Topic: Youth & HIV response in Pakistan
Issue: Lack of youth friendly services & youth friendly organizations
Pakistan has a large ‘young’ population bulge with 21.5 percent of the population of the world’s sixth most populous nation, between 15-24 years. While most are not at risk for HIV, many are vulnerable due to economic and cultural factors and weak service provision systems to support them. Youth reproductive health services are virtually non-existent, community based information interventions are few with low coverage, and there is no in-school sexuality education for the young people completing primary or secondary school. Opportunities for synergies with development sectors such as Child Protection, Education and Social Welfare to address structural vulnerabilities exist in Pakistan, but these sectors themselves face many challenges and competing agendas, and coordination with the HIV sector is weak. Despite this, their existing programming is assumed to have a structural impact on overall vulnerability leading to risk behaviours. The infrastructure is in place to scale up services for young key populations, including those living with HIV and to address structural vulnerabilities of young people in general. Government stakeholders and donors now need to commit to accelerating the HIV response for young people, including securing funds for youth specific interventions in the country.
Pakistan is experiencing a concentrated HIV epidemic, amongst key populations, including people who inject drugs, sell sex, males who have sex with males, and transgender persons. As reported through the Integrated Biological and Behavioural Surveillance (IBBS) in Pakistan, young people, comprise a substantial portion of key populations, however, no HIV prevention, treatment, care and support services are available to young PLHIV & key populations. The estimated HIV prevalence, among young key population, 15-24 year-olds from 2005 to 2012, decreased in some countries in South Asia, while it has more than doubled in Pakistan. At the end of 2012, there were an estimated 2200 adolescents 15-19 years living with HIV, and 1100 new infections. In 2011 IBBS R IV, prevalence among adolescent key populations were reported as: PWID: 1% of all PWID were 18-20 years; HSW: 0.3 per cent of all HSW were HIV positive and 15-19 years; MSW: 0.7 per cent of all males who sell sex were 13 – 19 years (a total of 3.1 per cent of all MSW were HIV positive, meaning one third of all MSW HIV infections in 2011 were among adolescents); 0.1 per cent of all FSW were 15 – 19 years.
Those young people, already practicing risk behaviours, need basic services with information relevant to their social context, and delivered to them in a way that allows for maximum access. All young key populations, having sexual intercourse – whether paid or not – need condoms. And they all need access to HIV testing and counselling, and young people, who inject drugs need as many clean needles as the number of times they inject. And if they are HIV positive, they need young people appropriate treatment, care and support services. HIV prevention services including targeted information, HIV Testing and Counselling (HTC), sexually transmitted infections (STIs) treatment and needle exchange are primarily being provided through private public partnerships between the Government and non-Government organizations.
In Pakistan, fragmented data was available on the needs of young people until an exercise was under taken by the APLHIV at National level to synthesize and generate strategic information in relation to HIV and young people to inform the National Strategic Plan review and Investment Cases. As per available data by early 2015, there are over 12,200 PLHIV within age group of 15-24 years and 150,000 members of KPs in same age group. Approximately 4,252 new infections occurred in 2014, alone. In Pakistan’s concentrated epidemic, most new HIV infections occur in young injecting drug users, young hijra and MSM, and young hijra, males and females engaged in selling sex. The behaviours and/or social circumstances of these YKPs, put them at risk of HIV infection. All these face similar risks related to their age, their economic status and their education levels. In Pakistan risks are also compounded by stigma and discrimination. Punitive environments associated with homosexual sex, injection drug use and selling sex also hinder access to the few health or social services available youth, in Pakistan in general, and especially to Young key populations. This data shows a certain increase in KPs and HIV infection, which illustrates a dire need to introduce youth specific services in the country.
Need For Policy Analyses Brief On The Subject
Pakistan like, most countries in the Asia-Pacific region is experiencing a concentrated HIV epidemic. HIV prevalence is generally low, yet infections are concentrated in few identified groups of people who engage in risky behaviours, making them vulnerable to HIV. At the same time, a significant and increasing number of new infections within key populations are among young people aged 15-24. The Data from the Independent Commission on AIDS in Asia indicated that in the region, 95 per cent of all new infections in young people are among young key populations. While particular behaviours put young people at risk of HIV infection, there is an urgent need to see what role and responsibilities and benefits the youth has from existing national structures and funding to access to protection and health care services.
HIV Related Risk Behaviours
It is important to understand, the extent and nature of HIV-related risk behaviours among YKPs, to understand, why young people engage in risky behaviours and factors that inhibit or enable HIV risk reduction among young people. A study focusing YKPs/YPLHIV conducted by the APLHIV indicates that 86.3 percent of the youth engage in sexual activities. Majority of the study respondents, reported engaging in sexual activities; for pleasure / leisure, followed by to satisfy body needs and to earn money. Young people engage in drug injecting behaviours, to get relaxation, enjoyment/pleasure/relaxation and peer/friends pressure/company.
Social Factors & HIV
While developing this analysis, the team of the APLHIV met with around 25 young people from HIV Community and KPs and tried to know the view point of the young members about access to social factors associated with HIV. The social factors affecting the vulnerability of young people to HIV/AIDS, includes; perceptions and responses of young people, their status and role in the community and their access to resources relevant to HIV. Five  questions related to stigma were asked and approximately 21 respondents out of 25 confirmed high level of ‘stigmatization’ for young PLHIV/YKPs. They also felt being marginalized in their daily life activities due to their HIV status and/or relation to KPs. They also felt discriminated while performing their daily activities and duties. Important reasons for feeling stigmatized, included, abusive language , attitude of family and peers, social isolation, involvement in risk behaviours, HIV status and their company. Vast majority suggested to break the stigma barriers, social acceptance, awareness and sensitization, access to preventive services and treatment, vocational training, capacity building on right’s awareness and initiation of youth specific services.
Health Support System For YPLHIV/YKPs
Effectiveness of interventions, depends upon its appropriateness, coverage and usefulness, or need to change existing interventions or develop new one, based on a comprehensive understanding of what young people in any given society or community want and need. Those young people, already practicing risky behaviours need basic services with information relevant to their social context, and delivered to them in a way that allows for maximum access. Unfortunately, coverage rates for the basic services are low. Only 3 respondents out of 25 confirmed availability of youth specific services in their areas which also includes the treatment centers. Approximately 11 respondents confirmed about availability of SRH services for them. Major reasons described for non-availability of HIV preventive services, included; non-availability of youth friendly services, lack of knowledge about these services and youth not involved in service delivery. Majority of the respondents described the attitude of staff engaged in HIV related services as satisfactory. Very few were satisfied with the services. Majority described the access to services as a costly matter. Breach of confidentiality reported was high. Young respondents suggested, to improve the ‘quality of health services’ for the young people as; establishment of youth friendly health services, engagement, in planning & delivery of health services, establishment of youth specific organizations.
Majority of the respondents were not aware about their health rights and also denied existence of any mechanism to provide them with legal support. A huge number faced issues while exercising their health rights. Major reasons for this barrier were stigma/ discrimination, degrading/discriminatory attitude towards YKPs, breach of confidentiality and violent attitude of law enforcing agencies. Awareness about rights, easy access to justice, and sensitization of law enforcement and empowerment of Y-Chapter under the APLHIV were the recommended options to address the right’s illiteracy.
Care & Support Services
YPLHIV acknowledged role of their families for ensuring conducive environment, to cope with consequences of their HIV status and treatment related issues. Out of 25 respondents 15 were YPLHIV who confirmed the availability of ARVs, though most of them were unable to meet the expenses to access the treatment centers. Majority of them expressed satisfaction over the role of APLHIV for provision of continued services [ARVs] at the treatment centers. The respondents from the KPs denied availability of youth specific services adequately meeting the youth specific needs. They were optimistic about the future role of the Y-Chapter under the APLHIV. Majority confirmed their access to nutritious diet through their own pockets or families.
Representation At Policy & Decision Making Levels
Overwhelming majority [23 out of 25] denied inclusion of young people at policy and decision making levels to shape HIV response and to include them in issues related to them. They felt out of pace to participate at such forums. Young respondents were of the view that their meaningful involvement at policy and decision making level may play a vital role in reducing new HIV infections in youth. Lack of their experience, low level of capacity, non availability of youth specific services and organizations were identified as major reasons for absence of youth at policy and decision making levels. All the respondents were found to be optimistic about their engagement at such for a in future through Y-Chapter under the APLHIV.
Interaction With Policy & Decision Makers
Keeping above discussions in mind the APLHIV team had a specific meeting with policy and decision makers which includes, National Program manager [NACP], Provincial Program Managers- Punjab & Sindh AIDS Control Programs, CCM Coordinator and a representative each from UNAIDS and UNICEF. Majority of the stakeholders were of the view that non existence of any youth specific/friendly organizations in the past was the leading factor for non availability of youth specific services. Another gap identified was of the resource constraint and low levels of infection in youth. However these stakeholders appreciated the initiative of APLHIV to launch the Y-Chapter and assured to fully consider the way forward suggested by the Y-Chapter to meet the needs of youth tailored to their needs.
HIV preventive services in Pakistan, whatever to the extent that are existing, are heavily ‘adult focused’ with scanty access by the young population and even more rarely by marginalised young key populations. Young people in Pakistan, practicing high risk behaviours, need information and services, relevant to their local context and delivered in a way that allows for maximum access. HIV risks are compounded by prevailing stigma and discrimination, in the country. Stigma is main barrier to access to HIV prevention, care and treatment services. 22% of the population comprise of youth aging from 15-24 years, however, there aren’t any ‘youth focused’ service delivery available for them across the country. In Pakistan there is narrow space to provide SRH for key population, through public health care delivery system, while youth friendly reproductive health services are virtually, non-existent. Enabling cultural, social, legal and political environments and developing synergies with sectors outside of health while addressing immediate prevention and treatment needs is vital. Households with young people living with HIV may need specific care and support needs, including nutrition. Ensuring a comprehensive HIV response for young people in Pakistan, including reduction in new infections, and increasing access to quality HIV preventive, care, support and treatment services, especially for young key populations, demands an “all in” response. Youth-friendly public health services have never taken root in Pakistan. An effective HIV response for young people, in Pakistan, must use limited investments smartly to close the prevention and treatment gaps through innovative, evidence-based youth-responsive programmes and services. The response should leverage on-going proven programming for key populations to reach young people. A model suggested by a study focusing youth in Pakistan for comprehensive needs of YPLHIV & YKPs is indicated below: –
QUESTIONNAIRE FOR PLHIV AT TREATMENT CENTER
- Do you feel discriminated in your daily life?
- Do you feel stigmatized in performing your daily duties/activities?
- Does your HIV status or relation to KP affects your life/status in society?
- Do you feel self stigma?
- What do you think, how you can overcome the fear of stigma and discrimination?
- Do you have youth specific services in your area or nearby?
- Are you aware of SRH services in your area or nearby?
- Is the attitude of HCP satisfactory in your opinion?
- Are you satisfied with provision of services?
- Is it manageable for you to access these services?
- Do you think your records are kept confidential?
- What are your suggestions to improve the services?
- Are you aware of your health rights?
- Do you feel any difficulties in exercising these rights, if yes what are the reasons?
- In Your opinion how the status of rights can be improved?
- Is your family supportive to cope with your status?
- Are the ARVs available and easily accessible to you?
- Are the care and support services available to you in your area?
- Do you think youth are well represented at policy and decision making levels?
- If, no what are the reasons in your opinion?
- How, youth representation can be ensured at policy and decision making levels?