Transcript Hunt N - Children and young people, injecting and HIV

Children and young people,
injecting and HIV
Under-18 and overlooked
ISSDP 6th Annual Conference, University of Kent
30th- 31st May, 2012
Neil Hunt, Damon Barrett, Adam Fletcher
Funded by the Open Society Youth Initiative
Outline
• Project goals
• Convention on the Rights of the Child
(1989)
• Problems, problems, problems
– Data
– Legislation and ethics
– Effective interventions?
• Good practice examples
Project goals
1. Provide a global snapshot (as far as possible), based on existing data,
of:
 the prevalence of injecting drug use among under 18s/minors in different
countries/regions;
 which drugs are injected by this population (and how this varies geographically);
 the age of initiation into drug use/injecting drug use; and
 HIV incidence and prevalence among this population, and other harms.
2. Highlight data gaps and priorities for further research
3. Collate and analyse existing best practice guidelines, including
examples from both international and national levels (governmental and
non-governmental) on harm reduction related to injecting drug use among
under 18s/minors.
4. Examine legal frameworks surrounding injecting drug use among under
18s/minors and harm reduction services for them in selected case-study
countries.
United Nations Convention on the
Rights of the Child (1989)
Article 33
States Parties shall take all appropriate measures,
including legislative, administrative, social and
educational measures, to protect children from the illicit
use of narcotic drugs and psychotropic substances as
defined in the relevant international treaties, and to
prevent the use of children in the illicit production and
trafficking of such substances.
YOUTH RISE AND IHRA 2009. Drugs, Harm Reduction and the UN Convention on the Rights of the Child: Common
themes and universal rights. Youth RISE and International Harm Reduction Association.
UN Drug Control Conventions
“how ‘up to date’ are the UN drug control
conventions in the 21st century, and in the light of
drug use among children? How does the CRC
(coming from the different tradition of international
human rights conventions) fit in? What does the
CRC add, including via its various other
interconnected provisions? Finally, what is the
relationship between these two branches of
international law?”
BARRETT, D. & VEERMAN, P. E. 2010. Children Who Use Drugs: The Need for More
Clarity on State Obligations in International Law. International Journal on Human Rights and Drug
Policy, 1, 63-82.
Taras, 17, cries after Denis, 12, who
was not able to find a vein to inject him
a self-made drug based on ephedrine,
known as ‘baltoushka’. Photographed in
an abandoned house where they lived in
Odessa, Ukraine, on 16 June 2006.
Taras died of an overdose in 2008.
Denis’ whereabouts are unknown.
BLAME AND BANISHMENT
The underground HIV epidemic affecting children in
Eastern Europe and Central Asia. UNICEF 2010
CRC: All appropriate measures...to protect children?
Philippines (an example)
• Archipelago of 7,107 islands
• 3 main geographical divisions:
Luzon, Visayas, and Mindanao
• 98 million people plus 12.5m
Filipinos overseas
• Median age: 22.7
• Ethnically diverse
– 30.1 % Visayans
28.1 % Tagalog
10.1 % Ilocano
9.1 % Moro
6.9 % Bicolano
3.3 % Kapampangan
1.75 % Pangasinense
1.30 % indigenous and nonindigenous.
ZAMBOANGA 
GENERAL SANTOS

Youth: Injecting Drug Users Integrated HIV Behavioral
and Serological Survey (IHBSS) (DoH, 2009)
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Male/female, aged 15-24, injected drugs in the past 6/12.
Cebu, General Santos, Zamboanga (N = 494, 5% ♀)
468 males (15-24): 12.8% <18
26 female (15-24 ): 0% <18
Male injecting initiation: 11-24 (18)
Female injecting initiation: 14-22 (18)
Shared last injection: males 67%, females 58%
Males received free needles: 23% <18; 27% 18-24
Never had HIV test: <18 = 100%; 18-24 = 97%
Mateo et al. "HIV/AIDS in the Philippines."
“In various national and international
forums, HIV experts are baffled as to why
HIV prevalence has remained low,
despite the obvious presence of almost all
the ingredients for explosive HIV
spread.”
Aids Education and Prevention. 16(3): 43-52. 2004
HIV experts no longer baffled...
IHBSS data – CEBU (People Who Inject Drugs)
2007 = 00.4%
2009 = 00.6%
2011 = 53.8%
2012 Philippine National AIDS Council UNGASS report
Data problems
• Not a shortage of data...but a lack of
coherence of data
• UNGASS indicators
• Data gaps and priorities for research
– How many, inject what, how early, with what
harms?
– Proximal and distal causes
– Environmental, group and individual factors
UNGASS indicators
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Indicator 8. Percentage of most-at-risk populations (MARPs) that have
received an HIV test in the last 12 months and who know their results
Indicator 9. Percentage of most-at-risk populations reached with HIV
prevention Programmes
Indicator 14. Percentage of most-at-risk populations who both correctly
identify ways of preventing the sexual transmission of HIV and who reject
major misconceptions about HIV transmission
Indicator 20. Percentage of injecting drug users reporting the use of a
condom the last time they had sexual intercourse
Indicator 21. Percentage of injecting drug users reporting the use of
sterile injecting equipment the last time they injected
Indicator 23. Percentage of most-at-risk populations who are HIV
infected
Reporting required disaggregated by sex and age (<25/25+)
But what about under 18s?
Proximal and distal causes
CIS countries “Death rates ranged from exceedingly high (e.g. Russia) to
very low (e.g. Armenia).
“AOD abuse risk factors divided into ‘proximal causes’ (e.g. AOD
availability) and ‘distal causes’ (e.g. social cohesion, welfare, culture).
Proximal factors appeared to explain some of the AOD use and death data,
but...did not explain all the country differences. Analysis of distal risk
factors suggested that family and community strength are important factors
in the trends in AOD abuse and youth mortality.”
“The policy response to AOD abuse and mortality among young people
needs to attend to both proximal and distal factors... the social
determinants of child and youth development need to be considered.”
Redmond, G. and C. Spooner (2009). "Alcohol and other drug related deaths among young people in CIS countries:
Proximal and distal causes and implications for policy." International Journal of Drug Policy 20(1): 38-47.
A few recurring themes
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Environmental factors
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Vulnerable groups
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Repressive drug control policies
No identity papers, no access
Exclusionary health service costs
Medical/police corruption
Orphaned children and street children
Gender
Sexual safety/sex work
Ethnic minorities
Trafficked children?
Individual factors
– Mental health problems
– Foetal alcohol syndrome?
– Epigenetics?
Injecting normalised or
symbolic of modernity
Я уколов не боюсь, если
надо уколюсь
I’m not afraid of injections
and if needed will inject
right away!
With thanks to Jean-Paul Grund
Legal, policy and ethical problems
• Repressive laws
– Death penalty, extra-judicial killing, compulsory drug detention
and rehabilitation centres, registering/reporting ‘addicts’, arbitrary
arrests, detention, evidence-planting and fabrication of cases by
police
• Arbitrary exclusion of under-18s from services
• Mandatory reporting/registering with authorities
• Parental consent required (groups with no-one in loco
parentis excluded e.g. orphaned street children)
• Consent – evolving capacity and the “mature minor”
principle
Effective interventions?
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How far can we generalise from an adult evidence-base?
– Pharmacotherapies
– Psychosocial interventions
– Novel psychoactives : e.g. Desomorphine (krokodil), synthetic cathinones
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How best to address distal/proximal causes (environmental, group,
individual factors)
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How best to address system issues?
– Narcology/medicalised models
– Nascent/evolving social services
– Legal and cultural obstacles
– Lack of integration: within state-run services & across the state/NGO divide
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Resource poor settings
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New epidemics: e.g. Philippines, East Africa
New South Wales, Australia:
Needle and Syringe Provision (NSP)
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“Depending on the age of the child, a clinical decision may be required to determine that it is
appropriate to provide injecting equipment. It is essential that advice be provided regarding
drug and alcohol and other support services prior to provision of injecting equipment.”
The following actions must be undertaken:
– attempt to engage the child to assess the level of risk (including risk of exposure to blood
borne virus)
– assess whether the provision of clean equipment is appropriate
– assess the extent of any other risks faced by the child and provide appropriate support,
advice or other interventions
– prior to providing equipment NSP staff must provide the child with information on
alcohol and other drugs support services available to the child
– make a report to the Department of Community Services.
Under Section 24 of the Children and Young Persons (Care and Protection) Act 1998, needle
and syringe exchange programme (NSP) staff may report concerns about risk of harm
relating to a young person. NSP staff should also endeavour to reduce vulnerability to the risk
of harm relating to a young person through the provision of support and referral to
appropriate alcohol and other drugs (AOD) and youth specific services.
UK: OST, opioid detox, naltrexone,
alcohol/benzodiazepine withdrawal
Pharmacological management:
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Should be in line with the recommendations in the National Service Framework
for Children, Young People and Maternity Services (2004).
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Is only one component of addressing substance-related needs.
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Should be based on a holistic assessment of the child or young person’s needs
and tailored to those needs, not delivered as a ‘one model fits all’ programme.
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Could reduce self-harm and suicidal behaviour.
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Should be delivered alongside specific psychosocial interventions to provide
comprehensive care for substance misuse.
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Should be delivered alongside mental health services for those children and
young people with mental health needs.
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Should be delivered in the context of a clear clinical governance framework.
National Treatment Agency (2009) Guidance for the pharmacological management of substance misuse among young people. Department of Health.
National Treatment Agency (2009) Guidance for the pharmacological management of substance misuse among young people in secure environments
[online]. London
Question
How can we best increase awareness and
understanding of this issue and move
towards effective, ethical global
programming?
Thank you
[email protected]
[email protected]
[email protected]