HIV and young people who inject drugs

Introduction

Governments have a legal obligation to respect, protect and fulfil the rights of children to life, health and development, and indeed, societies share an ethical duty to ensure this for all young people. This includes taking steps to lower their risk of acquiring HIV, while developing and strengthening protective systems to reduce their vulnerability. However, in many cases, young people from key populations are made more vulnerable by policies and laws that demean, criminalize or penalize them or their behaviours and by education and health systems that ignore or reject them and that fail to provide the information and treatment they need to keep themselves safe.

Legal and policy constraints

International human-rights law is clear on the obligation of States parties to protect children from the illicit use of narcotic drugs and psychotropic substances, provide evidence-based and human-rights-compliant harm reduction, HIV prevention and drug dependence treatment programmes.(87) In practice, however, the access of young people who inject drugs to information and harm-reduction services is affected by significant legal and policy constraints, including weak implementation of the law by justice and law enforcement officials, and the rights of children to life and health under the CRC are contravened when they are excluded from effective HIV prevention and life-saving treatment, care and support services.

A.1) Overarching considerations for services for young people who inject drugs

Promote the best interests of young people who inject drugs, including prioritization of access to effective HIV and health services, including harm-reduction programmes and voluntary, evidence-based treatment for drug dependence, rather than the arrest, detention or imprisonment of young people who inject drugs.

Involve young people who inject drugs meaningfully in the planning, design, implementation, monitoring and evaluation of services suited to their needs in local contexts.

Fully utilize existing infrastructure and services that have been demonstrated to be appropriate and effective, e.g., services for youth, and ensure improved coverage and access for young people who inject drugs.

Ensure that health, welfare, protection, education, and social protection programmes and services are integrated, linked and multidisciplinary in nature, with a strong system for referral and the continuum of care, in in order to utilize the most comprehensive range of services possible and address the overlapping vulnerabilities and intersecting behaviours of different key populations.

Ensure that there is sufficient capacity amongst professionals, particularly health workers, social workers and law enforcement officials, to work with young people who inject drugs and apply rights-based approaches and evidence-informed practice.

Partner with community-led organizations of youth and people who inject drugs, building upon their experience and credibility with young people who inject drugs.

Build robust baselines, monitoring and evaluation into programmes to strengthen quality and effectiveness, and develop a culture of learning, evidence based practice and willingness to adjust programmes accordingly.

2) Implement a comprehensive health package

Harm reduction, in particular provision of sterile injecting equipment through needle and syringe programmes, opioid substitution therapy for those who are dependent on opioids, and other evidence-based drug dependence treatment, and access to naloxone for emergency management of suspected opioid overdose. It is important that countries where injecting drug use occurs prioritize immediate implementation of NSPs and OST. Implementation of these essential harm-reduction services should facilitate and enhance access to HIV-specific services, such as HIV testing and counselling and antiretroviral therapy, and improve adherence to treatment.

HIV prevention including condoms with condom-compatible lubricants, post-exposure prophylaxis, and voluntary medical male circumcision for heterosexual men in hyper endemic and generalized HIV epidemics.

Voluntary HIV testing and counselling in community and clinical settings, with linkages to prevention, care and treatment services.

HIV treatment and care including antiretroviral therapy and management including access to services for prevention of mother-to-child transmission.

Prevention and management of co-infections and co-morbidities including prevention, screening and treatment for tuberculosis and hepatitis B and C.

Routine screening and management of mental-health disorders, including evidence-based programmes for those with harmful alcohol or other substance use.

Sexual and reproductive health including access to screening, diagnosis and treatment of sexually transmitted infections, a range of contraceptive options, services related to conception and pregnancy care, cervical cancer screening and abortion, and services that protect health and human rights.

Promote mobile Health staffed by trained operators, counsellors, and young people themselves, to provide developmentally appropriate health and welfare information to young people who inject drugs, as well as the opportunity for referrals to relevant services. (118,119,120)

Ensure that young people who inject drugs have access to health and HIV prevention information, regardless of their marital status and whether their parents/ guardians consent,(123) and that medical treatment without parental/guardian consent is possible and effectively considered when in the best interests of the individual. Develop or strengthen protection and welfare services that help parents and families to fulfil their responsibilities to effectively protect, care for and support young people who inject drugs, and in the case of children who inject drugs aim to reintegrate the children with their families, if in their individual best interests, or provide other appropriate living arrangements and care options in line with the 2010 UN Guidelines for Alternative Care.(124)

Provide services at times convenient to young people who inject drugs and make them free of charge or low-cost.(66)

Ensure that services are non-coercive, respectful and non-stigmatizing, that young people who inject drugs are aware of their rights to confidentiality and that any limits of confidentiality are made clear(3,4) by those with mandatory reporting responsibilities.

Train health-care providers on the health needs and rights of young people who inject drugs, as well as relevant overlapping vulnerabilities such as sexual exploitation/selling of sex.(3)

4) Address the additional needs and rights of young people who inject drugs, including:

Primary health-care services including services for survivors of violence, including physical, emotional and sexual violence.

Immediate shelter and long-term accommodation arrangements, as appropriate, including independent living and group housing.

Livelihood development and economic strengthening, and support to access social services and benefits.

Access to free or affordable legal information and services for advocacy and assistance, including information for young people who inject drugs about their rights, reporting mechanisms and access to legal redress(69).

B.1) Supportive laws and policies regarding young people who inject drugs (…)

Apply a rights-based, public-health and harm-reduction approach to drug use.(54)

Work for the decriminalization of drug use, and for the implementation and enforcement of anti-discrimination and protective laws, based on human-rights standards, to eliminate stigma, discrimination, social exclusion and violence against young people who inject drugs based on actual or presumed behaviours and HIV status.(125)

In the context of children, uphold laws, administrative, social and educational measures to protect children from illicit use of narcotic drugs and other psychotropic substances as stipulated in the CRC (Annex 1) and defined in the relevant international treaties. Change law enforcement procedures so they do not allow the confiscation of needles and syringes for use as evidence of drug use for criminal charges or other penalties.(126)

Examine current consent policies to consider removing age-related barriers and parent/guardian consent requirements that impede access to HIV and STI testing, treatment and care.(3) Address social norms around drug use through education with adolescents in schools, using evidence-based methods to build social skills and decision-making capacities, delivered by health professionals and peer.(127)

3) Funding

Ensure that there is dedicated funding in national plans for HIV, and child protection for programmes that target young people who inject drugs, and other programmes that address overlapping vulnerabilities.