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In Ukraine, the oldest profession meets state of the art HIV programmes

© UNICEF Ukraine / 2011
When night comes one can easily find young female sex workers in the streets of Mykolayiv and Odessa in the south of Ukraine. [Two girls standing in the street and waiting for clients]

Adolescent female sex workers in Ukraine live on the fringes of society. They negotiate risk as routinely as they negotiate prices. Their exposure to health services is low, they place a low value on health-seeking behaviours, they commonly experience police harassment, and fear being sent to state child care institutions, which are home to far too many young Ukrainians.

A staggering statistic underscores their vulnerability to HIV- nearly one in five sex workers is living with HIV, and nearly one in five sex workers is considered an adolescent. [UNICEF Country Office, 2011].

Surveys conducted in 2006 share the following insights: 15% report selling sex before the age of 15; 25% report using condoms at the last sexual intercourse; and 19% reported ever having injected drugs.

These facts were suspected, but not always known.

In 2006, UNICEF and partners initiated research to address critical gaps in data, including prevalence of HIV among adolescent female sex workers. Keeping in mind the the lack of data on adolescents living and working on the streets, the same research team carried out a behavioural survey among street-based adolescents (N=805, age 10-19, 565 boys, 240 girls) in four regions of Ukraine, which found that a considerable proportion of these girls also face a number of risks.

A policy and legislative review within the framework of UNICEF most-at-risk adolescents (MARA) Programming in Ukraine, a capacity assessment among service providers, and qualitative research among A-FSWs and adolescent injecting drug users in four regions rounded out the base of evidence that would guide subsequent action.

Data pulls the levers of action

This evidence was fed into strategic planning processes at the national and regional levels. Multi-sectoral planning groups, with the participation of MARA, developed strategic action plans to guide programme design and pilot testing.

Structured consultations with partners and advocacy with policy-makers were then coordinated by UNICEF, and an innovative HIV intervention model was developed and approved by local policy bodies.

For the first year, planning groups opted to pilot models in four of the most HIV-affected regions of Ukraine, including the city of Mykolayiv, a city known for its particularly high incidence of HIV among young sex workers.

Given the paucity of models for good programming for adolescent sex workers, a strong monitoring and evaluation framework was adopted for the piloting phase of this new model of service-provision.

© UNICEF Ukraine / 2011
Partner NGOs such as UNITUS keep records and monitor the number of YFSW in the streets and increase girls awareness on HIV/AIDS and other STIs.

Delivering comprehensive services in a verticalized environment

The project employs a straightforward model of direct provision of prevention, harm reduction and social services; and refererrals to government health and social services. Clients are recruited by a locally known non-governmental organization, UNITUS, on the streets and through mobile outreach clinics, a local AIDS centre, the Women’s Consultation Centre, an STI clinic and the Criminal Police for Minors. Several other highly fruitful partnerships between local service centers, government clinics and the implementing partners yielded further coordination of services.

A common coding system across referral points enabled tracing of referrals. The referral system proved partially successful, and was further strengthened by formal cooperation agreements.

Results

In total, 117 A-FSWs were served by UNITUS and its partners within the 11-month timeframe (February-December 2009.) 11 (9%) were placed in state child-care institutions while receiving services.

  • 49 (42%) clients were tested for HIV, and 4 (10%) were tested positive. 46 (39%) clients were tested for STIs. Two received positive tests for Syphilis and nine for Gonorrhoea.
  • 62 used the services more than once.
  • 68 reported overall satisfaction, including improved HIV knowledge and skills for prevention, and better access to health care.
  • 97% (67 girls) have already recommend the project services to their peers, and 84% said that they would accompany other clients to health services.
  • 10 A-FSWs volunteered to refer peers to services and distribute HIV prevention information.

Results of empowerment efforts: A-FSWs participated actively in various aspects of the HIV intervention and one girl participated as an advocate in a meeting of the Regional Coordination Council. She discussed the significance of the programme with local stakeholders.

The model supported and informed advocacy work that resulted in revisions to the national AIDS Law on age of consent for testing: 14-18 year olds can now receive HIV tests without parental consent. A-FSWs are also now included in the National AIDS Programme and the work of State Social Services.

Lessons learned

  • Demand rapidly exceeded expectations. By July, UNITUS and partners were serving around 100 clients, though plans were in place to only serve 50. Active recruitment came to a halt when demand far exceeded capacity.
  • Vocational migration adversely affected the number of visits to the drop-in center. Clients reported travel to resorts in the south of Ukraine during the holiday seasons and summer.
  • Data collection during the pilot phase was challenged by the location of the interviews (within the drop-in center) and interference by pimps.
  • The pilot demonstrated the importance of psychological counselling, especially as related to experiences of violence and abuse, and the critical role of close communication between the A-FSWs and social workers. The personal relationship was important to ongoing client retention and support, and personal cell phones of social workers were preferred over hotlines by clients.
  • In the strongly verticalized environment of Ukraine, provision of all essential services under one roof was impossible. The referral system (described above) proved partially successful, and formal cooperation agreements strengthened the referral system.

Many lessons can be gleaned from UNICEF Ukraine’s work to uncover the epidemic’s proportions, spur action and inspire policy and legisltative reform.

To learn more, contact Olena Sakovych at osakovych@unicef.org.

 

 
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