Experiences from the field

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HIV prevention among most at risk adolescents in Central and Eastern Europe and the Commonwealth of Independent States.

The countries of Central and Eastern Europe and the Commonwealth
of Independent States (CEE/CIS) have the fastest growing HIV epidemic
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/CIS.

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Experiences from the field

  1. 1. EXPERIENCES FROM THE FIELD: HIV PREVENTION AMONG MOST AT RISK ADOLESCENTS in Central and Eastern Europe and the Commonwealth of Independent States
  2. 2. 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
  3. 3. FOREWORD ©AmerKapetanovic
  4. 4. 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
  5. 5. ACKNOWLEDGEMENTS ©G.Pirozzi
  6. 6. 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
  7. 7. INTRODUCTION ©AmerKapetanovic
  8. 8. 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
  9. 9. INTRODUCTION ©MugurVarzariu
  10. 10. 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
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. “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.
  15. 15. ALBANIA ©RobFew
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. “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.
  25. 25. BOSNIAANDHERZEGOVINA ©EdinTuzlak
  26. 26. BOSNIAANDHERZEGOVINA ©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
  27. 27. 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
  28. 28. ©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 BOSNIAANDHERZEGOVINA 15
  29. 29. 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
  30. 30. ©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 BOSNIAANDHERZEGOVINA 17
  31. 31. 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
  32. 32. ©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. BOSNIAANDHERZEGOVINA 19
  33. 33. “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.” UNICEF Programme Specialist 20
  34. 34. ©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 BOSNIAANDHERZEGOVINA 21
  35. 35. 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
  36. 36. 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
  37. 37. 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. BOSNIAANDHERZEGOVINA 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
  38. 38. “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.
  39. 39. MOLDOVA©AngelaMunteanu
  40. 40. 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
  41. 41. 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.
  42. 42. 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
  43. 43. 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.
  44. 44. 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.
  45. 45. 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. UNICEF Programme Specialist
  46. 46. 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
  47. 47. 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.
  48. 48. 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
  49. 49. 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
  50. 50. “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
  51. 51. Silke Steinhilber MONTENEGRO
  52. 52. 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
  53. 53. 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
  54. 54. 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
  55. 55. 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
  56. 56. 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
  57. 57. 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
  58. 58. 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
  59. 59. 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
  60. 60. “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.
  61. 61. ROMANIA ©MugurVarzariu
  62. 62. 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
  63. 63. 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
  64. 64. 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
  65. 65. 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
  66. 66. 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
  67. 67. 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
  68. 68. 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
  69. 69. 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
  70. 70. “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
  71. 71. 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
  72. 72. “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
  73. 73. ©SladjanaStankovic SERBIA
  74. 74. 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
  75. 75. 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
  76. 76. 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
  77. 77. “We had to open their eyes and ears to [at-risk] adolescents.” UNICEF Programme Specialist 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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