Author: Burrows, D.; Alexander, G.
This paper has been prepared as input into the preparation of UNICEF's regional strategy for HIV prevention in the CEE/CIS and Central Asia. It aims to lays out choices for UNICEF's work with young injecting drug users (IDUs) and young sex workers. And, in the context of the broader strategy being developed, identify feasible strategies on working with such highly vulnerable groups - ones that will have greatest impact on the epidemic as well as fall within the mandate and capacities of UNICEF to carry these through effectively.
Purpose / Objective
Provide an outline of:
- rationale/situation analysis in CEE/CIS
- state of the art and experience to-date (including in SE Asia UNICEF experience in the region)
- considering UNICEF's MTSPs and comparative advantage in relation to regional strategic planning on HIV/AIDS and other agencies' on-going activities, propose for UNICEF:
Possible targets and programming entry points 2002-2005
Broad programming approaches
Suggested operationalization and next steps
- Risks, concerns, gaps
Development of the paper involved a review of the epidemiology of HIV, especially among young people, in the CEE/CIS region; and a review of the evidence for effective methods of addressing HIV/AIDS among young injecting drug users (IDUs) and sex workers - the two groups most affected by HIV and most vulnerable to HIV in the region at present. In addition, a series of key informants were contacted to solicit their views of where UNICEF's comparative advantage related to this area of work lies; visits were made to selected countries and UNICEF-supported programmes; and a questionnaire was sent to all UNICEF country offices in the region to ascertain views and further information from the national level.
Key Findings and Conclusions
A developmental approach is needed that can address underlying causes of vulnerability - the social dynamics that have left young people disoriented and without the skills and knowledge they need for life. This includes Life Skills training and social policy that tackle poverty and exclusion and provide opportunities for young people's participation. Such efforts, however, necessarily represent long-term investments and are unlikely to impact on the current epidemic. An emergency response is also needed that is based on what has been found to be effective in reducing HIV infections - and focuses on the most vulnerable groups, now.
An emergency response in this region must include targeting explicit IEC materials to young IDUs and sex workers, outreach programmes providing sterile needles and injecting equipment and links to IDU-"friendly" services. Each city or oblast is likely to need a mix of services specific to behaviours and practices found to be current amongst young people in their setting. Three phases of interventions with injecting drug users are identified. The key element across all phases is the link between government and local programs - and the advocacy needed to make this ownership significant. Experience suggests it may well take at least 7 years for such efforts to become fully established; an early start to interventions in countries that, as yet, may not have high HIV infection levels becomes critical.
The paper concludes that UNICEF - using its position with government and NGOs, between national policy and local practice - could have a major role in advocating for a response that addresses both the developmental and emergency aspects of the crisis. This is laid out as a combined strategy of "walking on two legs". UNICEF should continue its work on longer-term primary prevention -- though, in the face of the drug epidemic, this too cannot be business as usual -- while, at the same time, move strongly to promote the emergency response required.
The real questions (and genuine difficulties) facing UNICEF as it decides on role, however, are not technical but ones of deciding on focus and of ensuring capacities. Lessons from UNICEF's earlier work in HIV/AIDS are considered along with where UNICEF's mandate and other regional objectives point to priority UNICEF engagement. Three major issues emerge as critical in deciding UNICEF's future role in working with highly vulnerable young people: first, whether there are political costs (and how high these are) of UNICEF entering a field as sensitive and, at times, controversial as injecting drug use among young people. Second, whether UNICEF is not better engaged in staying in areas related to primary prevention where it has established itself and is more comfortable in its relations with government -- in Life Skills promotion and information for young people. Third, the question of UNICEF's own capacities -- what can it realistically commit itself to and what are the choices that have to be made in terms of opportunity costs of pursuing work in this as opposed to other areas?
Whatever decision UNICEF takes, it is emphasised this should be one taken with a full understanding of implications and risks. It is recognised that in some country settings, controversy around work with injecting drug users will make the environment more complex. However, partners in national governments have made it clear that work by UNICEF on IDU issues will not cause problems for UNICEF's other work. UNICEF's work must be based on evidence of effectiveness. Risks can be mitigated by a careful choice of strategy and by sharing risk with partners such as WHO, UNDCP and international NGOs.
Should UNICEF focus on what it feels it know best? Life skills promotion and communication of knowledge to prevent HIV among young people already represents a huge proposition, if taken to scale. But, unless action is taken to stem the epidemic among young IDUs now, a generation may be lost before the primary prevention work begins to make a major impact. Many of the heterosexual infections among young people will continue to be directly or indirectly from IDUs or sex workers. And with the IDU-led epidemic still at its very early stage in the region, there are large numbers of young people who are presently uninfected but, given what we know about the explosive nature of epidemics in such groups, could easily become so.
Capacities are central to the debate. Many UNICEF offices in the region are small, lightly staffed, and already have considerable commitments. There is a real limit in terms of what they can take on. We agree. The approach proposed will need HIV-dedicated staff in every office and resources. We suggest financial resources need to be channelled to both developmental and emergency responses -- on a 50-50 basis. A set of internal management indicators to track progress towards the goals set for UNICEF in this area is identified in the paper. The main role that is proposed for UNICEF is one of advocacy for governments to take up strategies on the scale needed. Support to service development should be very limited -- focusing on young people's needs -- and very specific to support policy advocacy. New capacities will be needed -- but they need not be all found in-house. UNICEF, working closely with sister UN agencies, can engage in "strategic partnerships" with other more technical agencies -- including INGOs such as Medecins Sans Frontières (Holland) and the Open Society Institute (OSI) -- so as to ensure the technical support needed.
In sum, it is argued that UNICEF is uniquely positioned to make a critical contribution, one that is feasible and closely positioned around its mandate. And that if a decision is taken, capacities can be built swiftly. A draft mission statement for UNICEF's work with young injecting drug users is proposed:
"UNICEF's mission with respect to young injecting drug users should be focussed around advocacy for a combined developmental and emergency response to HIV amongst young people. This should
« within the developmental approach, give support to, and advocate for, change in factors that contribute to vulnerability to drug use and drug-related risk among young people
« simultaneously advocate for an effective emergency response to the current HIV crisis in the region by focusing on young IDUs and commercial sex workers, and promoting evidence-based interventions so that they can reach a high percentage of these highly vulnerable groups."
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HIV/AIDS - IDU