High-Risk Youth in Lower-Income Countries Who Inject Drugs: Challenges and Opportunities

Panelists of "Bridging the Drug Stigma" at AIDS 2018 in Amsterdam, the Netherlands
Esther Bartelds

Young people who inject drugs represent a significant portion of new HIV cases around the world, especially in lower-income countries in Eastern Europe, Central Asia, and Southeast Asia. Data shared at the Global Village workshop at AIDS 2018 in Amsterdam entitled "Bridging the Drug Stigma: Breaking Barriers for Young People Who Inject Drugs" highlighted this trend with an in-depth look at youth who inject drugs in three countries: Ukraine, Moldova, and Indonesia. Eastern Europe and Central Asia are regions with very high rates of new HIV infections driven by injection drug use of both opioids and amphetamines. Surprisingly, despite repressive policies and criminalization, some drug users in these areas are men who have sex with men (MSM) engaging in chemsex: the use of drugs in combination with high-risk sex. Such patterns of drug use, combined with a general lack of HIV services, negatively impact both health promotion and intervention.

Youth are particularly affected in these countries by policies that put them at significant risk. The typical age of initiation of drugs, for example, often doesn't align with the age at which services can be accessed. Different countries have varying policies that require parental consent for both HIV testing and treatment, as well as access to drug information. This is compounded by high levels of stigma in these countries at every level: society at large, community, peers, and even service providers. Criminalization of drug use and homosexuality, including harsh policies -- such as those that permit the execution of drug users (Indonesia and the Philippines) -- drives many young people who inject drugs further underground. The severity of the situation is compounded by an overall lack of access to information and harm reduction services, needle and syringe programs, and opioid substitution therapy, as well as a lack of youth-friendly and youth-focused expertise and services.

According to the Eurasian Harm Reduction Association, from 2010 to 2015, there was a 57% increase in HIV cases in Eastern Europe and Central Asia and, in 2015, people who inject drugs accounted for over 50% of new HIV infections in that region. It is estimated that one-quarter of all people who inject drugs in this region are under the age of 20, and one-third of new HIV infections occur among young people aged 15-24. Despite policies in most of these countries both criminalizing and stigmatizing drug possession without intent to distribute, the problem of youth who inject drugs continues to expand.

One of the countries highlighted during this session at AIDS 2018 was Ukraine. Panelists reported that, in 2009, the country had over 50,000 adolescents (aged 10-19) who inject drugs and, of these, 29% were girls. By 2010, according to data presented, one-third of street youth aged 15-17 who inject drugs were living with HIV. Drugs can be obtained on the Internet, where there are increased sales and availability. The impact of this pervasive drug use is compounded by the fact that 45% of young people who inject drugs in Ukraine began injecting before they were 15 years old.

Despite the adverse political climate, harm reduction efforts are being undertaken in Ukraine, often utilizing online platforms, such as drugstore.org.ua, which presents information about sexual health choices using an interactive, video-game format. Other online groups are available for discussion on topics related to drug use, reducing injecting risks, and overdose prevention. No parental consent for these services is required for youth 14 years and older. Other online formats include online chat channels, which don't support messaging and therefore are not as popular, and the use of closed user groups (CUG), a service provided by mobile operators that allow members of specific groups to make calls to one another for little or no charge.

There are two ongoing projects in Ukraine targeting young people who inject drugs. In three years, they have provided health-related services and social support to 8,100 youth who inject drugs, as well as their sexual partners. Such services are available without parental consent (for youth aged 14 and older), including needle and syringe programs and HIV testing and hepatitis C services, although anyone under age 18 requires parental consent for HIV treatment. Opioid substitution therapy is available for individuals aged 18 and older.

Youth who inject drugs from Moldova, another Eastern European country, were also highlighted at AIDS 2018. There, the median age of first injection is 17 and, while needle and syringe programs are available on a limited basis, they tend not to be utilized by younger injection drug users but rather by older people who inject drugs (ages 18-24). In 2017, the government of Moldova announced support for HIV prevention services in the amount of US$120,000 to fund work by the non-governmental organization "Youth for the Right to Live." These services target key populations: sex workers, gay men, and other MSM, along with people who inject drugs. Services for youth provide psychosocial support to those living with HIV/AIDS and addiction, as well as the promotion and protection of youth rights. This NGO has also opened the youth-friendly clinic "ATIS" for the education and training of young people on issues concerning healthy lifestyles and the formation of volunteer groups. At the clinic, pediatricians, therapists, psychologists, and social workers also provide medical consultations and treatment for vulnerable youth.

A country with even more drastic policies concerning people who inject drugs is Indonesia. Data from Harm Reduction International (2013) was presented at the conference, including statistics about injection drug initiation that are consistent with other lower-income countries: 6% began injecting before age 15; 42% began between ages 15 and 19; and 52% began over the age of 19. Like the countries of Eastern Europe and Central Asia, about half of youth who inject drugs initiated this behavior as adolescents. It was also reported that 96% of females were injected by someone else the first time, a risk factor for HIV transmission. In 2015, Indonesia declared illegal drug use a national emergency, invoking extreme measures. A policy of "shoot in place" was established for anyone using drugs. In 2017, 139 drug users were executed. The government can also mandate drug tests without consent, and youth who use drugs can be forcibly removed from their homes. Additionally, parents who don't report drug use by their own children face legal jeopardy.

The Indonesian Drug Users Network, formed in 2006, continues to provide services in the country. Its mission is to address stigma, violence, discrimination, and violations of human rights against people who use drugs. It advocates for drug policy reforms and the promotion of human rights. In 2014, it began to focus on issues of women who inject drugs, creating a network of women in 12 cities. Legal assistance for drug users is available in the country on a restricted basis, including strategic litigation, ensuring client assessment, and addressing any special needs.

People who inject drugs, and especially youth, represent a high-risk group facing stigma, arrest, limited health-promotion opportunities, and an overall lack of assistance. Unless harm reduction efforts, such as information and needle and syringe programs, are expanded and provide access to treatment services such as counseling and opioid substitution therapy, rates of HIV and hepatitis C will continue to soar. The efforts of several organizations to assist youth who inject drugs, as spotlighted at AIDS 2018, indicate a creative use of technology, maximizing limited financial support, persistent advocacy, and profound courage carrying out this important work in hostile and potentially lethal environments. They deserve both our support and respect.