Draft: 4th November 2003
A situation assessment and review of the evidence for interventions for the prevention of HIV/AIDS among Occasional, Experimental and Young Injecting Drug Users
Background Paper prepared for:
UN Interagency and CEEHRN Technical Consultation on Occasional, Experimental and Young IDUs in the CEE/CIS and Baltics
by:
John Howard, Neil Hunt and Anthony Arcuri
John Howard and Anthony Arcuri Neil Hunt
Ted Noffs Foundation Honorary Research Fellow
PO Box 120 Centre for Research on Drugs and Health
Randwick Behaviour, Imperial College
NSW 2031 C/o 55 Mackenders Lane
Australia Eccles
Kent ME20 7JA
United Kingdom
Phone: + 61 2 9310 0133 Phone: +44 1622 716012
Fax: + 61 2 9310 0020 Mobile: +44 7780 665830
Email:
This background paper draws heavily on a document prepared by John Howard and Anthony Arcuri, titled “Review of Evidence for Harm Reduction Interventions among Young Drug Users to provide Prevention of HIV/AIDS”, prepared for the WHO Department of Child and Adolescent Health and Development, for a WHO/UNAIDS/UNFPA/UNICEF/YouthNet “global consultation on the health services response to the prevention and care of HIV/AIDS among young people: accelerating country level action”, held in March, 2003 at Montreux, and on an unpublished manuscript towards an uncompleted PhD by Neil Hunt.
Introduction 2
Rationale 4
Section 1: A brief review of relevant national level data on the extent of injecting and HIV/AIDS with special reference to people aged under 25 4
UKRAINE 5
RUSSIAN FEDERATION 5
BELARUS 5
MOLDOVA 5
LATVIA 6
LITHUANIA 6
ESTONIA 6
CAUCASUS REPUBLICS – (ARMENIA, AZERBAIJAN, GEORGIA) 6
CENTRAL AND SOUTH EAST EUROPE 6
BULGARIA 7
POLAND 7
SERBIA and MONTENEGRO 7
ROMANIA 7
CENTRAL ASIAN REPUBLICS 7
KAZAKHSTAN 7
KYRGYZ REPUBLIC 8
TAJIKISTAN 8
TURKMENISTAN 8
UZBEKISTAN 8
Section 2: A summary of what is known about the nature of injecting among young people, transitions into and out of injecting, relevant risk behaviours and contact with prevention and treatment services 8
Transition 10
First Injection 10
Section 3: Identification and consideration of relevant macro-level risk and protective factors 11
Section 4: A review of existing and potential interventions and commentary on their advantage and disadvantages and factors that may affect their adoption and implementation 18
Needle and Syringe Programmes (NSPs) 23
Outreach services 24
Linking Information, Education and Communication (IEC) with service provision 24
Substitution Programmes 25
Strength of evidence 27
IV Evidence obtained from case series, wither post-test or pre-test and post-test 27
Other potential approaches to preventing and curtailing injecting 28
Evidence that providing harm reduction services to young people engages or encourages their utilisation of health services. 28
Legal and Policy Considerations 30
Section Five: Avenues for future research 31
References 35
Introduction
The HIV/AIDS epidemic in Central and Eastern Europe (CEE)/the Commonwealth of Independent States (CIS) and the Baltic States is believed to be the fastest growing in the world, with injecting drug use as the dominant mode of transmission (UNAIDS/WHO 2002). While the limitations of HIV/AIDS surveillance and reporting in Central and Eastern Europe and the Central Asia Republics are well known, all countries in the region report substantial and increasing numbers of young people (defined here as those who are aged from 12 to 24) who are HIV infected. Behavioural surveillance of young people in general is poorly developed and young drug users, especially occasional and experimenting drug injectors, are particularly hard to reach populations. Nevertheless, the limited evidence available suggests that these same young people may be especially vulnerable to HIV infection
The presence of substantial proportions of young people among injection drug user (IDU) populations is of great concern. The World Health Organization (2002a) has highlighted explosive HIV epidemics among IDUs. Broadly speaking IDU related epidemics have rapidly developed in a number of countries (most notably in Belarus, Estonia, Russia and Ukraine) and in specific geographic locations in those countries (for example: Odessa and Nikolaev (Ukraine), Svetlogorsk (Belarus), Moscow, Rostov-on-Don, Kaliningrad, Togliatti City and Irkutsk (Russian Federation), Narva (Estonia), Termitau (Kazakhstan), (Kroll, 2003; Rhodes et al., 2002; WHO, 2002b, 2002c). Injecting drug use, the sharing of injecting equipment and associated risks of HIV infection, has also been increasing in countries throughout Central and Eastern Europe (CEE) and the Central Asian Republics (CAR) since the mid-1990s. It is estimated that up to 1 per cent of the population in some countries in the region (and up to 5% in some cities in Eastern Europe) are injecting drugs. Many of these HIV+ IDUs are young people; how many is not clear.
However, the limited evidence suggests that young people are especially vulnerable to HIV infection. Experimental or occasional drug use and drug injecting among young people is reported to be common in many countries in the region; the number of young people in the region injecting drugs is increasing and young people are initiating injecting drug use at increasingly younger ages. Increases in IDU also relate to the availability of readily injectable drugs, or injectable forms of available drugs, and local rituals and traditions. While there have been interruption to drug markets, the opioid group of drugs remain as the major substances injected (whether produced in ‘home laboratories/kitchens from pharmaceuticals or as heroin). However, there is evidence of increased use of Amphetamine-type Stimulants (again, home made or imported ready to use) both within ‘club’/dance and other settings. While much of this use might be occasional and cause few difficulties for this group of possibly ‘functional users’, within some of these ‘scenes’ there are concerning trends. For example, 41% of a sample of about 200 ‘clubbers’ in Moscow indicated they saw a possibility of transitioning to IDU. In addition, while most were in ‘relationships’, 60% indicated that they had sex with others while in these relationships (Khachatrian, 2003).
The limited evidence available indicates: increasing numbers of young people seeking treatment for their drug use (in Estonia 71% of people in drug treatment are under the age of 25 years), that many of those who inject drugs are young, and the average age at first injection in CEE/CARs is between 16 and 19 years (Rhodes et al., 2002). For example, in Russia, the age at first injection has been decreasing (Rhodes et al. 1999) and that some young people begin injecting at ages less than 15 years. In Moscow, 6% of 15-16 year-old high school students report a history of heroin use (Dehne, 2002). An estimated 70 per cent of IDUs across central Asia, the Russian Federation and central and Eastern Europe are under 25 years of age (UNICEF, UNAIDS, WHO, 2002).
However, there are indications, for example from Russia, that not all IDUs are frequent injectors, and that for some young people, drug injection may be experimental and a passing phenomenon. Where HIV prevalence and incidence rates are high and where risk behaviour is common during initiation into injecting - as in many countries and cities in the region - the risk of HIV infection per sharing act is increased so that young, and recent injectors become infected very quickly. Therefore, it is of concern that little attention appears to have been given to the specific needs of occasional and young IDUs in the prevention of HIV/AIDS,
Important interactions also arise between drug use and sexual risk. Drug operates as a mediating or co-factor for sexual risk taking, social network effects (in which drug using networks and sexual contacts overlap) along with sex work, which is a feature of some young people’s lives. Understanding the immediate risk and protective factors for initiating, continuing and ceasing injection drug use and the associated sharing of injecting equipment and sexual risk behaviours is crucial for effective HIV/AIDS prevention
It is important to note that many other macro-level factors are also thought to increase the vulnerability of young people including: social and economic disadvantage, poverty, unemployment, changing social controls and values, failing education and health systems, changing trafficking routes for drugs, arms and people, imprisonment and detention, marginalization and discrimination, migration, civil and armed conflict. Various corresponding protective factors are thought likely to make initiation into drug use, injecting and the risk of infection with HIV/AIDS less likely. These extend the range of potential interventions and intervention points that warrant consideration in any comprehensive appraisal of how injecting and the spread of HIV/AIDS can best be minimised among young people in CEE/CIS and the Baltic States, which – with as much of a focus on occasional, recent and experimental injectors as we have been able to bring - is the topic of this paper.
The paper is organised as follows:
· A brief review of relevant national level data on the extent of injecting and HIV/AIDS with special reference to people aged under 25;
· A summary of what is known about the nature of injecting among young people, transitions into and out of injecting, relevant risk behaviours and contact with prevention and treatment services;
· Identification and consideration of relevant macro-level risk and protective factors;
· A review of existing and potential interventions and commentary on their advantage and disadvantages and factors that may affect their adoption and implementation;
· Provisional proposals for a programme of research and responses across the region, which will be refined through the consultation process.
It is important to note that the authors do not claim any special expertise with the issues as they particularly affect the region and that this paper is offered very much as a departure point to facilitate a refining of our understanding of the situation in partnership with local experts and not as a definitive account of it.
Rationale
Why do occasional, recent, experimental and young IDUs require special attention?
· Young people account for the greatest number of people in developing countries where the epidemic is concentrated, and if not protected from HIV their nations will face staggering human and economic costs.
· Of those infected with HIV after infancy, at least 50% are young people under 25 years of age.
· Young IDUs may have limited awareness of risks due to limited education about and knowledge of HIV and other Blood Borne Viruses (BBVs)
· Young people are curious and can be easily influenced by peers and/or are reactive to or sceptical of adult warnings about risk.
· Young people may feel they are resilient and invulnerable to harm.
· Young people have less economic security and access to resources.
· Risks to health may be perceived at quite distant and remote and mainly affecting older IDUs.
· Young people may have limited capacity to identify with older IDUs who they believe to be ‘losers’ and that they will be able to stop IDU when they choose.
· Young people may feel unwanted or have had negative experiences at adult services, especially if such services primarily cater to adult men who have sex with men (MSMs) and rarely to IDUs of whatever age.
· Due to age and youth ‘status’, young people may be denied access to certain services by policy or legislation.
· Young people may believe that adult services will not respect their privacy and right to confidentiality.
· Young people may be unaware of the right to health and access to health services.
· The young age at which IDU begins and is established, the greater likelihood of later poly-substance use and chronic and life-threatening health illness.
· Early IDU is associated with early school leaving and difficulties in gaining and maintaining employment and stable accommodation.
· Young people in prison or refugee camps, immigrant and minority youth, those working in forced labour or as child/adolescent soldiers, those displaced by natural disasters or civil or armed conflict, and street children and young MSMs are among those at increased vulnerability.
· Young girls may be at greater risk, due to an increased likelihood that they will engage in commercial sex to finance their drug use and living situation.
· Congregating with peer and/or older IDUs can tend to reinforce risky health behaviour (including limited attention to nutrition and self-care) and marginalisation.
· Young people are a force for change. (developed from UNAIDS, 1999; UNODC/The Global Youth Network, 2003).
Section 1: A brief review of relevant national level data on the extent of injecting and HIV/AIDS with special reference to people aged under 25
This section is largely adapted from the work of Grund (2001) and attempts to provide a brief overview of the regional situation. It needs to be noted that drug use and IDU and HIV/AIDS are not equally distributed across the region or within countries.
UKRAINE
· Between 1988-1994 less than 100 registered HIV infections, mainly among foreigners.
· 1995 - more than 1000 cases detected among drug injectors in Odessa and Nikolayev, producing a population prevalence among drug injectors of 31% and 57% in each city respectively.
· HIV infection reported among drug injectors in all 25 regional capitals within 12 months and continued spread into rural areas and cities in the eastern and central parts of the country.
· By the end of 2001 UNAIDS estimated between 180,000 and 320,000 cases of HIV infection of which 50-80% are among people who inject.
· HIV prevalence among IDUs tested in sentinel surveillance studies in 2002 ranged from 17% in Kharkiv to 58% in Odessa
· By April 2003 54,680 HIV cases were reported, 71% attributed to injection drug use
RUSSIAN FEDERATION
· Fewer than 1100 cases of HIV infection registered until the end of 1995 with very few injecting drug users.
· 1995 – rapid escalation of infection among injecting drug users (IDUs) in Kaliningrad
· 1996/7 – IDU infections spread to Krasnodar, Nizhnyi Novgorod, Rostov Na Donu, Saratov, Tula, Tumen and Tver
· 1998/9 - average age 18-25. Nine cases of HIV infection arising from injecting among 11-14 year olds
· 1999 – epidemic detected in Moscow
· 2000 – epidemic spread to 30 cities and 82/89 oblasts. 130,000 people infected with HIV
· Studies in thirteen cities between 2000 and 2002 found HIV prevalence rates among IDUs ranging from 0% among treatment seeking IDUs in Archangelsk to 64% among syringe-exchange clients in Irkutsk