove
of initiating new injectors. It supports them to avoid injecting in
the presence of non-injectors and discourages them from talking
about the drug’s effects, telling a non-injector to inject, or demon-
strating how to inject in front of non-injecting drug users. The pro-
gramme also aims to increase IDUs’ skills to resist any request
from a non-injector for a first hit. Those interested were taught
about HIV/AIDS and other health risks from injecting and trained
to share this information with their peers.
Early evaluation of Break the Cycle6
is encouraging. IDUs re-
sponded well to the notion that they could help protect young
drug users from starting to inject drugs. They were motivated to
take part in the programme and reported heightened self-worth
because they were consulted and saw their views being taken
into account. Peer educators provided information and encour-
aged young IDUs to access services. Strategies were developed
to reach marginalized young female injectors.
9

UNICEF will continue to support interventions
for MARA and other vulnerable adolescents in
Albania. Assistance has been given to endors-
ing and implementing the National Plan of Ac-
tion.UNICEF is supporting the government to
develop and implement a five-year National
Drug Use Prevention Strategy for 2011–2016.
Albania’s submission to the Global Fund Round
10 included a specific request for funds to scale
up Break the Cycle.
UNICEF will continue to work with government
and NGO partners to support and expand Break
the Cycle and integrate it into the broader Drug
Use Prevention Strategy and other HIV preven-
tion services. Particular attention will be paid
to reaching young female injectors and pre-in-
jectors. In addition, it will be critical to continue
to address the broad behavioral and socioeco-
nomic factors that influence risk taking among
adolescents.
Results from Break the Cycle
in Albania
From April to September 2010, participants in
Break the Cycle achieved 111 “interventions”
(peer-to-peer discussions following guidelines
designed to prevent initiation of drug injection).
Thirty-four percent of those reached by STOP
AIDS were under 19 years of age. Compari-
son of pre- and post-intervention monitoring
data from 82 of the 111 people who received
the intervention was encouraging, particularly
the drop in the number of those who reported
injecting someone for the first time or showing
them how to inject. Results are summarised to
the left.
THE WAY FORWARD
.
ALBANIA
Further monitoring will be required to assess
the potential for Break the Cycle to have long-
term impact in Albania. But the intervention
has also provided other useful findings:
• Participants stressed the need for a range
of other services and interventions, in-
cluding: hepatitis B and C testing, treat-
ment and immunization; overdose preven-
tion and management; relapse prevention
and training; family support services; and
leisure and recreation activities.
• The intervention made even clearer the
challenges of reaching young female
injectors – further work in this regard will
be required.
Implementers will continue collecting monitor-
ing data with a view to scaling up services,
after completion of the pilot and further evalu-
ations of Break the Cycle.
©RobFew
10

“You know, as the saying goes, that we have an angel
on one shoulder and a devil on the other. I had the devil
on both of them ...”
We work with ANDREA and LAMIJA
in BOSNIA AND HERZEGOVINA
Andrea and Lamija are among a small number of young
female injecting drug users (IDUs) from Bosnia and Her-
zegovina (BiH) who agreed to discuss their lives, their
experience of drug use, violence, stigma, discrimination
and other sensitive topics with UNICEF and partners.
UNICEF collaborated with the NGO Viktorija in Banja
Luka andAssociation of Citizens Proi in Sarajevo to con-
duct qualitative research aimed at better understanding
how the health and social sectors and society in general
can better help these marginalized and misunderstood
young women.

BOSNIAANDHERZEGOVINA
©EdinTuzlak

©EdinTuzlak
ANDREA’S STORY
Andrea, from Banja Luka, discussed how she got started as an
injecting drug user: “You know, as the saying goes, that we have
an angel on one shoulder and a devil on the other. When I was
young, I had the devil on both of them ... male and female friends
who persistently said, ‘Take it, take it.’ Almost two months they
nagged me – ‘Take it, you will feel better, why do you think you
are any different?’ ... and I had an aversion to heroin. I thought
that it was the rock bottom, the black hole that sucks up every-
thing, the family, yourself ... Then I succumbed, I just put out my
arm. I took it intravenously right away.”
She went on to describe the abuse she has suffered at the hands
of the police: “I was walking and two men were approaching
me, and all of a sudden they caught me – one from one side and
another from the other side, gripping me by my arms, and taking
me to the station. I did not want to say my name because I was
pretty much drugged and then [they] started saying, ‘Oh, you’ll
get the crisis, if you’re female we will kick you, you will get yours
when the crisis hits ...’ They banged on the wall above my head
... they changed their methods and after 15 hours of harassment
they released me. When I exited the station I was beside myself, I
flung myself in front of a car, but it slammed on the brakes in time
and I continued on, home.”
13

Lamija, from Sarajevo, described the mis-
treatment she experienced at an outpatient
clinic following complications from injecting:
“[My] arms were swollen, full of pus, I had
abscesses ... I came [to the clinic] at 5:30, I
was first in line with a temperature of 40 de-
grees ... They did not call me in first; several
people were examined before me ... A male
nurse, not knowing that I could hear him –
because I sat alone next to the door of the
office – said, ‘Junkie, let her drop dead, she
got what she deserved ... let her arm burst
up.’ And I was in pain, I cannot describe how
much ... The driver of their van came in and
saw me lying on the tiles [with] cold hands,
and yelled to them, ‘What’s the wait? She
could die ...’ Only then they entered me in
the clinic and began to work.”
Yet Lamija, and many other female IDUs
showed exceptional motivation to become ac-
tively involved in drug abuse and HIV preven-
tion activities. They express the view that if they
quit, they could offer their own personal experi-
ence and they would feel useful and fulfilled: “It
is incredible how much desire I have to save at
least one person ... to explain how many bad
situations there will be and to tell the person
that the beginning should be the end ... that’s it
... so that, in some way, the person would know
that what they think and what the drugs provide
is a false sense of security, an escape from re-
ality ... I have been there and lived to regret it. I
put my grandmother and my brother in difficult
situations ... It is a big step that leads to chaos
… That is what I want to tell them.”
LAMIJA’S STORY
14

©EdinTuzlak
THE APPROACH
Although there is low HIV prevalence in BiH, the seeds of a rap-
id increase of HIV are being sown. Risk behaviours are present
among young people and data from recent bio-behavioural sur-
veys (BBS) indicate that these behaviours are starting at an early
age.
Working with national partners, UNICEF built a foundation for an
effective HIV/AIDS response for vulnerable and at-risk
adolescents through:
• conducting research among IDUs and children and
adolescents living in institutions, to support programm
planning
• supporting changes in strategies and legislation to ensure
that policies support an enabling environment for adoles-
cents’ access to service
• improving the provision of confidential HIV voluntary coun-
seling and testing (VCT) through the development of pro-
tocols and guidance, and building the capacity of service
providers to work more effectively with at-risk populations,
including adolescents
• developing behaviour change communication (BCC) initia-
tives to increase knowledge and reduce violence, stigma
and discrimination, and encourage understanding and sup-
port for most- at-risk adolescents (MARA) and other vulner-
able adolescents, including those in institutions
UNICEF supported national efforts to include young people and
adolescents in the 2007 BBS among IDUs1
, with the aim of de-
veloping targeted interventions for adolescent IDUs. However,
because legal barriers prevented testing minors under age 18
for HIV, the focus of the study was shifted to behavioral factors
among younger respondents. Still, very few adolescents under
15

18 were reached, suggesting that the same legal
barriers would also prevent adolescents from ac-
cessing HIV prevention services. Consequently,
the Ministry of Health of BiH and UNICEF decid-
ed to use the BBS to gain a retrospective under-
standing of the risk behaviours and vulnerability
of young IDUs. The decision was made to build
a more effective response to prevention among
IDUs in general, to address legal and other ser-
vice access barriers, and to explore risk and vul-
nerability among other marginalized adolescents.
Findings from the BBS confirmed that risk be-
haviours start at an early age. The research also
found that younger IDUs are not being reached
by existing harm reduction and HIV prevention
services. While the high prevalence of hepatitis
B and C showed that there is no room for com-
placency, low HIV prevalence suggested there
was a temporary window of opportunity for the
Government and its partners to take action with
effective HIV prevention interventions.
16

©AmerKapetanovic
Research among 18–24-year-old IDUs
in Sarajevo, Banja Luka and Zenica1
• The median age of first drug use among respondents in
Banja Luka was 14.
• More than half in Banja Luka, half of respondents in Sara-
jevo, and one-third in Zenica first used drugs when aged 15
or younger.
• More than half of those surveyed (55%) in Sarajevo, 39% in
Zenica and 38% in Banja Luka had shared injection equip-
ment during the previous month.
• Half of IDU respondents in Sarajevo, and more than one-
quarter in Zenica experienced first sexual intercourse
before the age of 15.
• Approximately three-quarters of respondents in Sarajevo,
62% in Banja Luka, and 67% in Zenica had not used a con-
dom during last intercourse with their regular partner.
• Prevalence of Hepatitis C was 36% in Sarajevo and 34% in
Banja Luka. HIV prevalence was extremely low.
• Less than half the respondents in Banja Luka
DATA AT A GLANCE
17

Qualitative research among female IDUs2
found
that young female IDUs are influenced to start
injecting by peers and partners, denied access
to health and prevention services including
counselling, and abused by law enforcement of-
ficers.
“I was terribly afraid of crisis.
I attempted suicide in the moments of
crisis. I would see it all before me, as in
some misty mirror, all that gnawed on
me and burdened my conscience … that
was horrible, I did not endure and I tried
to cut my veins. But the intervention by
doctors was swift, they stitched me up
and sent me home. When I came home,
I threw myself on the railroad tracks. I
remember the sound of the train and the
strong pressure from my mother. She
managed to pull me off the rails and save
me. I do not know
where she got her strength … ”
(Young female IDU, Sarajevo.)
18

©AmerKapetanovic
UNICEF and government partners explored the risks and vul-
nerabilities of adolescents living in institutions without parental
care, and those in boarding schools. These adolescents grow
up outside the family environment and experience particularly
difficult, often traumatic, circumstances which can affect their
physical and mental health. They are usually hard to reach with
health and social protection services, particularly HIV/AIDS
prevention.
A behavioural study examined the risk behaviours, knowledge
and social experiences of 392 adolescents in 10 collective ac-
commodation institutions. The study was led by the Health
Protection Institute in Republika Srpska and the Public Health
Institute of the Federation of BiH. The majority of respondents
(83%) were under age 18. Less than one-third of respondents
(29%) had correct knowledge about HIV/AIDS. Just under half
knew where HIV testing and counselling services were avail-
able. As many as 84% of both girls and boys reported using
alcohol. One-quarter of the boys and 13% of the girls had initi-
ated sexual activity. Ten percent of respondents
reported that they had experienced violence within or outside their
institution once or twice within the last 12 months. Those exposed
to violence said that the perpetrators were most often other chil-
dren who did not live in collective accommodation (57%), or their
peers who lived in the same institution (35%), or staff of their in-
stitution (17%).
Although this survey did not find strong evidence of risk behav-
iours for HIV, it did find other areas that required attention. Their
limited knowledge about HIV, high levels of alcohol consumption
and experience of violence meant that these adolescents were
vulnerable to a number of health and social development prob-
lems. The data also showed that adolescents in institutions are
heavily stigmatized in their communities, and vulnerable to vio-
lence and discrimination from other young people.
19

“When advocating for MARA, it is eas-
ier to take advantage of ongoing leg-
islation development processes or the
adjustment of those laws that have re-
cently been endorsed by the authori-
ties, rather than putting efforts into
the development of completely new
legislation or strategies.”
20

©AmerKapetanovic
The research findings and need to develop policies and services
for young IDU led UNICEF and partners to agree that program-
ming should focus on:
• advocating for changes to legislation to support data collection
and service provision among adolescents, including a review of
policies related to parental consent requirements for the provi-
sion of medical services
• improving the quality of HIV testing and counselling services
• promoting an enabling community environment which would
increase awareness of HIV/AIDS, encourage HIV testing,
and reduce stigma and discrimination
• increasing HIV knowledge and promoting safe services for
adolescents in institutions.
1. Advocating for changes to legislation
UNICEF and partners recognised that interventions would not be
able to reach MARA and other vulnerable adolescents if legal
barriers, including policies requiring parental consent for preven-
tion and care services for adolescents remained.
Therefore, significant efforts were focused on advocating for
changes to legislation and including adolescents in the National
AIDS Strategy. Significant progress was made – new laws were
developed, and national strategies for drug use and HIV/AIDS
now make specific reference to MARA and other vulnerable ado-
lescents.
THE PROGRAMME
21

Laws and strategies to increase adolescent ac-
cess to HIV testing and other health services
• Laws, policies and practices were reviewed3
to
assess legal barriers to adolescents accessing
information and health services related to HIV/
AIDS and sexually transmitted infections (STIs).
The analysis3
found that adolescents under age
18 were not accessing services and not allowed
to request “invasive” health interventions without
prior parental consent. These interventions in-
cluded HIV testing.
• UNICEF and health sector partners advocated
for changes to the law, providing technical assis-
tance and data from the BBS surveys to support
the case of adolescents. In response, the Ministry
of Health and Social Welfare of Republika Srpska
developed the Law on Health, and the Ministry
of Health of the Federation of BiH developed
the Law for the Protection of Patients’ Rights.
Both laws lower the age at which a young per-
son can access health services, including HIV
testing, without parental consent – from age 18
to age 15. Both laws have been endorsed.
• A Strategy for Diminishing Drug Use was de-
veloped under the leadership of the Ministry of
Security of BiH. The strategy provides a legal
framework for NGOs to provide HIV preven-
tion and harm reduction services without com-
ing into conflict with the law. Adolescents and
young people are included in the strategy.
• The National AIDS Strategy refers to adoles-
cents as a sub-group of most-at-risk popula-
tions.
2. Improving the quality of HIV testing and
counselling services
The work to develop a protective legislative en-
vironment for HIV prevention services was com-
plemented by efforts to increase access to VCT
services that meet the needs of at-risk and vul-
nerable adolescents.
With support from UNICEF, protocols were ap-
proved for VCT for HIV for most-at-risk popula-
tions (MARPS), including adolescents. A VCT
Guidebook for Service Providers4
, which includes
guidance on providing services to MARA, was
produced. A pool of trainers was established to
train service providers in VCT, including test-
ing for MARA and other vulnerable adolescents.
Health workers and NGO staff were trained to
provide VCT to MARPs, including adolescents.
22

At community level, the VCT centre in Banja Luka was strength-
ened to provide improved HIV counselling and testing services
for MARA, people living with HIV, and other at-risk populations.
In the first few months after capacity building, 563 clients were
seen, nearly a quarter (24%) of whom were adolescents. Test kits
were supplied to increase testing and improve access to health
information, in recognition of the high levels of Hepatitis B and C
evidenced in the BBS.
UNICEF strengthened the capacities of local NGOs dealing with
MARPS and other key stakeholders to respond to the needs of
MARA. Partnerships were also built at various levels, ranging
from the Ministry of Security of BiH at the central level, as well as
“entity” ministries of health, education, social welfare and interior,
and the cantonal and municipal level governments and ministries
responsible for health, education and social welfare. These new
partnerships have been critical as the Global Fund project is im-
plemented.
3. Promoting an enabling community environment
UNICEF is also working to change community attitudes and in-
crease social support for MARA, other vulnerable adolescents
and those affected by HIV/AIDS. A BCC strategy to fight stigma
and discrimination was developed in partnership with young peo-
ple. UNICEF advocated for this strategy to be integrated into the
National AIDS Strategy.
An edutainment mass media campaign, “Without Risk,” which
addresses alcoholism, drug use and safe sex, was developed
for the wider youth population. A television serial for youth, and
videos and radio clips promoting HIV prevention, were produced
for national broadcast.
4. Increasing HIV knowledge and promoting safe services
for adolescents in institutions
UNICEF and local NGO Viktorija developed an intervention to
increase knowledge about HIV-related risk behaviours and im-
prove the social environment of adolescents living in collective
accommodation. This intervention targeted adolescents and staff
in institutions, school children from those primary schools at-
tended by the adolescents in institutions, and key stakeholders
responsible for the adolescents at the municipal level.
In addition to learning about HIV and AIDS, adolescents were
introduced to HIV testing facilities and youth-friendly health ser-
vices. Peer education sessions were conducted in schools and
institutions, staff members were trained, and roundtable discus-
sions were held for key stakeholders. In all, 954 adolescents and
294 adults were reached.
23

UNICEF and partners will continue to work with
national authorities and civil society organiza-
tions to support the development and imple-
mentation of HIV prevention, care and support
services targeting the needs of MARA, includ-
ing adolescent IDUs.
Emphasis will also be given to the children of
at-risk populations and the needs of the at-risk
partners of drug users – mostly women, as well
as vulnerable adolescents. UNICEF will pro-
mote increased awareness of HIV among young
parents through Integrated Early Childhood
Development Centres. In addition, UNICEF will
continue to collaborate with institutions for the
collective accommodation of adolescents to
support institutional reform, strengthen
THE WAY FORWARD
institutions’ collaboration with local services
and support increased attention to juvenile
justice.
Additional funds were obtained to provide VCT
and other HIV prevention services to adoles-
cents across BiH. UNICEF and partners suc-
cessfully advocated for MARA to be included
in Global Fund grants. In 2010, BiH received
an unprecedented US$11.4 million in Global
Fund programme funds for two years.
Of this amount, US$ 400,000 was dedicated
to prevention of HIV among MARA, including
through VCT services. UNICEF will continue
to work on improving the health and wellbeing
of the most vulnerable adolescents, including
by addressing the broader determinants of
HIV risks.
The partnerships established with institutions
demonstrate how initiatives that begin with HIV
prevention are relevant to broader child protec-
tion interventions. The research findings and the
networks established will be used to inform and
implement UNICEF’s support for the reform of
collective accommodation institutions and other
interventions focusing on juvenile justice.
The HIV programme’s emphasis on building an
enabling environment at policy, health system
and community levels should have a wide-reach-
ing and sustainable impact. The new laws and
VCT protocols will facilitate the Global Fund pro-
ject’s efforts to provide services for MARPS and
MARA. Additional work is still needed to tackle
stigma and discrimination.
©AmerKapetanovic
24

“We try to hide my HIV status, because people do not
know a lot about HIV and they do not understand
there is nothing to be afraid of.”
We work with TAMARA
in MOLDOVA
Tamara is one of about 5,000 young people who regu-
larly benefit from the services of ATIS1
, a youth-friendly
health service (YFHS) that opened in 2005 with UNICEF
support. ATIS offers information about sexually trans-
mitted diseases and HIV/AIDS, and provides counsel-
ling and testing services, access to contraceptives, and
care and support for the most vulnerable adolescents.
Located in one of Moldova’s most HIV/AIDS-affected
towns (Balti), ATIS offers services to vulnerable adoles-
cents and young people aged 10–25, not only from Balti
but also from nearby villages and small towns.

27
MOLDOVA
TAMARA’S STORY
In a courtyard in the town of Balti in Northern Moldova, Tamara
and other young people are discussing what they have learned at
a seminar they have just attended.
Tamara came to ATIS when she was 17 years old. “I started do-
ing drugs at the age of 15 and that’s how I got infected with HIV
... I went to see my family doctor and he only wanted to get rid
of me.” Despite a law requiring medical staff to keep a diagnosis
confidential, Tamara said the doctors were writing the code “20”
(signifying that the patient is HIV positive) on her file, even on her
prescriptions. “I felt depressed and had the feeling that nobody
cared. Although I stopped taking drugs and my life changed for
the better, I still felt rejected by people around me because of my
HIV-positive status ...”
In Moldova, people living with HIV and their families face discrimi-
nation. They are often unable to get a job, their children may not
be accepted in preschools, and these circumstances force them
to hide their status. Many of the youth and adolescents at risk
avoid seeking health care because they are afraid of how they
will be treated. This has consequences for their health and af-
fects their lives in other ways.
Tamara is now a young mother and her son attends a local kin-
dergarten. She is aware that, if the teachers and other parents
knew that she were HIV positive, her child would face the same
stigma – even though he is HIV negative. “We try to hide my
HIV status, because people do not know a lot about HIV and
they do not understand there is nothing to be afraid of,” she
explains.
Tamara’s life changed when she learned about the ATIS clinic.
“One day a friend told me about a youth-friendly clinic where
people like me can get help. I decided to go and it worked ...
Here I feel safe, accepted and feel the comfort of not having to
hide anything … the doctors treat me without judging me.”
Asked how she would feel if the centre closed down, Tamara
says it would be a real shock. “I cannot even imagine what I
would do. If ATIS did not exist, I would have to travel to the
©LinaOsoianu

28
specialized HIV centre in Chisinau each time I
had a health problem,” she says. “It would cost
me a lot, as I need medical examinations for
myself and my child every three months or so,
and here I don’t have to pay for anything, all the
services are free.” Tamara comes to the centre
every day, both for medical examinations and to
attend seminars and support groups and social-
ise with other young people and the staff.
THE APPROACH
Moldova is classified as a country with low HIV
prevalence. The HIV epidemic in Moldova is par-
ticularly concentrated among injecting drug users
and their sexual partners. In 2008 the Ministry of
Health, with UNICEF’s support, conducted a base-
line study among 369 IDUs aged 12–24 and their
sexual partners in Balti, Chisinau and Tiraspol2
.
The research confirmed that young IDUs are taking
risks: they are sharing needles and they are less
likely than older IDUs to use condoms with casual
partners. Young injectors are reluctant to use health
and harm-reduction services, and outreach activi-
ties are not managing to reach them.

29
Surprisingly, sampled IDUs had similar education levels and oc-
cupations to their friends of the same age who did not inject drugs.
This made it difficult to identify young IDUs as a specific group in
the community. In addition, adolescents and young people in Mol-
dova were found to inject drugs much less often than their peers
in Albania, Romania and Serbia3
– nearly one-quarter had not
injected during the previous month.
Research among 12–24-year-old IDUs in Balti, Chisinau and
Tiraspol
• 30% of respondents were under age 18.
• 79% said they had obtained their injecting equipment from
pharmacies and adolescents were significantly more likely
to do so.
• 85.3% said they had shared injecting equipment at least once
in the previous month.
• A majority of female IDUs had IDU sexual partners.
• Younger IDUs seemed more likely to engage in higher risk
sex with casual partners.
• Injection patterns were found to be very sporadic – nearly
25% had not injected during the previous month.
DATA AT A GLANCE
MOLDOVA
Igor, young IDU
“I started to hang out with those people who had it (hero-
in) permanently. Everyone was looking for it, I was look-
ing for it, and we were together all the time and it ap-
peared all the time and then it gets to a point when it is
stupid to refuse. In any case, you are going to do it and
you do it and you feel fine. And I did it time and time
again.”
©LinaOsoianu

30
Fyodor, young IDU
“I saw for myself how these people were
using, and they said to me, ‘Don’t even
think about it.’ And I thought the oppo-
site, ‘Why are they using and yet per-
suading me not to?’”
Anatoli, IDU
“I am in withdrawal, I need money. I met
Vasya who has money and he wanted to
try, and tells me he will give me money.
Almost everyone would accept his mon-
ey to get the drug for himself and for this
guy. There are not many conscientious
people who would say, ‘I would not get
you the drug.’ ... As they say, ‘If it’s free,
even the vinegar is sweet.’ So of course
the drug addict will take the money and
will give him the drug without thinking
twice. When a person is a dependent
drug user, he has no boundaries.”
UNICEF undertook a qualitative study4
to clarify
these unusual results5
. Interviews in Balti with
31 current IDUs and 11 ex-injectors showed
that young injectors tend to be initiated into in-
jecting drugs by their peers.
This contrasts with the situation in Albania,
where older injectors were found to initiate new,
younger injectors. The research confirmed that
the Balti environment was unlikely to support
interventions aimed at working with older IDUs
to dissuade them from initiating younger, non-
injecting drug users into injecting.

31
Following discussions with service providers and NGOs, UNICEF,
the Ministry of Health and other partners opted to:
• build understanding of most-at-risk adolescents (MARA) and
the actions required to produce a comprehensive response to
their complex needs
• advocate for national strategies, plans and monitoring systems
to include MARA and especially vulnerable adolescents
• strengthen capacity of existing YFHSs to provide high quality,
targeted services for MARA
• improve cross-sectoral communication and cooperation, and
pilot high quality services and referrals to meet the needs of
at-risk and vulnerable adolescents.
1. Building understanding and support for MARA
UNICEF began by introducing the concept of MARA and dem-
onstrating the need for data and targeted responses. Key stake-
holders and decision makers came together to identify an ap-
THE PROGRAMME
MOLDOVA
Other factors, including a shift in the focus of law enforcement to
mid-level dealers and producers, were found to contribute to an en-
vironment in which interventions such as Break the Cycle* would be
unlikely to be effective.
The research had significant implications for the types of pro-
grammes that were supported in Moldova. Findings showed that ex-
isting harm-reduction programmes have not been reaching younger
IDUs who inject intermittently with their peers, nor are these types
of services particularly relevant to them. Therefore, alternative entry
points were needed.
©LinaOsoianu
*Piloted in the U.K., Break the Cycle interventions promote to current IDUs that
they not discuss, demonstrate or initiate injecting among or with non-injectors.

32
propriate national response. A National Action
Plan for MARA was developed by the govern-
ment, NGOs and young people from all sectors.
The Plan identifies the key issues and sets out
a range of actions required for a comprehensive
HIV prevention response.
2. Advocating for national strategies,
plans and monitoring systems to
include MARA
UNICEF’s advocacy led to integration of
MARA into the National AIDS Programme
2011–2015 (NAP)6
. The NAP includes refer-
ences to adolescents in its definition of at-risk
populations (ie, IDUs, sex workers and men
who have sex with men [MSM]) and, among
its list of vulnerable populations, identifies
children living/working on the streets, in con-
flict with the law and/or living in institutions.
A joint UN/Ministry of Health working group is
reviewing legislation to identify potential bar-
riers to adolescents’ access to reproductive
health services.
It was a new issue, and at the start of the
programme we didn’t have data.
Developing the MARA Action Plan gave
ministries and civil society the time to
absorb the issues. This process lasted a
year but it meant people understood the
issues and challenges MARA face. In the
end they became allies of MARA.

33
MOLDOVA
sionals. The standards set out a minimum package of services
to be delivered by YFHSs. They include a focus on equitable
access to services and a chapter on providing services to MARA
and vulnerable adolescents. A guide to implementing the stand-
ards, which includes advice on how to reach MARA, is under
development. Key staff from YFHSs and reproductive health
services have been trained in outreach, case management ap-
proaches and use of a referral mechanism for MARA. Supervi-
sion and monitoring systems are being developed and tested.
Funding for YFHSs has also been secured, with the state’s Health
Insurance Fund taking over their funding in 2008. Two new YFHS
centres are being introduced in Transnistria with funding from lo-
cal authorities, the Global Fund and UNICEF.
Support groups for young drug users, adolescents living/work-
ing on the streets and young people living with HIV are in place.
A national NGO of young people living with HIV, Positive Youth,
has been established. Members actively participate in the devel-
opment of policies and programmes related to HIV.
As a result of UNICEF advocacy, indicators related to MARA and
other vulnerable adolescents are now included in the monitor-
ing and evaluation (M&E) plan of the NAP. The National Health
Management Centre routinely collects data on 15–18-year-olds.
A monitoring system that was developed for YFHSs is also being
integrated into the national M&E system. It includes indicators on
at-risk and vulnerable adolescents reached through outreach ac-
tivities and services provided in health facilities.
3. Strengthening the ability of youth-friendly health services
to reach MARA
For a number of years, UNICEF has worked with its partners to
establish YFHSs as part of the broader adolescent development
programme in Moldova. As a result, YFHSs are integrated into the
health system and are included in Moldova’s health policies and
youth strategy.
UNICEF led development of a national concept for YFHSs, stand-
ards of quality, monitoring tools and training materials for profes-
©LinaOsoianu

34
4. Improving cross-sectoral communication
and cooperation
Pilot projects have also been established in Bal-
ti, Chisinau and Tiraspol to determine how best
to provide integrated services for MARA and
other vulnerable adolescents using outreach ac-
tivities, case management approaches and re-
ferrals. These are focused on identifying at-risk
adolescents as early as possible and providing
high quality services that respond to their needs.

Methodological and support materials have been developed
to support the referral system. These include: a map of social
services describing education, health and social services in
Balti and their contact details; a guide on working with vul-
nerable children; leaflets for professionals about the referral
mechanism; and leaflets and posters for the general public
to promote attendance at services. The YFHS standards and
protocols help to ensure good communication between pro-
viders and contribute toward creating a “safety net” of ser-
vices for vulnerable young people.
Experience from the pilot clinics suggests that the referral
system can succeed. Outreach workers are working with lo-
cal authorities and social assistants to help street children go
back to school, help undocumented adolescents get identity
papers, and mediate contact between vulnerable families and
social assistance services in the community.
35
Prior to establishment of the referral mechanism, cooperation
between sectors in Balti was weak. Health professionals did not
refer their clients to other services, nor did they consult with pro-
fessionals from other sectors to provide a joint response.
In Balti, the social assistance, health, education and police de-
partments, prosecutor’s and probation offices, and civil society
organizations agreed to work together to identify and refer vul-
nerable and at-risk adolescents to the services they need. They
agreed that health professionals should provide direct referrals
to other services and that a social assistant, acting as a case
manager, would develop an intervention plan for adolescents,
referring them to a range of services, periodically evaluating
their progress and making adjustments as needed.
Piloting a referral mechanism to ensure compre-
hensive services for most-at-risk adolescents in
Balti
Experience has shown that services for MARA and other vul-
nerable adolescents need to be cross-sectoral – addressing
problems related to their health, education, experiences of vio-
lence and problems with the law. A referral system developed by
UNICEF and local partners in Balti aims to improve the commu-
nication and cooperation between sectors and provide quality
services that deal with adolescents’ complex needs.
“There are children who cannot even explain the prob-
lem they have. We work with children living in the
streets, with the victims of domestic violence, males
having sex with males, trafficked women and girls. We
counsel adolescents giving birth and thinking of aban-
doning their babies.”
Therapist, ATIS

36
MOLDOVA
UNICEF’s on-going support for MARA and vul-
nerable adolescents in Moldova will be guided
by the activities outlined in the NAP. UNICEF
will work with the Ministry of Health, with sup-
port from the Swiss Agency for Development and
Cooperation, to develop a strategy for scaling up
YFHS that ensures that services reach the most
vulnerable young people and to identify ways to
promote adolescent participation in this process.
UNICEF will support the revision of pre-service
and in-service curricula for health professionals
to ensure a youth-friendly approach within health
services, including primary health care.
THE WAY FORWARD
UNICEF will continue to revise and adjust exist-
ing legislative and normative frameworks in or-
der to remove barriers among most vulnerable
adolescents to accessing youth friendly care
and support. Also, a cost effectiveness analysis
of YFHS will be carried out to help the Moldo-
van Government identify and implement appro-
priate financing for YFHS, to expand and to in-
clude outreach for most vulnerable adolescents
in YFHS. UNICEF will continue to monitor and
evaluate the pilot referral mechanism in Balti,
with the aim of scaling up the model through-
out the country, to better ensure supportive re-
sponses to the complex needs of adolescents
in Moldova.
©LinaOsoianu

“I feel that there are many moments when people
look down at me because I am a Roma.”
We work with IRFAN
in MONTENEGRO
Irfan, a 16-year-old Roma boy, first heard about
HIV/AIDS, gender issues, and sexual and reproductive
health in a UNICEF-supported youth workshop in Pod-
gorica. Sexuality is strictly suppressed in his commu-
nity. “We never talk about personal matters, especially
not between girls and boys,” Irfan explains.
©SilkeSteinhilber

IRFAN’S STORY
Irfan has not been able to go to school since arriving in Monte-
negro in 2001. Only one in four children in Irfan’s community ac-
cess primary education; only 18 per cent of them will complete it.
Three-quarters of the community’s parents are illiterate.
Irfan lives in Konik, a community of over 2,000 Roma, Ashkali and
Egyptians (RAE) on the outskirts of Podgorica. Many here are
refugees from Kosovo. The poverty rate of displaced RAE fami-
lies is five times the national average. Irfan’s 10-member family
is slightly better off than others. They rent a two-room apartment
but struggle to pay the 150 euros monthly rent.
Sometimes Irfan can work with his father in order to bring home
a little money. “We boys are expected to help our fathers, while
girls help their mothers with women’s work.” But girls are more
likely than boys to have their movements restricted, to lack ac-
cess to health services and education, to be unaware of their
rights – indeed, to lack control over their own lives.
Every day, young people like Irfan face exclusion. They have
limited opportunities to shape their own lives and they dream of
living like other young people. “I dream of becoming a profes-
sional football player,” says Irfan, “but most of all, I would just
like to have a real house, a job and a family.” Irfan’s minimal
educational opportunities are further limited by his community’s
lack of support for education and strongly gendered belief in
the male as family provider. “I have no idea how I could provide
for a family,” he says.
Irfan has seen some of his friends engage in human and drug
trafficking: “They were looking to make quick money and are
now much better off than I am.” Some have resorted to sex
work out of economic necessity. One in five young RAE men
from Podgorica have reported having had sex with men, typi-
cally unprotected. Most had their first anal intercourse before
age 18. Some of them reported that they had experienced
forced sex.
©SilkeSteinhilber
39
MONTENEGRO

Irfan attends youth workshops organized by a
local NGO with UNICEF support. It was there
he first heard about HIV/AIDS, gender issues
such as violence and the limitations of tradition-
al roles for girls, and sexual and reproductive
health. He realized the need for such spaces
where boys and girls can be together and speak
freely. “The leaders here in Konik do not pay
much attention to our needs as young people,”
he says. “We would like to form a group and do
our own youth leadership training now ... In the
end, all that I want is equal rights, as a Roma
and as a refugee.”
40

THE APPROACH
Overall, Montenegro has very low HIV prevalence. However,
young Roma are extremely vulnerable to the rapid spread of
HIV/AIDS in the region. Isolated from the wider community, dis-
criminated against, poorly educated and unable to easily access
health services, they lack both the knowledge to protect them-
selves and the confidence to demand better services.
There is a great need for sexual and reproductive health services
in Roma communities. Baseline research1
conducted in 2007–8
among a sample of Roma aged 15–24 in Podgorica and Nik-
sic demonstrated their poor knowledge of HIV/AIDS. In a society
with unequal gender relations, girls are particularly vulnerable.
Domestic violence is widespread. Early and unprotected sex is
very common and girls have little knowledge of how to protect
themselves. One-quarter of girls surveyed reported that they had
experienced forced sex and some of them reported having had
an abortion or miscarriage.
Based on these research findings, UNICEF engaged with nation-
al authorities and partners to develop targeted interventions for
young Roma in Podgorica and Niksic.
The approach encompassed:
• laying systemic foundations through policy and service
strengthening for long-term support to young Roma
• providing targeted, community-based services that will help
and encourage young Roma to make positive behaviour choic-
es to protect themselves and their peers.
41
MONTENEGRO

Research among Roma aged 15–24 in
Podgorica and Niksic
• 29% of girls had first sex before age 15. 25% of
these girls had had an abortion, and an alarming
30% had had a miscarriage.
• Only 44% of boys and 22% of girls had ever
been enrolled in school.
• 50% of males, and only 5% of females, had used
a condom with a casual partner at last sexual
intercourse.
Evidence from the 2007–8 study that looked into
the risks and vulnerabilities of young RAE for HIV
and sexually transmitted infections (STIs) provided
UNICEF and its partners (including the Institute of
Public Health, Red Cross, youth NGOs and Roma
NGOs) with clear parameters within which to design
an effective programme.
DATA AT A GLANCE
©SilkeSteinhilber
42

Targeted interventions focused on young Roma aged 15–24
living in settlements in Podgorica and Niksic, and aimed to:
• reduce risk behaviour among sexually active Roma
• reduce the vulnerability of young Roma in settlements
for displaced persons
• increase their HIV-related knowledge and skills, and build
their confidence
• challenge prevailing social norms and attitudes toward
violence and gender relations
• improve their access to quality health services by
strengthening national strategies, policies and standards.
1. Building foundations for sustained support – Gender
advocacy
For the UNICEF programme to be successful it had to address
gender inequality, while reducing risk and vulnerability to HIV and
other STIs. Gender-sensitive programming was new to many of
the partners, so there were several challenges:
Building stakeholder support – Community advisory boards, each
including a local doctor and youth and Roma leaders, ensured
community participation and ownership. Community elders and
parents had to be convinced to allow their girls to participate in re-
search and attend discussion workshops. Personal visits to 120
Niksic families resulted in some 20 girls and 50 boys participating
in the programme.
Data collection – Young women were actively involved in the be-
havioural survey of 15–24-year-olds, the first baseline survey of
RAE adolescents. Ensuing discussions about sexual health and
HIV/AIDS prevention assisted planning of prevention measures
for boys and men. However:
• more women than men dropped out during the survey’s
training phase
• constricted living conditions and family controls impacted
on the random selection of respondents and interview privacy
• cultural attitudes (eg, prohibition on men who have sex with
men [MSM]) may have produced biased responses.
THE PROGRAMME
MONTENEGRO
©SilkeSteinhilber
43

Capacity building and empowerment – This was
achieved through an HIV/AIDS analysis of Mon-
tenegro, a regional training package and brief-
ings on developing gender-sensitive prevention
programming for adolescents.
Promoting community dialogue – Openness was
the key, including provision of shared and fe-
male-only spaces to empower girls, weekly visits
by doctors and peers, and open exchanges be-
tween policy makers and community representa-
tives.
Empowering RAE adolescents – Two young men
were the first from Konik’s RAE community to
attend secondary school. Young women have
been empowered by open participation in the
programme. There is increased awareness that
girls lack role models, and of the effects of the
community’s restrictive gender norms.
2. Integrating young Roma into national
strategies
UNICEF and partners advocated successfully for
young Roma to be specifically targeted in national
plans, strategies and monitoring systems. The
National HIV/AIDS Strategy3
sets out the Govern-
ment’s long-term commitment to young Roma.
The national monitoring system for measuring the
national response to HIV/AIDS and STIs now in-
cludes indicators on knowledge levels and con-
dom use among young Roma. These are also
included as indicators for monitoring the imple-
mentation of Global Fund programmes.
Discussion workshops
In 2010, young Roma attended 56 workshops
and about 500 were influenced through peer dis-
cussion on such topics as human rights, gender
stereotypes, family violence, stigma and discrim-
ination, access to youth-friendly social services,
the right to education, and healthy lifestyles.
Opening such topics to discussion was an im-
portant achievement. Female-only discussions
allowed girls to speak openly about sensitive
topics, while mixed discussions gave them the
opportunity to voice their ideas in front of boys.
(See Gender Case Study2
.)
44

3. Changing legal systems to improve
access to health services
UNICEF has successfully advocated for better systemic recogni-
tion and response, not only to HIV/AIDS-related needs but also
to the broader health needs of young Roma. As a result, the Gov-
ernment is committed to providing free, youth-friendly primary
health services (YFHS) across the country, offering information
on sexual and reproductive health and referrals. Young Roma
have been involved in developing protocols and standards for
YFHS appropriate to their needs and circumstances, and a set of
rights-based principles for use in YFHS has been promulgated.
As a result, access to YFHS will be increased.
UNICEF and partners continue to advocate for staff training pro-
grammes to be systematized by the health, education and social
protection systems. This is critical if quality services are to be
provided to vulnerable adolescents over the long term.
“We needed to promise that we would
take the girls home, one-by-one, after the
workshops; otherwise they would not be
allowed to participate.”
Workshop Organiser, Niksic
4. Working with adolescents who live in settlements
Participatory workshops were facilitated by UNICEF, with support
and participation from representatives of the Institute of Public
Health, the Ministries of Health, Education and Human and Minor-
ity Rights, professionals from primary health centres, NGO repre-
sentatives and young Roma.
Along with the workshops and peer-to-peer discussions, 350
home visits were conducted and resulted in an increased number
of girls participating in the workshops. UNICEF, in partnership with
the youth NGO Forum MNE and the Centre for Roma Initiative,
supported continuous, intensive training in project development
and report writing, NGO management, human rights, and educa-
tion and health issues, for 30 RAE adolescents from Podgorica
and Niksic, to enhance their knowledge and skills.
45

The programme has generated a new sense
of solidarity, common purpose and national-
commitment to issues affecting young Roma in
Montenegro. A new NGO for Roma youth has
been established to increase their participation
in planning and implementing programmes,
both within and beyond their own community.
UNICEF will continue to support community-
based activities with adolescents and their par-
ents, and strengthen the youth NGO and peer
education programmes. The aim is to establish
youth clubs in all municipalities to bring Roma
youth together with their non-Roma peers.
THE WAY FORWARD
MONTENEGRO
There are many remaining challenges that need
to be addressed, including reproductive health is-
sues, violence, family support and child care, and
enhancement of active participation by Roma
youth, to name a few. As Montenegro moves to-
wards EU accession, resources must be found
and political support must be sustained to consol-
idate and build upon the programme’s success.
Roma adolescents and other youth NGO mem-
bers have been trained to talk to their peers
about HIV and reproductive health and inform
them about YFHS. Some 500 young Roma
have been reached through this approach,
which has proved effective and popular with
adolescents and their parents.
In December 2010, young Roma helped to es-
tablish Montenegro’s first Roma youth NGOs
(one in Podgorica and one in Niksic) as a
means to strengthen community participation
among young Roma boys and girls and ad-
dress their issues of concern.
©SilkeSteinhilber
46

“People see us as … I don’t know! They don’t see us.
They look at us as criminals, knowing that we use drugs
and therefore we are the worst criminals.
I think that drug dependence is a disease and
we need support, not to be excluded …”
We work with MARIA
in ROMANIA
Maria struggles with drug addiction, hepatitis C and
many other challenges. UNICEF and partners are work-
ing with marginalized young people like Maria to build
trust and increase equitable access to community ser-
vices throughout Romania.

ROMANIA
MARIA’S STORY
Maria lives on the streets of Bucharest. She used to live with her
aunt who sent her out to work or beg. Tired of this life, Maria ran
away to live on the streets. At 17 years of age Maria has a two-
year-old child who lives in a State Care Placement Centre, but
she never visits her.
The Romanian Association Against AIDS (ARAS)1
found Maria at
the city’s railway station a year ago. She was high from the heroin
she had just injected and reluctant to use the services offered by
ARAS as she was afraid she would be placed in state care. Maria
had once lived in a state protection centre for street children but
she felt isolated and vulnerable there – the older girls used to
beat her and she could not access drugs, so she ran away.
Eventually Maria began to trust the staff from ARAS and she start-
ed to visit their drop-in centre. ARAS helped her get her identity
papers but it was a long and difficult process as she would only
come to the centre occasionally – usually high on drugs. Eventu-
ally Maria agreed to undergo detoxification treatment (the only
service available to minors) but after a month in hospital she
learned that she has hepatitis C. Maria is back on the streets ...
she wants to stay clean, but with all her friends using drugs and
with no place to go her options are limited. She hopes to start
substitution treatment when she turns 18.
©MugurVarzariu
49

UNICEF Romania has focused in recent years
on prevention among at-risk and especially vul-
nerable young injecting drug users (IDUs), fe-
male sex workers (FSWs) and men who have
sex with men (MSM), in Bucharest, Iasi, Con-
stanta and Timisoara. The work with local part-
ners has centred upon a three-pronged strate-
gic approach that includes:
• building support for targeted HIV prevention
for most-at-risk-adolescents (MARA) at
national and community levels
• improving the quality of health and social
services
• piloting interventions linked to drop-in
centres, outreach activities, HIV testing and
counseling (HTC), and medical and social
services.
THE APPROACH
The following are some of the results from
UNICEF and partner programming among MARA
in Romania:
• Baseline research conducted in 20082
confirmed high rates of risk behaviour.
Especially striking was overlapping risk and
vulnerability among IDU and FSW populations
(see Data At-A-Glance).
• Advocacy led to the inclusion of marginalized
adolescents in the proposed 2011–2015
National AIDS Strategy.
• Standards, protocols and a training curriculum
were developed to ensure that services
reached adolescents effectively.
• Pharmacists and social service providers were
trained to refer and work with MARA and
other vulnerable adolescents.
• A voucher system was developed to increase
access to and use of health and social
50

services, including child protection services.
• Evaluation research conducted in 20103
showed that projects
intended for MARA are considered to be efficient and relevant
to the specific needs of these groups (IDUs, FSWs, MSM) both
by beneficiaries and by those who have managed the projects
on behalf of each of the eight organizations involved.
Community-based services were effective in reaching over 1000
MARA and other vulnerable adolescents. Of these, 200 were
tested for HIV and counselled. Pilot medical–social services
served over 500 young clients. However, changes in the politi-
cal environment led to delays in addressing laws that require
parental consent for minors to access testing, counselling and
other services. The political situation and economic crisis limited
government involvement in the programme overall, thus hinder-
ing efforts to integrate MARA programming into national plans,
budgets and systems. The programme has shown that govern-
ment leadership is critical if programmes and interventions are to
be sustained and taken to scale.
During initial consultations with government and civil society,
UNICEF and partners decided to investigate risk behaviours and
the extent to which existing services were addressing the needs
of young IDUs and FSWs. Recent data show that 15–24-year-
olds account for almost 50% of new cases of HIV.
The Faculty of Sociology and Social Work of the University of
Bucharest conducted a baseline study during 2008 among 300
IDUs aged 10–24 in Bucharest, and 295 FSWs aged 10–24 in
Bucharest, Constanta, Iasi and Timisoara2
. The study showed
that:
• IDUs and FSWs are at high risk of HIV infection, and their
level of risk increases as their age decreases.
• adolescents do not use harm reduction services as often as
older injectors
ROMANIA
51

Research among FSWs and IDUs under
age 24
• 6% of IDUs and 20% of FSWs surveyed were
under age 18; over one-quarter (29% and 27%
respectively) in each sample were Roma – 3
times more than in the general population.
• Nearly one-quarter (22%) of FSWs surveyed
said they inject drugs.
• Younger IDUs, FSWs and respondents of
Roma ethnicity had less knowledge about HIV
transmission and available services than their
older counterparts.
• Adolescent IDUs were more likely to have
shared equipment during the previous month
than those over 18 (26% vs 19%), and less
likely to have accessed outreach and/or
needle-exchange services.
• 41% of steady sexual partners of IDUs were
injecting drug users.
• 23% of FSWs had partners who inject drugs.
• More than one-third of FSWs and 14% of
IDUs did not have identity papers – reducing
their access to health and social services.
DATA AT A GLANCE
• younger FSWs are less likely than older FSWs
to use condoms consistently with commercial
and casual partners.
The data also demonstrated the overlap between
sex work and injecting drug use and confirmed
that being Roma increases the likelihood of prac-
ticing risk behaviours.
©MugurVarzariu
52

There were some encouraging findings. One was that adoles-
cents had lower rates of anal sex and injecting drug use than their
adult counterparts. This suggests there is an opportunity for early
health promotion interventions that would prevent initiation of risk
behaviours.
An assessment of existing services confirmed that Romania has
a strong network of NGOs providing HIV prevention and harm
reduction services which have good experience of working with
IDUs. However, legal restrictions on providing services to ado-
lescents without parental consent limit NGOs’ ability and willing-
ness to openly provide appropriate services to them. Although
UNICEF tried to advocate for a review of policies that would fa-
cilitate improved access to prevention, care and support services
for younger populations, political instability made revision of laws
impossible. In order to avoid problems with authorities, NGOs
working with MARA in Romania, as in many other countries, tend
to use unique codes for all beneficiaries, without asking for iden-
tity data and while adhering to principles of confidentiality.
Baseline data showing risks and the overlap between sex work
and injecting drug use meant that comprehensive services had to
be developed for both FSWs and IDUs. As a result, UNICEF and
NGO partners focused on:
• building support for targeted HIV prevention for MARA
at national and community levels
• improving the quality of medical and social services for
adolescents
• piloting interventions to increase adolescents’ access
to services.
Partners for the work have included: Ministry of Health; Ministry
of Interior and Administration (National Antidrug Agency); Minis-
try of Labour, Family and Social Protection (National Authority for
the Protection of Child Rights); General Directorates for Social
Assistance and Child Protection; and eight NGO partners – the
Romanian Harm Reduction Network (RHRN)4
; Accept5
; Aliat6
; In-
tegration7
; ARAS1
; Parada8
; Samusocial9
and Sastipen10
.
ROMANIA
THE PROGRAMME
©MugurVarzariu
53

1. Building support for targeted
HIV prevention
UNICEF advocated with central and local authori-
ties to build a better understanding of at-risk ado-
lescents and create a supportive environment for
HIV prevention and harm reduction interventions.
As a result of UNICEF advocacy efforts, the draft
National HIV/AIDS Strategy 2011–2015 includes
a chapter on MARA. Data from the baseline stud-
ies and lessons learned from programming were
used to inform the chapter, which sets out actions
to develop, and provides communication strate-
gies and services tailored to at-risk adolescents.
UNICEF facilitated regional advocacy meetings
with government partners, the police, media,
pharmacists, at-risk adults and adolescents, par-
ents and service providers, to address HIV and
harm reduction. Special sessions on the stigma
and discrimination experienced by MARA were
included. Participants identified priorities and
developed action plans based on the research
findings and local capacity to respond.
2. Improving the quality of medical and
social services
National partners developed standards and
protocols to help ensure equity and quality of
HIV/STI services for young people, including at
harm reduction drop-in centres and in needle-
exchange programmes, HIV counselling and
testing, outreach and interventions for FSWs.
Guidelines for outreach, drop-in centres and
substitution treatment for IDUs and FSWs were
adapted to include MARA.
A capacity assessment of services for MARA
was undertaken. The assessment reviewed
medical and social units, state institutions and
NGOs. It found that both state and NGO services
had been affected by the political and economic
situation and the lack of funding. A training cur-
riculum on providing services, including VCT, to
at-risk adolescents was developed, and profes-
sionals from the health and child protection sec-
tors were trained.
A study on access to sterile injecting equipment
and opioid substitution medication in pharma-
cies was developed and certified by the College
of Pharmacists11
. Attitudes, knowledge and prac-
tices of Bucharest pharmacists regarding inject-
ing equipment and opioid substitution treatment
were assessed. It was recommended that phar-
macists be involved more explicitly in developing
services for IDUs, that is, access to sterile inject-
ing equipment and availability of drug substitu-
tion treatment, with prescriptions from physicians
54

specialized in addiction.
Pharmacists were trained to support prevention and appropriate
counseling and harm reduction approaches for adolescent IDUs.
A manual and guidelines on harm reduction for pharmacists was
developed. Both documents were certified by the College of Phar-
macists – a training-of-trainers curriculum was developed and
credited with 64 hours of continuous pharmaceutical education,
thus ensuring its integration into the broader education system.
A database was set up to monitor adolescent use of harm reduc-
tion and HIV prevention services provided by NGOs. Managed by
RHRN, the database includes information on age, sex, services
received (syringes, condoms, medical and social assistance), ar-
eas where clients live, and HIV/HVB/HCV test results. A coded
system was established to protect the identity of clients. The da-
tabase serves as an important advocacy tool that holds informa-
tion on the number and typology of clients seen – providing tangi-
ble evidence that MARA do exist, highlighting the problems they
are dealing with and showing which services they need.
3. Piloting interventions to increase adolescents’ access
to services
The work by UNICEF and partners brought government service
providers from the health and social sectors together with repre-
sentatives of eight NGOs to see how appropriate HIV prevention
services, including harm reduction, could be provided to margin-
alized adolescents in four cities.
Outreach activities supported by the Global Fund were adapted
to respond to adolescent IDUs, FSWs and MSM in Bucharest,
Iasi, Constanta and Timisoara. A new drop-in centre was set up
in a Roma community, one of the poorest communities in Bu-
charest. The drop-in centre was developed in partnership with
the United Nations Office on Drugs and Crime (UNODC.) The
centre provides adolescents and vulnerable young people with
harm reduction services, medical assistance for emergency situ-
ations, and social services, including psychological counselling
and support in obtaining identity papers and increasing school
enrolment. In all, 507 clients were seen between January and
June 2010, all of whom were adolescents.
Another, pre-existing centre was adapted to better serve adoles-
cents. Special emphasis was placed on reaching socially exclud-
ed adolescents, including those living and working on the streets.
Services included social assistance and psychological support,
access to treatment, and HIV, Hepatitis B and C counselling and
testing.
During 2010, drop-in centres and outreach activities reached
1072 young people aged 15–24. The services focused mainly on
primary medical care of infected wounds due to injecting, gen-
eral medical check-ups, and social services adapted to clients’
needs, including support to obtain ID papers. Clients were also
referred to specialized medical services.
ROMANIA
©MugurVarzariu
55

UNICEF collaborated with medical and child
protection services to pilot a voucher referral
system aimed at increasing access by MARA
to a range of health and social services.
The voucher system was coordinated by
ARAS and implemented by seven NGOs, in
partnership with service providers at hospi-
tals, clinics and child protection departments.
When outreach workers or staff at drop-in
centres identified a prospective referral client,
the client was given a voucher to present to
providers at relevant services. The voucher
included information on the client’s age, sex,
health issues and referral source. The system
used outreach workers to accompany young
clients to meet health and social services
staff who were trained and sensitized to pro-
vide appropriate and friendly services to ado-
lescents.
By monitoring voucher use, programme im-
plementers were able to identify barriers that
MARA encountered in accessing services.
Piloting the voucher referral
system to increase equitable
access to services
Monitoring data collected through the voucher
system included:
• routine project data from referring institutions
and referral sites
• data from client interviews conducted with
MARA
• data from interviews with service providers
• results of quality-of-care “spot checks”
undertaken at referral sites
• case studies documenting project
experience.
ARAS analyzed vouchers from hospital and
clinic service providers, confirming that more
at-risk populations were accessing the services
as a result of targeted interventions. Neverthe-
less, the voucher project encountered signifi-
cant challenges. At the service level,clients lost
their vouchers, which interrupted service provi-
sion. At the systems level, access to medical
care remained limited since laws require that
clients show identity papers and proof of medi-
cal insurance before services can be provided.
Even when service providers were open to as-
sisting MARA, they could not overlook the fun-
damental problem that their own medical costs
would not be reimbursed if they treated at-risk
adolescents who did not have identity or insur-
ance documents.
The voucher referral experience showed that,
despite best efforts, legislative changes are
needed to enable adolescents to access medi-
cal treatment (including HIV testing and coun-
seling) without parental consent and without
medical insurance.
“The syringes were very useful be-
cause I didn’t have to use someone
else’s, I didn’t have to beg for money
to buy a syringe, the vial was mine
and I didn’t share it with anybody and
that helped me a great deal. I stopped
picking paper off the ground to wipe
my arm and get infected; instead I
have gauze swabs, stuff like this.”
14-year-old IDU
Of all the young clients seen, 200 (153 fe-
male and 47 male) requested HIV counsel-
ling and testing, 28 of whom were under
age 18. HIV tests were provided by partner
NGOs.
56

“Legislative barriers made it difficult for NGO staff to
work with young clients under 18 years of age.
“Considering this, more advocacy is needed to remove
policy restrictions and parental consent requirements
that restrict access to services.”
UNICEF HIV Consultant
An evaluation of the MARA programme in Romania3
was carried
out in 2010. A monitoring framework12
was used to assess results,
including the relevance, effectiveness, efficiency and sustainabil-
ity of harm reduction services for MARA, as well as referrals to
specialised medical and social services.
The evaluation showed the following:
• All beneficiaries claimed that the support offered was useful
and met their needs. Beneficiaries had good or very good
opinions about service delivery conditions and the staff who
provided these services (social workers, nurses, doctors,
psychologists and outreach workers).
• MARA knowledge about their own health and available
services increased. Adolescents also reported that they felt
empowered as a result of relationships formed with outreach
workers and service providers at the drop-in centres.
• From NGOs’ and other partners’ perspectives, without
technical and financial support from the State, MARA project
sustainability will be weak. If such projects were to stop, the
short- and long-term effects would be extremely detrimental to
MARA and to the society as a whole, leading to increases in
rates of HIV/AIDS, hepatitis B and C, and other STIs.
Changes in the political environment, along with the economic
crisis, have had a profound effect on programming for MARA,
as implementation rates have been affected by events beyond
the control of service providers and NGO programme managers.
Changes in staff at the Ministry of Health and shifting political pri-
orities delayed the adoption of the National AIDS Strategy 2008–
2013. This in turn hindered efforts to integrate MARA program-
ming into national plans, budgets and systems. The fluid political
situation also delayed the validation of standards and protocols
for outreach, drop-in, and counselling and testing services which
include a focus on MARA.
©MugurVarzariu
57

Programming experience has shown that gov-
ernment leadership is critical if prevention in-
terventions for MARA and vulnerable young
people are to be sustained and taken to scale.
UNICEF will continue to advocate that MARA
be kept on the national HIV/AIDS agenda in
Romania. As the epidemic evolves, political
commitment and sustained support to the re-
sponse to the epidemic will be essential.
THE WAY FORWARD
Given the strength and long history of provi-
sion of community-based HIV prevention, care
and treatment services by NGOs in Romania,
UNICEF will continue working to strengthen
partnerships between government and civil
society organizations and to ensure the inclu-
sion of adolescents in programming.
MARA interventions have been ensured, at
least in the short term, owing to inclusion of
MARA as a target group within a programme
funded through European Union Structural
Funds, implemented by a consortium of NGOs
and supported in part by UNICEF.
ROMANIA
58

“Had it not been for these people from
the Centre for Youth Integration,
who knows where I would have ended up?”
We work with MIRELA
in SERBIA
Mirela, a 17-year-old Roma, attends a drop-in centre
for marginalized, “street-involved” children in Belgrade,
Serbia. She has benefitted from the HIV and Hepatitis
Prevention services provided by the Centre for Youth
Integration (CYI)1
, supported by the Youth of JAZAS2
organisation and UNICEF. Thanks to the motivational,
educational and psychological support from the centre,
Mirela has resolved not to adopt her family’s lifestyle.
©SladjanaStankovic

MIRELA’S STORY
Mirela has learned to cope with challenges that would make even
the strongest among us give up hope. She manages to support
her entire family, including her mother, her older brother who is a
heroin addict, and a sister who is a sex trafficking victim and also
a drug user. Because of her family situation, Mirela is exposed
daily to the risks of HIV, and hepatitis B and C infection.
“You don’t see parents like mine every day, parents who don’t
care,” Mirela says. “Had I not been smart myself, I would have
ended up like my sister. She has been sleeping on the streets
and sniffing glue since she was a kid. She started to work ‘down
the street’ and sell her body when she was nine. The idea that
she could get ill and die never occurred to her. Her first husband
dragged her into the street to sleep with other men for money.
Now, she has plenty of men. It breaks my heart to watch her
walking, all doped up and other people touching her. Even while
pregnant, she was doped every day.”
Now 16, Mirela’s sister Danijela is already the mother of a six-
month-old baby and is pregnant again. Social workers have
taken away the baby, since Mirela was the only one taking care
of the child in their cottage in an unsanitary settlement in Bel-
grade. “When I was a little girl, I used to wash wind-shields at
the traffic lights. Now, I do cleaning as well. That is how I make
money to buy bread for the whole family,” Mirela says.
Her older brother (19) also had two children taken into care by
social workers. He beats Mirela every day, which is why she
sometimes runs away and sleeps in the street, thus facing ad-
ditional risks. “We were hungry, and I worked to make money
for his children as well. Still, I’m never good enough. He wash-
es wind-shields every day but only to buy drugs, and he beats
me if there is no bread at home. My brother does not want to
be helped,” she explains, tears falling down her cheeks. Her
brother and sister reject any kind of professional assistance.
Until recently, Mirela herself was constantly vulnerable to direct
risks – to try drugs or get involved in trafficking.
©SladjanaStankovic
SERBIA
61

Three years ago, when the CYI1
field activ-
ists found her, Mirela had lost faith in people,
and was unwilling to communicate with outsid-
ers. Only recently did she come to the drop-in
centre for “street-involved” children, and she
gradually became involved in the centre’s HIV
and Hepatitis Prevention, Drop-In and Out-
reach services, initiated by CYI and supported
by Youth of JAZAS2
organisation and UNICEF.
Following a series of motivational and educa-
tional sessions, combined with psychological
support provided by the education officers and
psychologists at CYI, she gave up the idea of
adopting her family’s lifestyle.
Mirela has no documents, not one paper that
proves legally that she exists. She never had the
chance to attend elementary school, or to use
health care services. Getting a medical check-up
meant taking money from the food budget. Natu-
rally, she had medical treatment only when it was
absolutely necessary. All she hopes for now is to
get an ID card, with the help of CYI and UNICEF,
and become a Serbian citizen, entitled to health
care and work.
62

THE APPROACH
Serbia has low HIV prevalence (0.1%); HIV affects mainly se-
lect, at-risk populations. In partnership with the Ministry of Health,
the Global Fund to Fight AIDS, Tuberculosis and Malaria, and
other partners, UNICEF has worked to prevent new infections
among excluded adolescents – “social ghosts” marginalized or
stigmatised by society – including those who live and work on the
streets, and adolescents who inject drugs (IDUs).
Initial assessments confirmed a dearth of data on at-risk adoles-
cents, a lack of ethical guidance for research and programming
for adolescents, the absence of appropriate policies and legisla-
tion supporting programmes for minors, and weak provider skills
for working with at-risk and vulnerable adolescents. Policy mak-
ers, researchers, and service providers (even those working with
adult, most at-risk populations) had not recognised the need for
a specific focus on adolescents.
UNICEF and the Ministry of Health conducted baseline research
among adolescents who live and work on the streets and those
who inject drugs. This included a rapid assessment of 178 chil-
dren aged 10–19 who were living and working on the streets in
three cities in 2007–8. UNICEF also worked with research teams
funded by the Global Fund to formally integrate adolescents and
young people aged 15–24 into national data collection, bio-be-
havioural surveillance surveys (BBS) and interventions intended
for most-at-risk populations. The research confirmed that risk
behaviours start in adolescence and that adolescents living and
working on the streets are especially vulnerable to HIV and other
risks.
SERBIA
63

“We had to open their eyes and ears
to [at-risk] adolescents.”
Research among 178 at-risk 10–19-year-olds
living and working on city streets
• 70% had used marijuana, 40% had sniffed glue,
15% of boys and 12% of girls had injected heroin.
• 17% of boys and 57% of girls had sold sex.
• One-third of girls and 16% of boys had never
attended school.
• One-third had come into contact with the police.
• Approximately one-third had lived in and run
away from an institution.
Research among 248 15–24-year-old IDUs3
in
Belgrade, Novi Sad and Nis5
• 50% of respondents were Roma, compared with
10% of all IDUs (10% of all IDUs in the three
cities are Roma).
• One-third started injecting drugs before age 18.
• 35% had shared needles during the previous
month.
• Younger injectors were less likely than older
injectors to use outreach and needle-exchange
services (4.8% vs 24.7%) and more likely to
obtain needles from acquaintances.
DATA AT A GLANCE
©ZoranJovanovicMaccak
64

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HIV Prevention for At-Risk Youth

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