Weak social welfare systems and lack of social safety nets to address family poverty are critical gaps in supporting most-at-risk-adolescents in many countries. With little family support and few formal foster care systems, children in families of key affected populations may end up in institutions, abandoned or living on the street. Out of desperation, many adolescents on the street turn to drug use and sex work for survival, increasing their risk for HIV infection. One of the first studies of HIV risk behavior among 805 street-based, most-at-risk adolescents, in four Ukranian cities, found that street-based adolescents in Ukraine were at significant risk of contracting HIV due to injecting drug use and unprotected sex. (1) A subsequent study of national HIV prevalence, among 15-24 year olds living and working on the streets in Ukraine, found 18.4% infection rates, confirming the extreme vulnerability of adolescents in this group.
At-risk-adolescents in concentrated epidemics are vulnerable to a range of health and social concerns and need access to multi-sectoral integrated services. Effective interventions include single entry points or “one-stop-shops” that use case management approaches and offer services and referrals to address violence and neglect, physical and emotional abuse, substance abuse, social isolation, health and psychosocial problems, and economic issues. (2)
While this level of outreach is optimal, adolescents often face numerous barriers to social protection and support services. Children and adolescents exploited through sex work, injecting drug users, males who have sex with males, and children without parental care encounter stigma and discrimination, harassment and abuse from police, violence, and lack of adolescent-friendly HIV prevention, care and treatment services. Parental consent requirements and age restrictions can inhibit adolescents’ access to essential sexual and reproductive health services, harm reduction programs (e.g. access to clean needles and condoms) and HIV counseling, testing and treatment. (3) Adolescents may be wary of seeking services in environments that tend to blame adolescents who inject drugs or engage in transactional sex or where they risk arrest or being taken into care.
Though reintegration of street adolescents into supportive families is ideal, trying to “rescue” or forcibly remove children from the street can “drive them into hiding, making them harder to reach with outreach services, and increasing their vulnerability to exploitation, abuse and HIV. Health and social services can be more effective when they build trust with at-risk and vulnerable adolescents and young people, reducing the risks in their environment, giving them access to services and seeking their views on the future.” (4)
Key messages and activities to support most-at-risk-adolescents in concentrated epidemics
Changing policies and social norms to provide a supportive environment, respectful treatment and equitable HIV-related service outreach for most-at-risk adolescent will require a collective effort at all levels of society — families and communities, civil society organizations, local authorities, and government policy makers. (5)
- Work with governments to revise laws and policies that prevent access to services for most-at-risk-adolescents (MARA), particularly those that criminalize children and young people. Support governments to modify drug policies, reduce stigma and discrimination, and provide comprehensive HIV services to injection drug users, sex workers, and MSM.
- Work with governments, civil society organizations and communities to develop innovative age and gender-specific outreach approaches for HIV prevention and harm reduction for vulnerable girls, people who inject drugs and adolescent males who have sex with other males.
- Identify and help adolescents overcome barriers to accessing HIV services. Build trust among key populations to increase their willingness to access essential services.
- Include MARA in national AIDS strategies, monitoring plans and surveillance systems and meaningfully involve them in planning and implementation of services.
- Strengthen referral systems to coordinate access to health, education and social protection programs and provide integrated services for adolescents that are accessible.
- Integrate service provider training activities into national training curricula; increase understanding of child and adolescent development and specific vulnerabilities of most at risk children and adolescents. Emphasize reduction of stigma and discrimination and provision of adolescent-friendly services.
- Design appropriate services to increase outreach, contact, and trust of street- connected adolescents and to provide them with child protection, HIV prevention, care and treatment, and harm reduction.
- Build on ‘entry points’ — services trusted by people who use drugs such as needle exchange at pharmacies. Include a comprehensive package of nine harm reduction interventions and additional services such as family support, psychosocial support, and social welfare services for people who inject drugs.
- Recognize adolescents as a time of emerging sexuality and exploration; provide youth-sensitive support to help adolescents address identity, psychosocial wellbeing and HIV prevention needs, including specific needs of young MSM in concentrated epidemics.
- Address high rates of harassment of most at risk adolescents by police and other authorities, and work with systems for law enforcement and protection of child and adolescent rights.