Structural Collapse Sets the Scene for the Rapid Spread of HIV/AIDS Among Young People in Eastern Europe

Children and young people in Eastern Europe and Central Asia are increasingly sharing drug-injecting equipment and engaging in unprotected commercial sex as early as 12 years of age. With the economy in many countries continuing to crumble and with unemployment rates soaring, the young are increasingly relying on alternative sources of economic and emotional sustenance. Many escape into alcoholism and drug use; others turn to the streets, to commercial sex and to criminal activity to earn money for their needs. Although current rates of HIV infection in the region are low compared with the shocking rates in some African countries, the region is ripe for an explosive AIDS epidemic unless effective preventive measures are urgently put into place.

In an attempt to prevent an exponential rise in the region’s currently low prevalence rates, the Joint United Nations Programme on HIV/AIDS (UNAIDS) has launched Listen, Learn, Live!, the World AIDS Campaign with Children and Young People. The Campaign calls on adults to stop telling young people what to do, and instead to listen to their concerns, ideas and aspirations, so as to understand the realities of their lives and fully engage them in developing programmes that make the difference. It is imperative that we Listen, Learn and Live:

· Listen to children and young people, hear their views and concerns, and understand what is important in their lives.

· Learn from one another about respect, participation, support, and ways to prevent HIV infection.

· Live in a world where the rights of children and young people are protected and where those living with HIV/AIDS are cared for and do not suffer from discrimination.

The number of HIV infections in Eastern Europe has increased nine-fold in just three years, growing from less than 30,000 HIV infections in 1995 to an estimated 270,000 infections by December 1998. Ukraine has had the most dramatic epidemic, with an estimated 110,000 people living with HIV in December 1997, two-thirds of them injecting drug users. Since then the epidemic has grown rapidly. Similarly, Belarus, Moldova, Kazakstan and the Russian Federation have growing HIV epidemics; over 80% of infections are in individuals with a history of injecting drugs.

Poverty has become widespread in the region even as the quality of, and access to, health care have deteriorated, a combination that is facilitating the spread of HIV. Poverty and high unemployment rates have led many young people to lose faith in the education system and in the very need for education, as they see possibilities for future employment diminish. Increasingly, young people are dropping out of school and spending time with their peers in unstructured environments. As there are few places such as youth and sports centres where young people can gather safely, some turn to drugs, violence and early sexual activity. Meanwhile, with the old safety nets gone and the painful transition to a free-market economy still continuing, many parents are spending less time with their children as they struggle to make ends meet. Many parents are also turning to alcohol to forget their dire situation. As a result, the relationship between parents and children is suffering. Parents are often less available to engage in the kind of open and caring dialogue that builds bonds of trust between a parent and a child. It is now known that such bonds serve to reduce young people’s risk-taking behaviour, by delaying sexual initiation and reducing rates of drug use.

Alongside the economic collapse, the region has also shown signs of startling health care deterioration. Increasing numbers of curable diseases are left untreated. From the standpoint of the AIDS epidemic, the most alarming example is syphilis and the other sexually transmitted diseases (STDs). In virtually all parts of the former Soviet Union, including the Russian Federation, Ukraine, Moldova, and the Baltic and Central Asian countries, reported syphilis rates have shown a steep increase since 1991, reaching more than 500 new cases per 100,000 population annually in the city of Kaliningrad and the Russian Far East. These high STD rates reflect the absence or inadequacy of STD treatment. They signal the extent of unsafe sexual behaviour in the region, because STDs are transmitted through unprotected sex (intercourse without a condom). And they have the potential to aggravate the HIV epidemic: it is well-established that when either partner has an untreated STD, there is a significantly greater risk of HIV transmission during sex.

STD rates among young people are dramatically under-reported because services are not youth-friendly, meaning that many young people often do not have access to health centres, or are refused treatment because of their age. In spite of this, we see high STD rates among those under 25 in some Eastern European countries. In 1998 in Moldova, for example, 156 young people per 100,000 population were infected with syphilis.

Illicit drug use in the region is also on the rise and the trend is towards an ever-younger initiation of injecting drug use. In Ukraine and St Petersburg (Russian Federation), up to 20% of injecting drug users (IDUs) are teenagers, with the youngest being around 12 years old. In Almaty, Kazakstan, surveys among drug users indicate that of the approximately 40,000 drug users in the city, half are under the age of 18. Here the average age for initiating drug use is 15-16 and for injecting drugs is 17-18. Surveys among IDUs in Almaty show that 76% had their first try at drug injecting by the age of 19, with 30% first trying before their 15^th birthday. The potential for HIV spreading through the drug-injecting community is extremely high. IDUs in the region overwhelmingly report sharing syringes and injecting from a common container. Many also add blood into the drug mixture they prepare for injecting.

There is also potential for significant HIV spread outside the drug-injecting community. Drug users also have sex, and unsafe sexual behaviour is highly associated with drug use. The majority of drug users state that they rarely use condoms. One-third of female drug users interviewed in Osh, Kyrgyzstan, report that they are periodically or constantly engaged in prostitution to earn their living or to purchase drugs. An estimated 90% of these commercial sex contacts take place without the use of condoms. In Tashkent, Uzbekistan, more than half of drug users’ sex partners do not use drugs themselves, but practise unprotected sex with their IDU partners.

In Kiev, Ukraine, reports indicate that young girls aged 13-15 are increasingly taking to the streets for prostitution. Because of their youth, they have neither the skills nor the experience to resist violence from clients or to demand condom use. The older prostitutes react strongly to the competition, which takes away their bargaining power for insisting that clients use condoms. In most of the region, child prostitutes and young working women or students who receive payment in cash or kind remain a hidden group, and to date, little information about them is available. As a result many of these children and young women do not have access to HIV prevention programmes.

A dramatic example of the impact of poverty and missing protective bonds between children and significant adults can be seen among Roma or gypsy children. Socio-economic and cultural traditions that guide life decisions have made many Roma children in Bulgaria and Romania highly vulnerable to HIV infection. It is estimated that 52% of healthy Roma children aged 7-16 years old in Bulgaria do not attend school, due to poverty, lack of value placed on education within the community, and the group’s migratory patterns. Illiteracy and lack of marketable skills make it difficult for Roma youth to later enter and succeed in the job market. In parallel, many Roma children grow up not with their families but in state institutions that provide for basic survival needs such as food and housing but pay little attention to emotional needs. Studies following such children after they leave the institution show that they often become involved in drug use and criminal activity, and are unable to maintain healthy relationships. Many other Roma children work on the streets. In Romania, for example, most of the 2000-5000 children working or living on the street, where they are exposed to sexual abuse, exploitative work and violence, are Roma children. For them, key relationships tend to be with other children who use drugs and engage in commercial sex, both of which increase their risk for HIV infection.

The 1999 World AIDS Campaign, Listen, Learn, Live! highlights the urgency of listening to children and young people so as to engage them effectively in action to protect their rights and reduce their vulnerability to HIV infection. With over six new infections occurring worldwide among young people every minute, and with the increasing numbers of young injecting drug users and young sex workers in Eastern Europe and Central Asia, there is an urgent need for governments to commit to change. To avert a runaway epidemic, these changes need to include: education for all children, including those living in poverty; implementation and expansion of lifeskills education, youth friendly services, and harm-reduction initiatives such as HIV education and needle-exchange programmes to reduce risk among drug users; easy access to condoms and to STD treatment; and greater economic opportunities for young women so that they are not forced into prostitution for economic survival.

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For more information, please contact Anne Winter, UNAIDS, Geneva, (+41 22) 791.4577, Lisa Jacobs, UNAIDS, Geneva, (+41 22) 791.3387, Abigail Bing, UNAIDS, New York, (+1 212) 584.5024 or Andrej Cima, UNAIDS, Kiev, (+380 44) 253.9323/63. You may also visit the UNAIDS Home Page on the Internet for more information about the programme (http://www.unaids.org).

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