ACKNOWLEDGMENTS

This technical brief series was led by the World Health Organization under the guidance, support and review of the Interagency Working Group on Key Populations with representations from: Asia Pacific Transgender Network; Global Network of Sex work Projects; HIV Young Leaders Fund; International Labour Organisation; International Network of People who use Drugs; Joint United Nations Programme on HIV/AIDS; The Global Forum on MSM and HIV; United Nations Children's Fund; United Nations Development Programme, United Nations Office on Drugs and Crime; United Nation Educational, Scientific and Cultural Organization; United Nations Populations Fund; United Nations Refugee Agency; World Bank; World Food Programme and the World Health Organization.

The series benefited from the valuable community consultation and case study contribution from the follow organisations: Aids Myanmar Association Country-wide Network of Sex Workers; Aksion Plus; Callen-Lorde Community Health Center; Egyptian Family Planning Association; FHI 360; Fokus Muda; HIV Young Leaders Fund; International HIV/AIDS Alliance; Kimara Peer Educators and Health Promoters Trust Fund; MCC New York Charities; menZDRAV Foundation; New York State Department of Health; Programa de Política de Drogas; River of Life Initiative (ROLi); Save the Children Fund; Silueta X Association, Streetwise and Safe (SAS); STOP AIDS; United Nations Populations Fund Country Offices; YouthCO HIV and Hep C Society; Youth Leadership, Education, Advocacy and Development Project (Youth LEAD) ; Youth Research Information Support Education (Youth RISE); and Youth Voice Count.

Expert peer review was provided by: African Men Sexual Health and Rights; AIDS Council of NSW (ACON); ALIAT; Cardiff University; Family Planning Organization of the Philippines; FHI 360; Global Youth Coalition on HIV/AIDS; Harm Reduction International; International HIV/AIDS Alliance; International Planned Parenthood Federation; Joint United Nations Programme on HIV/AIDS Youth Reference Group; Johns Hopkins Bloomberg School of Public Health; London School of Hygiene and Tropical Medicine; Mexican Association for Sex Education; Office of the U.S. Global AIDS Coordinator; Save the Children; Streetwise and Safe (SAS); The Centre for Sexual Health and HIV AIDS Research Zimbabwe; The Global Forum on MSM and HIV Youth Reference Group; The Global Network of people living with HIV; Thubelihle; Youth Coalition on Sexual and Reproductive Rights; Youth Leadership, Education, Advocacy and Development Project (Youth LEAD) ; Youth Research Information Support Education (Youth RISE); and Youth Voice Count.

The technical briefs were written by James Baer, Alice Armstrong, Rachel Baggaley and Annette Verster.

Damon Barrett, Gonçalo Figueiredo Augusto, Martiani Oktavia, Jeanette Olsson, Mira Schneiders and Kate Welch provided background papers and literature reviews which informed this technical series.

INTRODUCTION

Young people aged 10–24 years constitute one-quarter of the world's population,6 and they are among those most affected by the global epidemic of human immunodeficiency virus (HIV). In 2013, there were an estimated 5 million people aged 10–24 years were living with HIV, and young people aged 15–24 years accounted for an estimated 35% of all new infections worldwide in people over 15 years of age.7

Key populations at higher risk of HIV include people who sell sex, men who have sex with men (MSM), transgender people and people who inject drugs. Young people who belong to one or more of these key populations – or who engage in activities associated with these populations – are made especially vulnerable to HIV by widespread discrimination, stigma and violence, combined with the particular vulnerabilities of youth, power imbalances in relationships and, sometimes, alienation from family and friends. These factors increase the risk that they may engage – willingly or not – in behaviours that put them at risk of HIV, such as frequent unprotected sex and the sharing of needles and syringes to inject drugs.

Governments have a legal obligation to support the rights of those under 18 years of age 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 or criminalize 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.

The global response to HIV largely neglects young key populations. Governments, international agencies and donors fail to adequately fund research, prevention, treatment and care for them. HIV service-providers are often poorly equipped to serve young key populations, while the staff of programmes for young people may lack the sensitivity and knowledge to work specifically with members of key populations.

Young transgender people's immediate HIV risk is related primarily to sexual behaviours, especially unprotected anal sex with an HIV positive partner, but structural factors in addition to those already noted make young transgender people especially vulnerable to HIV. Stigma and discrimination against transgender people frequently cause them to be rejected by their families and denied health-care services, including access to HIV testing, counselling and treatment. Transgender people are almost everywhere denied legal recognition of their gender and may also be penalized by laws criminalizing same-sex behaviour. Some young transgender people have overlapping vulnerabilities with other young key populations, such as injecting drugs and selling sex,ⁱ which can put them at higher risk of acquiring HIV and also lead to increased stigmatization. In addition, experiences of abuse, exploitation and violence, including sexual violence, are commonplace.

This technical brief is one in a series addressing four young key populations. It is intended for policy-makers, donors, service-planners, service-providers and community-led organizations. This brief aims to catalyse and inform discussions about how best to provide services, programmes and support for young transgender people. It offers a concise account of current knowledge concerning the HIV risk and vulnerability of young transgender people; the barriers and constraints they face to appropriate services; examples of programmes that may work well in addressing their needs; and approaches and considerations for providing services that both draw upon and build the strengths, competencies and capacities of young transgender people.

YOUNG TRANSGENDER PEOPLE

The paucity of data on young transgender people is a barrier to providing adequate health and psychosocial services tailored for them, and highlights the need for more research and attention from national governments.

The severe stigma and discrimination that transgender people experience make it especially difficult to estimate the global size of the transgender population, their levels of risk for HIV and their protective behaviours. Research tends to focus on those who approach specialist clinics to seek counselling and health care related to gender transition, but these are a minority of all transgender people,12 and population estimates based on such sampling are likely to underestimate the true numbers and to fail to capture the diversity of transgender people's identities and experiences. In some regions of the world, for example, Africa, transgender people are almost completely overlooked.13 In addition, most research is conducted with transgender women, and there is very little that focuses on transgender men. The studies cited in this technical brief largely reflect this fact.

• Analysis of population-based surveys in Massachusetts and California, United States of America, suggests that 0.3% of adults in the USA may identify as transgender.14
• A study in the United Kingdom estimated that 0.6% of people aged over 15 identify as transgender.15
• In Pakistan, estimates of the numbers of transgender women (hijras) suggest that they represent 0.7% of birth-assigned males aged 15 years and above.16 In India, they make up an estimated 0.12–0.24% of the population.17,18
• The proportion of transgender women among birth-assigned males has been estimated at around 0.6% in Thailand;19 and at 0.1–0.2% in Malaysia.20

It is estimated that globally there are more people who identify as transgender women than as transgender men, but there are limited data on the relative population sizes.21

Estimating the number of young transgender people (aged 10–24 years) is even harder. Although anecdotal evidence suggests that an increasing number of young individuals are self-identifying as transgender,22 some may not develop a full awareness of their gender identity until later in adolescence or young adulthood. In addition, many young transgender people are particularly vulnerable to transphobia and isolation and thus less likely to acknowledge their identity to others.

There is limited understanding of the global burden of HIV and other STIs among transgender populations, and transgender people are rarely identifiable in national surveillance systems. Data are only available from middle- and high-income countries and indicate that transgender women, in particular, are at disproportionate risk for HIV infection.

• A 2012 review found that across 15 countries in North America, the Asia-Pacific, Latin America and Europe which reported data on 11 066 transgender women, the pooled HIV prevalence was 19.1%.23
• A 2008 analysis of studies completed in 1990–2003 in the USA found an average laboratory-confirmed HIV prevalence of 27.7% across all age groups of transgender women in four studies, but a much lower self-reported prevalence of 11.7% in 18 other studies, suggesting that many transgender women living with HIV did not know their HIV status.24
• Some transgender men engage in receptive anal intercourse,25 and there is some evidence that transgender men are also at risk for HIV: one clinic in San Francisco, USA, found that the prevalence of HIV was similar for transgender men (10%) and transgender women (11%),26 while a study in New York City, USA, found that 2% of transgender men were living with HIV.27

Little data are available on the HIV burden among young transgender people, but research suggests a similarly high prevalence of HIV as among adult transgender women. A study in Chicago, USA, with ethnic-minority transgender females aged 16–25 years found that 22% self-reported being HIV positive.28 A comparable proportion (19%) of transgender females aged 15–24 years self-reported HIV infection in a study in Chicago and Los Angeles.29 There is evidence that many young transgender women are unaware of their HIV status. A US-based study of transgender women who reported being HIV negative or unaware of their HIV status revealed that 8% of those aged 13–19 years were living with HIV.30 This suggests that the self-reported HIV prevalence of 19–22% among young transgender females may understate the true burden.

HIV RISK AND VULNERABILITY

Compared to their age peers in the general population, and to older transgender people, young transgender people are more vulnerable to HIV. This is due to numerous individual and structural factors that are linked with specific risk behaviours – inconsistent condom use and greater use of drugs or alcohol.

Unprotected sex: Studies among transgender women in the USA and Asia indicate that they commonly practise unprotected receptive anal intercourse.30,31 Transmission of HIV is 18 times more likely to occur through unprotected receptive anal sex than through unprotected vaginal intercourse.32 In a study of transgender females aged 16–25 years in Chicago, USA, 49% reported unprotected receptive anal intercourse.33 In Chiang Mai, Thailand, a survey of transgender people attending a voluntary counselling and testing centre found that three-quarters of them had practised unprotected anal intercourse with a regular partner in the previous six months, while 55% had done so with a casual partner.34 Transgender women may engage in receptive rather than insertive sex in order to affirm their feminine identity.35 Like other people, some transgender women consider unprotected sex a way to demonstrate trust in their partner, even if they do not know their partner's HIV status.9 For some transgender men, unequal power dynamics, low self-esteem and the desire for affirmation of their gender identity present barriers to negotiating safe sex with male partners.25,36

“When it comes to our permanent partners and lovers we would not use condoms at all. We want to show them how much we trust and love them.”

Young transgender person, Pakistan11

Drug and alcohol consumption: In studies conducted in Los Angeles and Chicago, USA, over 90% of transgender participants aged 15–24 years had used alcohol or drugs during their lifetimes.28 In the Chicago study, 57% of transgender females aged 16–25 years reported having sex under the influence of drugs or alcohol, and this was significantly associated with both unprotected anal intercourse, and with selling sex.22,28 A systematic review of studies in the USA found that 12% of transgender women in these studies reported injecting recreational drugs and that 39% of transgender men reported having sex while drunk or high.24

Other forms of injecting: Apart from using needles to inject recreational drugs, transgender people may also inject hormones or other substances for body modification. In the USA systematic review referenced above, about a quarter of transgender women reported injecting hormones or silicone,24 while in a study in Thailand, around two-thirds of male and female transgender people reported doing so.37

While data are still quite limited, no association has yet been found between injecting hormones and lifetime risk of acquiring HIV.38 However, sharing needles can transmit bloodborne pathogens including HIV and viral hepatitis. The risk of HIV transmission via shared needles is likely to be higher in settings where access to medically supervised hormone treatment is unavailable and illicit injections are commonplace.39 In the Chicago study of transgender females aged 16–25 years, 2% reported sharing needles to inject street drugs, while 6% had shared needles when injecting hormones or silicone.24

“At the beauty salon, they provide silicone injection for their nose, their breasts, their hips…Those who inject are not professional nurse or doctor. They just get it from the black market and try to make money from it.”

Transgender woman, 22, Indonesia40

Changes during adolescence: Adolescence is a period of rapid physical, psychological, sexual, emotional and social change. It is often a time of experimentation, which may involve alcohol or other drugs, and the period when sexual activity with other people may begin. The development of the brain in adolescence influences the individual's ability to balance immediate and longer-term rewards and goals, and to accurately gauge risks and consequences.41 This can make adolescents more vulnerable to peer pressure, or to manipulation, exploitation or abuse by older people, and therefore potentially to HIV. This is especially true for those who lack stable and supportive family environments.

Some transgender people are aware from early childhood that their gender identity differs from their birth-assigned sex, but their sense of their identity as a transgender person may not solidify until adolescence, adding a layer of considerable complexity to developmental processes during these years.42 Even transgender people who are clear about their gender identity before reaching adolescence are likely to feel that there is little social space available for them to safely express their identity.

The difficulty of negotiating the tension between a desire to express one's identity and the fear of being stigmatized for doing so often has a negative impact on the emotional well-being of transgender adolescents and may deter them from seeking guidance and information about gender identity as well as sexual and reproductive health and HIV.

“Sexuality preferences and gender identity don´t start at the adolescent stage; let's not wait [to start talking about it in school].”

Young transgender person, Uruguay8

Transphobia, stigma and discrimination: Many transgender people experience social rejection and marginalization because of their gender identity and expression, as well as their perceived sexual orientation. Transphobia can have a significant impact during adolescence and young adulthood, when many young transgender people are struggling to develop a sense of self while addressing feelings of guilt and shame about their identities, pressure to conform to familial, peer and gender norms, and often the need for secrecy.42 This dynamic affects their self-perception and sense of worth and can lead to self-stigmatization – feelings of depression, low self-esteem and anger, or self-harming acts.9 Self-stigmatization is also linked to HIV risk behaviour.43

Young transgender people may experience rejection and even physical and sexual violence from within their family or communities, causing them to leave home. A study in Latin America estimated that 44–70% of transgender women and girls leave home or are thrown out of their home.44

Young transgender people may also be subject to bullying and harassment at school because of their gender identity as well as their perceived sexual orientation. In a study in the USA, more than 90% of transgender learners reported derogatory remarks, more than half had experienced physical violence and two-thirds said they felt unsafe at school.45 In Argentina, transgender learners reported that they stopped studying, either because of homophobic bullying by other learners or because they were denied entry by school authorities. Of those surveyed, 45% dropped out of secondary school and only 2.3 % completed college.46 Apart from the physical and psychological effects, homophobic and transphobic bullying in educational institutions can undermine learning opportunities and educational achievement.47,48

“When fellow students mock [us], in general teachers or head teachers do not respond, as if they don't know what to do or how to deal with it.”

Young transgender person, Uruguay8

“In my school, teachers discriminate against me more than my own schoolmates.”

Young transgender person, Uruguay8

Participants in a community consultation in Asia reported that young transgender people who either identify as part of the MSM community, or are identified as such by others, face greater discrimination.9 Much of the available data on the impact of transphobia focuses on ethnic-minority transgender people in the USA:

• Transgender people aged 15–20 years in a New York study reported stigma, harassment and social isolation, and concerns about potential violence.49
• Among transgender women in a San Francisco study, verbal and physical abuse were reported as having been experienced more frequently before the age of 18 years than in adulthood (80% vs 37% for verbal abuse, and 64% vs 20% for physical abuse).50
• For transgender females aged 16–25 years in a Chicago study, self-esteem and depression were both independently associated with unprotected anal intercourse.33

Young transgender people have an elevated risk of suicidal thoughts and attempted suicide. In the USA, a study found that 45% of young transgender people had had serious thoughts about suicide, and 26% had actually attempted suicide.51 In Thailand, transgender females aged 15–19 years had higher levels of suicidal ideation than their older peers.29

The limited research available suggests the influence of parental support on HIV risk behaviours: young transgender women with no parental support reported inconsistent or no condom use with sexual partners, but those with at least one supportive parent reported using condoms consistently.52

Social marginalization: The rejection of young transgender people by their families or in their school or work environments may lead to homelessness, unemployment and economic instability.33,53,54 Transgender adolescents are particularly vulnerable to such consequences because of their dependence on family and educational institutions for housing and other resources. Loss of stable housing has been associated with increased HIV risk behaviours, including unprotected sex and exchanging sex for money.55 Living or working on the streets makes it harder for young transgender people to access health and other services.56,57

In some countries, such as India and Pakistan, hijras may live in tight-knit communities with their own cultural behaviours and norms, under the leadership of a guru. While these communities often provide security and support, access to information and services may be determined by the guru rather than by the needs or wishes of individual transgender women, and access to the community by outsiders may be similarly restricted.

Lack of information and misconception of risk: Many young transgender people, lacking information on sexual health specifically directed at people of their gender identity, underestimate their risk for HIV. A US-based review showed that 71.6% of transgender women perceived themselves to be at low or no risk of acquiring HIV. However, there was a large discrepancy between their low rates of self-reported infection and rates of laboratory-confirmed HIV, pointing to a gap in HIV-related knowledge and awareness among this population.24

“Young transgenders who sell sex do not know what HIV is. They have heard about AIDS but never HIV. They don't know where to go for testing or whom they can go with. They cannot comprehend the seriousness of HIV.”

Young transgender person, Pakistan11

Racial and ethnic marginalization: Some studies in the USA have found that HIV prevalence among transgender women is higher in ethnic-minority groups, particularly African Americans and Latinas.27,58 More research is needed to understand the reason for these disparities, though it has been suggested that the social isolation and discrimination suffered by some ethnic-minority youth may be linked to lack of knowledge about HIV prevention, lack of easy access to health services, and drug and alcohol use.59

Relationship status: Young transgender people in relationships, like non-transgender people, may use condoms less frequently with their main partners than with casual or commercial partners. A study in Los Angeles and Chicago, USA, found that young transgender women were less than one-third as likely to use a condom during receptive anal intercourse with their main partner than with commercial partners.22 In Thailand, 61.0% of transgender people reported inconsistent condom use with their steady partners, and 32.7% with their casual partners.37

Selling sex: Evidence suggests that a significant proportion of young transgender females engage in selling sex in some settings, often as a result of social exclusion, economic vulnerability and difficulty in finding employment.33,55 In the USA, sex work was reported as being a primary source of recent income for 50% of adult transgender women studied in Los Angeles,58 32% of those in San Francisco27 and 44% in Miami, San Francisco and New York.30 In a study in Chicago, 59% of ethnic-minority transgender females aged 16–25 years reported they had exchanged sex for resources.33

Selling sex places transgender people at risk of violence, and pressure from clients to have unprotected intercourse puts them at greater risk of becoming infected with HIV.60 A review of studies in 13 countriesⁱⁱ found significantly higher HIV prevalence among transgender women who were engaged in sex work (pooled prevalence 27.3%) than among those who were not (14.7%). In addition, transgender women engaging in sex work were four times as likely to be HIV positive as non-transgender female sex workers.61

In some South Asian countries, a decline in demand for hijras to perform traditional activities for payment, such as blessing births and dancing at social events, has led many to engage in selling sex instead. In a study of hijras in Pakistan, 84% had sold sex, and while almost all were familiar with condoms, 42% reported never needing to use one.62

There is relatively little data on the relationship between selling sex and HIV risk among young transgender women. In a Chicago and Los Angeles study, 67% of transgender females aged 15–24 years reported selling sex, and HIV prevalence among those who sold sex (23%) was almost four times as high as among transgender girls and women in the same age group with no history of selling sex. Selling sex was significantly associated with low levels of education, homelessness, drug use and a perceived lack of social support.28

“It's hard to get a job. We have to work as [a] sex worker, [do] makeup or sing at funerals.”

Transgender woman, Viet Nam9

“You have triple stigma if you are young, a sex worker and a transgender.”

Young transgender person, Asia11

LEGAL AND POLICY CONSTRAINTS

The United Nations Convention on the Rights of the Child (CRC, 1989) is the global treaty guiding the protection of human rights for people under 18 years of age.1 One of its key principles is that the best interests of the child should guide all actions concerning children (Article 3), also taking into account children's evolving capacity to make decisions regarding their own health (Article 5). The CRC also guarantees the rights to non-discrimination (Article 2), life, survival and development (Article 6), social security (Article 26), an adequate standard of living (Article 27) and protection from all forms of exploitation and abuse (Article 34). Article 24 stresses “the right of the child to the enjoyment of the highest attainable standard of health and to facilities for treatment of illness and rehabilitation of health”.

In practice, significant legal and policy constraints limit the access of young transgender people to information and services affecting their health and well-being. The rights of young people under 18 years 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.

Criminalization: Transgender people who have sex with people of the same birth-assigned sex are often perceived as “homosexual” (for example, a transgender female who has sex with a male, particularly if she is herself perceived as being male). As a result, transgender people are often subject to criminal penalties for homosexual behaviour, which as of January 2014 remained illegal between consenting adults in 78 countries.63

While the United Nations Secretary-General has explicitly stated that human rights apply to all people, including people who identify as transgender,64 gender identity is not a protected status in any binding international human-rights instrument. Although in some countries (such as parts of the USA) there are legal protections for transgender people under laws barring discrimination on the basis of sex, it is more common for transgender people to be without legal protection against discrimination or harassment, or to be protected only if given a mental-health diagnosis of “gender identity disorder”.5 Laws against cross-dressing make some transgender people vulnerable to arrest. However, it is notable that a few countries, such as Nepal and, to a certain extent, India, recognize transgender identity as a third gender on administrative documents, giving transgender people some legal entitlements and protections. Argentina's gender identity law respects the right to self-determination of all transgender people and their right to confidentiality and privacy, and allows them to change their name and sex details without requiring a medical diagnosis or specific medical interventions.65 Portugal and Uruguay have also legislated to allow individuals to choose the gender identity that is registered on their official documents.5

Police harassment: The severe stigmatization arising from transphobia makes police harassment a danger for transgender people on the basis of their appearance alone, although transgender sex workers are often also disproportionately targeted by the police in places where sex work is criminalized.5 Transgender people have little or no recourse to the police if they are the victims of harassment or violence, and they may be subjected to abuse, extortion, beatings or rape by the police themselves.5 In some places, for example some countries in Asia, sexual violence laws do not criminalize sexual assault on men and transgender individuals.9

“Police is one of the biggest problems we face on the streets … they take money and everything that we have, rape us and then leave us.”

Young transgender person who sells sex, Pakistan11

Restricted access to services: Transgender people under the legal age of majority may be deterred from seeking HIV testing and counselling if the consent of parents or guardians is required. Discrimination can also be a barrier to accessing the rights of citizenship more generally. Laws that do not allow official documents to be changed to match current gender identity can prevent transgender people from obtaining health care and other government services or employment. Young transgender women in the community consultation in Cambodia reported that they were unable to get ID cards from the local authorities because of a requirement that they cut their hair and dress in men's clothes to be photographed.11

SERVICE COVERAGE AND BARRIERS TO ACCESS

Despite evidence of heightened HIV risks and prevalence rates among transgender people (particularly transgender women), coverage of HIV prevention programmes among transgender populations remains poor across regions.66 Barriers to health care among transgender people have been significantly associated with depression, economic pressure and low self-esteem, which may reduce rates of condom use.67

Availability and accessibility: Some participants in the community consultations identified cost as the highest practical barrier to accessing services, followed by distance from the point of service delivery.8 Younger people are less likely to have financial means and mobility than older people.

Uptake of HIV testing and counselling: Demand for HIV services may be influenced by transgender people's perception of low risk for HIV, as well as lack of information. Conversely, some may fear the personal and social ramifications of testing positive for HIV. Some transgender people have competing health needs and may prioritize medical treatment related to gender transition, particularly if they perceive that HIV testing or treatment will cost money.

“Outreach workers always bring me to have an [HIV]/STI test, but they don't understand about our real problems … Sometimes I have pain in my face because of silicone surgery [or] side-effects from injecting hormones, and we really need counselling, but no one can help us.”

Young transgender woman, Cambodia9

Access to transgender-specific medical procedures: There is evidence that hormone therapy and sex-reassignment surgery can substantially support the psychological well-being of transgender people who choose these treatments, and by improving self-esteem they may also contribute to lowering HIV risk.68,69 However, access to hormone therapy is limited, and few health-care providers feel knowledgeable about transgender health care.70 Some transgender people therefore seek hormone therapy in the informal sector, despite the potential harmful side-effects of unmonitored treatment and the risk of HIV transmission through contaminated needles.71

Sex-reassignment surgery is unavailable in most countries and is prohibitively expensive for many to obtain through private care. Where surgery or hormone therapy is not available for free or at low cost, some transgender people sell sex in order to raise money for it, which may increase their risk of exposure to HIV. There is also a lack of data on the HIV risk for post-operative transgender women with a neo-vagina.

Medical therapies (known as hormone blockers) to suppress the onset of puberty are available in some settings, allowing transgender young adolescents to delay decisions about starting hormone therapy. These therapies require careful medical assessment and supervision and are best accompanied by professional psychological support.72

“I read a lot of [information about using hormones on the] Internet because I cannot get any access from the medical practice, medical providers … Illegal injections using silicone oil are quite prevalent here … Because of the general poverty of trans people in my country, because they cannot afford gender-affirming surgery in either public or private [health systems], they opt to get illegal injections from quacks.”

Young transgender woman, Indonesia40

“Transgender female youth who have had gender-affirming operations need specialized services – yet often health-care providers (treat) them as male sex workers and not as transgender people.”

Young transgender person, Asia-Pacific region11

Stigma and discrimination by service-providers: Participants in the community consultations identified discrimination by health-service providers as one of the most significant barriers to accessing testing, treatment and care.8,11 Young transgender people may fear having their gender identity divulged to others by health-care providers. Those who are open about their gender identity may be denied health services. Some patients report being refused HIV treatment by doctors who clearly disapproved of their transgender identity.40

“When [we] go to the doctor, first of all the doctor will give a smile … then they will make sarcastic remarks, ask strange questions and make [us] feel embarrassed.”

Young transgender person, Pakistan11

Lack of capacity among health-care providers: Where services are available, providers often do not have experience of working with young people, or the knowledge to deal with health issues specific to transgender people.23 Some transgender women are frustrated to find their sexual and reproductive health concerns conflated with those of MSM, or feel that they must educate health-care providers about their needs. They also express concern about the lack of guidance from health-care professionals regarding interactions between HIV treatment and hormone therapy.40

US-based studies have shown that transgender people who have had negative experiences with health-care providers tend to avoid accessing health care in the future.73,74 Services which are not acceptable to transgender people fail to provide effective HIV prevention, treatment and care to this population.

“The government services are not free or friendly for transgender youth. If you walk into a hospital, they call you ‘Mr’. I have long hair and they are not sensitive [to my gender identity].”

Young transgender person, Thailand11

SERVICES AND PROGRAMMES

Around the world, programmes with young transgender people are being implemented by governments, civil-society organizations and by organizations of transgender people themselves. Relatively few have been fully evaluated, but the elements of a number of promising programmes are presented briefly here as examples of how the challenges in serving young transgender people may be addressed. These examples are illustrative and not prescriptive. They may not be adaptable to all situations, but they may inspire policy-makers, donors, programme-planners and community members to think about effective approaches to programming in their own contexts.

APPROACHES AND CONSIDERATIONS FOR SERVICES

REFERENCES

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2.

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Youth Voices Count. Policy brief on self-stigma among young men who have sex with men and young transgender women and the linkages with HIV in Asia. Bangkok: Youth Voices Count; 2013. [16 June 2014]. http://www​.aidsdatahub​.org/sites/default​/files/documents/YVC​_Policy_Brief_on_YMSM​_and_TG_Self-stigma.pdf .

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Youth Leadership, Education, Advocacy and Development Project, unpublished data; cited in this technical brief as “Youth LEAD consultation”.

11.

HIV Young Leaders Fund. “First, do no harm:” an advocacy brief on sexual and reproductive health needs and access to health services for adolescents 10–17 engaged in selling sex in the Asia Pacific. New York (NY): HIV Young Leaders Fund; 2014. forthcoming.

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Gates GJ. How many people are lesbian, gay, bisexual, and transgender? Los Angeles (CA): The Williams Institute, School of Law, University of California at Los Angeles; 2011. [16 June 2014]. http:​//williamsinstitute​.law.ucla.edu/wp-content​/uploads/Gates-How-Many-People-LGBT-Apr-2011.pdf .

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Reed B, Rhodes S, Schofield P, Wylie K. Gender variance in the UK: prevalence, incidence, growth, and geographic distribution. Ashtead, United Kingdom: Gender Identity Research and Education Society; 2009. [16 June 2014]. http://www​.gires.org​.uk/assets/Medpro-Assets​/GenderVarianceUK-report.pdf .

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ACKNOWLEDGMENTS

This technical brief series was led by the World Health Organization under the guidance, support and review of the Interagency Working Group on Key Populations with representations from: Asia Pacific Transgender Network; Global Network of Sex work Projects; HIV Young Leaders Fund; International Labour Organisation; International Network of People who use Drugs; Joint United Nations Programme on HIV/AIDS; The Global Forum on MSM and HIV; United Nations Children's Fund; United Nations Development Programme, United Nations Office on Drugs and Crime; United Nation Educational, Scientific and Cultural Organization; United Nations Populations Fund; United Nations Refugee Agency; World Bank; World Food Programme and the World Health Organization.

The series benefited from the valuable community consultation and case study contribution from the follow organisations: Aids Myanmar Association Country-wide Network of Sex Workers; Aksion Plus; Callen-Lorde Community Health Center; Egyptian Family Planning Association; FHI 360; Fokus Muda; HIV Young Leaders Fund; International HIV/AIDS Alliance; Kimara Peer Educators and Health Promoters Trust Fund; MCC New York Charities; menZDRAV Foundation; New York State Department of Health; Programa de Política de Drogas; River of Life Initiative (ROLi); Save the Children Fund; Silueta X Association, Streetwise and Safe (SAS); STOP AIDS; United Nations Populations Fund Country Offices; YouthCO HIV and Hep C Society; Youth Leadership, Education, Advocacy and Development Project (Youth LEAD); Youth Research Information Support Education (Youth RISE); and Youth Voice Count.

Expert peer review was provided by: African Men Sexual Health and Rights; AIDS Council of NSW (ACON); ALIAT; Cardiff University; Family Planning Organization of the Philippines; FHI 360; Global Youth Coalition on HIV/AIDS; Harm Reduction International; International HIV/AIDS Alliance; International Planned Parenthood Federation; Joint United Nations Programme on HIV/AIDS Youth Reference Group; Johns Hopkins Bloomberg School of Public Health; London School of Hygiene and Tropical Medicine; Mexican Association for Sex Education; Office of the U.S. Global AIDS Coordinator; Save the Children; Streetwise and Safe (SAS); The Centre for Sexual Health and HIV AIDS Research Zimbabwe; The Global Forum on MSM and HIV Youth Reference Group; The Global Network of people living with HIV; Thubelihle; Youth Coalition on Sexual and Reproductive Rights; Youth Leadership, Education, Advocacy and Development Project (Youth LEAD); Youth Research Information Support Education (Youth RISE); and Youth Voice Count.

The technical briefs were written by James Baer, Alice Armstrong, Rachel Baggaley and Annette Verster.

Damon Barrett, Gonçalo Figueiredo Augusto, Martiani Oktavia, Jeanette Olsson, Mira Schneiders and Kate Welch provided background papers and literature reviews which informed this technical series.

INTRODUCTION

Young people aged 10–24 years constitute one-quarter of the world's population,7 and they are among those most affected by the global epidemic of human immunodeficiency virus (HIV). In 2013, there were an estimated 5 million people aged 10–24 years were living with HIV, and young people aged 15–24 years accounted for an estimated 35% of all new infections worldwide in people over 15 years of age.8

Key populations at higher risk of HIV include people who sell sex, men who have sex with men (MSM), transgender people, and people who inject drugs. Young people who belong to one or more of these key populations – or who engage in activities associated with these populations – are made especially vulnerable to HIV by widespread discrimination, stigma and violence, combined with the particular vulnerabilities of youth, power imbalances in relationships and, sometimes, alienation from family and friends. These factors increase the risk that they may engage – willingly or not – in behaviours that put them at risk of HIV, such as frequent unprotected sex and the sharing of needles and syringes to inject drugs.

Governments have a legal obligation to support the right of those under 18 years of age 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 or criminalize 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.

The global response to HIV largely neglects young key populations. Governments, international agencies and donors fail to adequately fund research, prevention, treatment and care for them. HIV service-providers are often poorly equipped to serve young key populations, while the staff of programmes for young people may lack the sensitivity and knowledge to work specifically with members of key populations.

It has long been acknowledged that sex workers – female, male and transgender – are at high risk of HIV exposure, especially in low- and middle-income countries.9 This is due in part to a high number of sexual partners and a working environment in which it is not always possible to negotiate protected sex. The social and structural factors already noted also play an important role. Studies of young people who sell sex suggest that they may be even more vulnerable to HIV than their older counterparts for reasons including a greater number of sexual partners, less power to negotiate condom use, and greater susceptibility to violence. 10,11,12,13,14,15

This technical brief is one in a series addressing four young key populations. It is intended for policy-makers, donors, service-planners, service-providers and community-led organizations. This brief aims to catalyse and inform discussions about how best to provide services, programmes and support for young people who sell sex. It offers a concise account of current knowledge concerning the HIV risk and vulnerability of young people who sell sex; the barriers and constraints they face to appropriate services; examples of programmes that may work well in addressing their needs; and approaches and considerations for providing services that both draw upon and build the strengths, competencies and capacities of young people who sell sex.

YOUNG PEOPLE WHO SELL SEX

Despite their vulnerabilities, young people who sell sex are severely under-represented in research on HIV and sex work. Studies of sex workers mostly do not disaggregate programme outcomes by age, and no accurate global estimates exist of the number of young people engaged in selling sex. Data is particularly weak on young people under 18 years who sell sex. In general, even fewer data are available on young males and young transgender people who sell sex than on young females who do so. Developing population size estimates is difficult in part because in most countries sex work (or some aspect of it) is criminalized,20 and those who sell sex are therefore often marginalized and disengaged from services due to fear of legal sanctions.

While young adults who sell sex are considered sex workers,5 multiple international conventions describe the participation of those under 18 years of age in selling sex as a contravention of human-rights law, and those who do so are considered sexually exploited.1,21 The majority of large studies and all intervention trials on prevention of HIV among people who sell sex have excluded those under 18 years of age, largely due to ethical and legal constraints.22 In addition, some young people involved in selling sex move frequently between sex-work establishments,23 and may give inaccurate information about their age because of fear of arrest, detention or rescue operations.

There is varying data on the age of entry of young people into selling sex. Behavioural surveillance studies24 suggest that 17% of female sex workers in India began selling sex before the age of 15 years. In Maldives and Papua New Guinea, the median age of entry into selling sex among young women was 17–19 years. In Cambodia, Malaysia and Pakistan the mean age among young women was 22–24 years, while in Pakistan, young hijras (transgender people) and young males selling sex began doing so at a mean age of 16 years.

Young people sell sex for various reasons. Some report doing so as an occupational choice, for example to escape poverty and meet financial responsibilities, including supporting their families, especially in rural communities where there is a lack of other livelihood opportunities.25,26,27,28 Participants in the consultation in Kenya said that they had parental responsibilities for their siblings and would rather sell sex than beg in the street.16

Limited access to education – whether due to gender inequality, poverty, or discrimination and bullying – is associated with involvement in selling sex. A study of female sex workers in Karnataka, India, found that 81% were not literate,29 nearly twice the rate as among the state's general female population.30 The majority of female sex workers in Kampala, Uganda, had only attended primary school.31 Bullying and discrimination on the basis of perceived or actual sexual orientation can be a factor in young males or transgender people dropping out of school.32,33 In Thailand, young males and young transgender people aged 15–24 years who sold sex were less likely to be educated than their age peers, and more likely to be living away from their family.34

Sex work is widely recognized as having a particularly high risk for transmission of HIV.35,9 Data characterizing HIV risk among sex workers remain limited, largely because this population is poorly represented in national HIV surveillance systems, but among females aged 15–49 years, those who sell sex are estimated to be 13.5 times more likely to be living with HIV than those in the general population.36 A recent review found that pooled HIV prevalence among females who sell sex varied significantly by region, from 6.1% in Latin America to 10.9% in Eastern Europe and 36.9% in sub-Saharan Africa.36

The underrepresentation of young people who sell sex in most biological and behavioural surveillance studies makes it very difficult to generate reliable HIV prevalence estimates for this subpopulation. However, those under the age of 25 who sell sex appear to be at significantly greater risk for HIV infection (and subsequent transmission) than their older counterparts, due to biological, behavioural and structural risk factors:

• In Kolkata, India, HIV prevalence among females who sell sex in six brothels was 8.4% among those over 20 years of age, but 27.7% among those aged 16–20.
• In Vancouver, Canada, initiation into selling sex before the age of 18 years was associated with a two-fold increase in baseline HIV infection among street-based female sex workers.37

There have been several studies on the prevalence of HIV and syphilis infection among female sex workers38,39,40 but few on other STIs including chlamydia and gonorrhoea.41,42 These infections not only can cause serious long-term health complications such as pelvic inflammatory disease, ectopic pregnancy and infertility problems,43 but may also facilitate transmission of HIV.44,45 One study in Madagascar showed that young people aged 16–19 years who sold sex were at higher risk of chlamydial and gonococcal infection than those aged 20 or older.46 In a Chinese study, females aged 15–20 years who sold sex had significantly higher prevalence of gonorrhoea and chlamydia than older sex workers.47 In Zimbabwe, prevalence of herpes simplex virus 2 was found to be around 50% among young women under 20 years selling sex, rising to 80% by the age of 25.48

HIV RISK AND VULNERABILITY

Specific risk behaviours – inconsistent condom use, and use of drugs or alcohol – are linked to numerous individual and structural factors that amplify the vulnerability of young people who sell sex to HIV, compared to their age peers in the wider population and to older sex workers.

Inconsistent condom use: Although female sex workers use condoms at a rate that is generally greater than in the wider population,5 they are at higher risk of HIV because of factors such as poor access to condoms in some settings, the unwillingness of some clients to use condoms, the risk of violence,11,49 and the local prevalence of HIV infection.50 In one study, participants under 18 who sold sex had a greater number of sexual partners than older sex workers10 and fewer skills or power to negotiate condom use. In another study, women who had begun to sell sex before the age of 18 years reported fewer attempts to negotiate condom use with steady partners than those who began to sell sex as adults.51

For male and transgender (particularly male-to-female) sex workers, the dynamics of HIV transmission also include the increased risk associated with unprotected anal intercourse, the high prevalence of HIV in some subgroups of men who have sex with men, and the large proportion of male and transgender sex workers who report bisexual practices.52

LEGAL AND POLICY CONSTRAINTS

Young people who sell sex face a complex legal environment that varies widely between countries. The Convention on the Rights of the Child (CRC) provides a framework that obliges signatories to protect the rights of all people under 18 years of age to life, health and freedom from discrimination (Articles 2, 6 and 24), among other rights, while making the child's best interest a primary consideration (Article 3) and taking into account their evolving capacity to make decisions regarding their own health (Article 5).ⁱ These rights are contravened when they are excluded from effective HIV prevention and life-saving treatment, care and support services. In practice, significant legal and policy constraints limit the access of young people who sell sex – including those under 18 years of age – to information and services affecting their health and well-being. The criminalization of sex work in most countries further complicates the situation, both for young people who sell sex and for service-providers.

Sexual exploitation: Under the CRC and ILO Convention No. 182,86 governments have a legal obligation to protect those under 18 years of age who sell sex that goes beyond public-health concerns. However, the CRC is not always implemented through policies and programmes in a way that prevents exploitation. Law enforcement sometimes responds to trafficking with “raid and rescue” operations in which those suspected of being trafficked – including those under 18 years – may be arrested, ostensibly to protect them by placing them in “rehabilitation” centres, sometimes for long periods and against their will. 87,88,89

Some participants in the Asia-Pacific consultation reported that sentences for young people under 18 years of age in detention centres or involuntary centres were longer than for adults in jails.19 Others reported that violence and abuse sometimes occur at such centres. To avoid arrest, detention or “rescue”, or forced return to abusive family homes from which they may have run away, those under 18 years who sell sex may provide false information about their age or avoid health and other services altogether.90,91

Young women who sell sex in the India community consultation said they never give their real age when they visit any health-care facility.19 Two participants recalled an incident where the staff of an NGO-run clinic handed a young girl over to the police. They called for a clear law to protect rather than punish young people under 18 years of age involved in selling sex.

Involuntary detention and “rehabilitation” of those under 18 years who sell sex contravenes the CRC's principle that protective and judicial interventions be used only as a last resort (Article 37). The Joint UN Statement on Compulsory Drug Detention and Rehabilitation Centres, the UNICEF Position on Compulsory Detention Centres in East Asia and Pacific and the Global Commission on HIV & the Law call for the abolition of compulsory detention and “rehabilitation” of those under 18 engaged in selling sex.20,92,93 Instead, they recommend voluntary, evidence-informed and rights-based health and social services.92,93

“Under-18s are sent to rehab and taught sewing. Young people run away and prefer to live on the street – [rehab] is punishment and does nothing but hurt young people.”

Young person, Myanmar19

“One day I went to a shelter… and I had to lie that I had been trafficked to protect myself from more serious punishment.”

Young person, Thailand19

“If space isn't available in adolescent prison they get sent to adult prison, despite drug use and sex [there].”

Young person, Asia-Pacific Region19

“One Bangladeshi girl was ‘rescued’ by police considering her as a minor, [but] we know that she was not a minor, but even after one year […] we still don't know anything about [what became of] that girl.”

Young person, India19

Mandatory reporting: Some countries have mandatory reporting laws which require adults, including those engaged in the delivery of health services, to report to social services or the police anyone under 18 years of age engaged in selling sex.61 Health professionals and other service-providers may experience a conflict between their reporting obligations and the young person's expectation of confidential care. Such rules can cause young people not to engage with the services they need and can make providers reluctant to serve those under 18 years.94 Similar reporting obligations for researchers deter those who manage sex work operations from cooperating with research.95

Consent requirements: The access of legal minors to sexual and reproductive health and other services, including harm reduction for those who use drugs, may be restricted by laws and policies requiring the consent of parents or guardians for testing or treatment. This is a particular problem for minors who live away from their parents. The principle of the evolving capacity of those under 18 years (Article 5, CRC) is not always observed, even though this is particularly important for “mature minors” – a term used in some national policies to describe those aged under 18 years who are living independently, have no parents/guardians or no contact with them, have abusive parents/guardians, or who are pregnant.

“Because of parental consent and ID requirements, [there are] problems for young people to go to private clinics and instead we self-medicate.”

Young person, Thailand19

“While we are under 18 years old and unmarried it [is] very difficult to collect condoms and lubricant.”

Young person, Bangladesh19

Criminalization: Laws criminalizing sex work reduce the control of young people who sell sex over their working conditions and deter them from seeking services for fear of arrest and prosecution.96 These laws are often enforced punitively through confiscation of condoms, which are used as proof of solicitation; mandatory, compulsory or coerced testing for HIV; absence of lack of labour and social security rights; and denial of identity documents and citizenship rights.97

In countries where sex workers are not criminalized but those who purchase sex are, there is anecdotal evidence that sex workers are forced to go “underground” – contacting and meeting clients in less public places and reducing the time spent assessing clients for risk. This can make it harder for them to maintain their physical safety and to access social and health programmes, including for HIV prevention and treatment.98,99,100,101 The criminalization of same-sex behaviour and of injecting drug use further increases the vulnerability of some young people who sell sex to arrest or prosecution.

“If a customer has raped you, you cannot go to the police station… The police would think you are the guilty one.”

Young person, Asia-Pacific region19

“In Thailand you can carry a condom for safe sex, but in reality if a sex worker or a transgender [person] has a condom then you have to pay 500-5,000 baht to the police … in exchange for not arresting you.”

Young person, Thailand19

SERVICE COVERAGE AND BARRIERS TO ACCESS

Coverage levels for effective HIV prevention services among female sex workers remain low (generally less than 50%),102 and HIV prevention services for male and transgender sex workers have even less coverage.36 This situation is linked to insufficient acknowledgement and recognition of needs, and a lack of funding and investment for rights-based prevention programmes.103,104 Globally, less than 1% of HIV prevention funding is spent on programmes for sex workers.105 Exceptions to this pattern are Latin America and southern Africa, where domestic spending on HIV prevention services for sex workers is greater than international contributions.9 However, around the world many programmes are not rights-based and thus present their own barriers to access.

The effects of violence, punitive law enforcement and forced rehabilitation have already been noted, but several other barriers make it difficult or impossible for young people to access the services they need.

Availability and accessibility: Participants in the consultations said that public-health services are often far away and difficult to reach (particularly for those in rural areas); they are not open at convenient hours – especially for those who work late and must sleep during much of the daytime; and there are often long waits to be seen. Some participants said that police stationed near clinics or mobile clinics made it harder to get to the services.16

The physical location in which young people sell sex can make it more difficult for them to be contacted through outreach services:

• In China, a study found that mobile young people (averaging 18 years of age) who were selling sex, and those who were self-employed or who worked on the street, in bars, massage parlours or dancehalls, were less likely to have received HIV prevention and testing services than those who sold sex at larger, fixed venues.78
• In a study in the Philippines, almost all participants under 18 years who were selling sex in entertainment establishments or at cruising sites had never had an HIV test.106

“When (they) understood our identity as sex workers then (they) completely refused to provide health services; most of the time doctors ignored us.”

Young person, Bangladesh19

“We often have to pay for services ourselves at private clinics because the government [clinics] will not serve us [because we are under 18], which is very expensive.”

Young person, Asia-Pacific Region 19

Refusal to hospitalize a young person who sells sex “is very common, especially if the girl is alone. Denials to perform medical termination of pregnancy at government centres are common, so young girls prefer private centres.”

Young Person, India 19

Restricted access to support: As well as requirements for parental/guardian consent for clinical services for young people under the age of 18, there may be age restrictions which exclude them from housing and other kinds of social support provided by nongovernmental organizations (NGOs) or community-based organizations. In some countries, women require their husband's consent for some medical services. Some health-providers refuse to serve young people who identify as selling sex, or whom they suspect of doing so. Nationality or migration status can also affect access to services.107

• Among Chinese females aged 15–19 years selling sex, half reported a need for free condoms and low-cost STI diagnosis and treatment services. Of those who reported STI symptoms in the past year, only one-quarter had sought care at public-health facilities.78
• Reluctance to undergo an HIV test was predicted by younger age, lack of social support and lower income in studies in India and in Uzbekistan.108,109

“If we don't know about what the primary health services are and where the centres and resources are, we can't go further.”

Young person, Asia-Pacific Region19

“I personally have never [been] tested. I am afraid and would rather not know.”

Young person, Kenya16

“Some NGOs take blood by forcing us and blackmailing us that if you do not give blood for testing we will not give free condoms to you.”

Young person, India19

“Due to fear we are forced to do testing – even though we know that we are supposed to do the HIV test twice a year, we land up doing it 6 to 7 times in a year.”

Young person, India19

Poor service quality: Young people who sell sex are often unable to access a comprehensive range of health services. Services are usually provided in contexts that are not designed for young people, by staff who may not have been trained to consider the needs of young people in general, nor the specific needs of young people who sell sex. This has a direct and negative impact on their health.

• Consultation participants in Kenya complained of the unfriendliness of staff, perfunctory or inadequate examinations and treatment, and unavailability of prescribed drugs at facility pharmacies.16
• Young female participants in the consultation in Asia named unintended pregnancy as a major concern, along with inadequate access to forms of contraception (including emergency contraception), safe abortion, prenatal care and services for prevention of mother-to-child transmission.16
• Several participants in the community consultations raised the issue of the cost of first- or second-line antiretroviral drugs (ARVs), as well as discrimination at ARV clinics against those who sell sex. Where ARVs are not available for free, young people living with HIV who wish to have treatment are more likely to continue selling sex in order to pay for medication.19

“You can go to jail if you have an abortion; as a result, the abortion services that exist are very limited, high-priced and highly criminalized.”

Young person, Myanmar19

“Blood test without following proper counselling and informed consent process was a common experience.”

Young person, India19

Discrimination: Judgemental attitudes from providers of health-care and other services deter young people who sell sex from seeking services, for fear of being criticized or having their medical details or occupation made public. Some young people who test positive for HIV are afraid to disclose their status to intimate partners or to clients, for fear of losing their relationship or their source of income. Participants in the consultation reported cases of young people who sell sex through entertainment venues being fired when their employers learned they were HIV positive. Enforced testing of bar staff was also reported.19

“[Newcomers to selling sex] are afraid of going and buying medicines from the pharmacy. They don't dare to tell a pharmacist about their situation because they are sex workers. And if they are going to see a doctor, the doctor will ask them ‘Why did you get it?’… They feel ashamed so they will not access health services anymore.”

Young person, Viet Nam19

Bangladesh participants said that young MSM and females who sell sex are afraid to go to a clinic or the doctor because of fear of stigma, discrimination or breach of confidentiality. As a result, many “keep their diseases to themselves and suffer for a long time.” 19

“The time I used to go to clinic while pregnant, the doctors used to abuse me and I felt bad. They told me that a child like me shouldn't be giving birth. I am requesting that the health services [providers] be talked to on how to handle us.”

Young person, Kenya16

Competing priorities: For many young people who sell sex, taking care of their health is not always their top priority. Some are the primary providers not just for themselves but for other family members. For others, the need to find shelter, food, alcohol or drugs may take precedence over seeking out services for sexual and reproductive health, particularly if those services are inadequate or discriminatory. The lack of access to basic social protection thus also becomes a barrier to accessing sexual health services.

Participants in several of the community consultations expressed a need for options for education and vocational training.16,19

SERVICES AND PROGRAMMES

Around the world, programmes with young people who sell sex are being implemented by governments, civil-society organizations and organizations of sex workers themselves. Relatively few have been fully evaluated, but the elements of a number of promising programmes are presented briefly here, as examples of how the challenges in serving young people who sell sex may be addressed. These examples are illustrative and not prescriptive. They may not be adaptable to all situations, but they may inspire policy-makers, donors, programme-planners and community members to think about effective approaches to programming in their own contexts.

APPROACHES AND CONSIDERATIONS FOR SERVICES

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ACKNOWLEDGMENTS

This technical brief series was led by the World Health Organization under the guidance, support and review of the Interagency Working Group on Key Populations with representations from: Asia Pacific Transgender Network; Global Network of Sex work Projects; HIV Young Leaders Fund; International Labour Organisation; International Network of People who use Drugs; Joint United Nations Programme on HIV/AIDS; The Global Forum on MSM and HIV; United Nations Children's Fund; United Nations Development Programme, United Nations Office on Drugs and Crime; United Nation Educational, Scientific and Cultural Organization; United Nations Populations Fund; United Nations Refugee Agency; World Bank; World Food Programme and the World Health Organization.

The series benefited from the valuable community consultation and case study contribution from the follow organisations: Aids Myanmar Association Country-wide Network of Sex Workers; Aksion Plus; Callen-Lorde Community Health Center; Egyptian Family Planning Association; FHI 360; Fokus Muda; HIV Young Leaders Fund; International HIV/AIDS Alliance; Kimara Peer Educators and Health Promoters Trust Fund; MCC New York Charities; menZDRAV Foundation; New York State Department of Health; Programa de Política de Drogas; River of Life Initiative (ROLi); Save the Children Fund; Silueta X Association, Streetwise and Safe (SAS); STOP AIDS; United Nations Populations Fund Country Offices; YouthCO HIV and Hep C Society; Youth Leadership, Education, Advocacy and Development Project (Youth LEAD) ; Youth Research Information Support Education (Youth RISE); and Youth Voice Count.

Expert peer review was provided by: African Men Sexual Health and Rights; AIDS Council of NSW (ACON); ALIAT; Cardiff University; Family Planning Organization of the Philippines; FHI 360; Global Youth Coalition on HIV/AIDS; Harm Reduction International; International HIV/AIDS Alliance; International Planned Parenthood Federation; Joint United Nations Programme on HIV/AIDS Youth Reference Group; Johns Hopkins Bloomberg School of Public Health; London School of Hygiene and Tropical Medicine; Mexican Association for Sex Education; Office of the U.S. Global AIDS Coordinator; Save the Children; Streetwise and Safe (SAS); The Centre for Sexual Health and HIV AIDS Research Zimbabwe; The Global Forum on MSM and HIV Youth Reference Group; The Global Network of people living with HIV; Thubelihle; Youth Coalition on Sexual and Reproductive Rights; Youth Leadership, Education, Advocacy and Development Project (Youth LEAD) ; Youth Research Information Support Education (Youth RISE); and Youth Voice Count.

The technical briefs were written by James Baer, Alice Armstrong, Rachel Baggaley and Annette Verster.

Damon Barrett, Gonçalo Figueiredo Augusto, Martiani Oktavia, Jeanette Olsson, Mira Schneiders and Kate Welch provided background papers and literature reviews which informed this technical series.

INTRODUCTION

Young people aged 10–24 years constitute one-quarter of the world's population,5 and they are among those most affected by the global epidemic of human immunodeficiency virus (HIV). In 2013, there were an estimated 5 million people aged 10–24 years were living with HIV, and young people aged 15–24 years accounted for an estimated 35% of all new infections worldwide in people over 15 years of age.6

Key populations at higher risk of HIV include people who sell sex, men who have sex with men, transgender people and people who inject drugs. Young people who belong to one or more of these key populations – or who engage in activities associated with these populations – are made especially vulnerable to HIV by widespread discrimination, stigma and violence, combined with the particular vulnerabilities of youth, power imbalances in relationships and, sometimes, alienation from family and friends. These factors increase the risk that they may engage – willingly or not – in behaviours that put them at risk of HIV, such as frequent unprotected sex and the sharing of needles and syringes to inject drugs.

Governments have a legal obligation to support the rights of those under 18 years of age 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 or criminalize 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.

The global response to HIV largely neglects young key populations. Governments, international agencies and donors fail to adequately fund research, prevention, treatment and care for them. HIV service-providers are often poorly equipped to serve young key populations, while the staff of programmes for young people may lack the sensitivity and knowledge to work specifically with members of key populations.

According to joint estimates by the United Nations Office on Drugs and Crime, the World Health Organization (WHO), World Bank and the Joint United Nations Programme on HIV/AIDS (UNAIDS), an estimated 12.7 million (range: 8.9 million-22.4 million) people globally inject drugs,7 with the majority living in low- and middle-income countries.7,8 The age distribution is not known. The continued high prevalence of injecting drug use, combined with insufficient coverage of harm-reduction programmes, is of concern because of the strong association of unsafe injecting with risk for transmission of HIV and other infections such as viral hepatitis.9,10 Although global coverage of harm-reduction services has slowly increased, there is a lack of services focused on and accessible to young people, despite low ages of initiation into injecting drug use in many countries and important differences in vulnerability and risk between younger and older people who inject drugs. Consequently, young people who inject drugs find it difficult to obtain information, sterile injecting equipment, drug dependence treatment, including methadone treatment for opioid dependence, and HIV testing, counselling and treatment. Age restrictions or requirements for parental consent can also make services less accessible. Programmes are frequently not designed to respond to the overlapping vulnerabilities of young people who inject drugs or the specific challenges in working with legal minors. These vulnerabilities require responses that may go beyond the harm-reduction programmes recognized as effective for adults.

This technical brief is one in a series addressing four young key populations. It is intended for policy-makers, donors, service-planners, service-providers and community-led organizations. This brief aims to catalyse and inform discussions about how best to provide services, programmes and support for young people who inject drugs. It offers a concise account of current knowledge concerning the HIV risk and vulnerability of young people who inject drugs; the barriers and constraints they face to appropriate services; examples of programmes that may work well in addressing their needs; and approaches and considerations for providing services that both draw upon and build the strengths, competencies and capacities of young people who inject drugs.

YOUNG PEOPLE WHO INJECT DRUGS

There is a critical need for more comprehensive age-disaggregated data on young people who inject drugs, their levels of risk for HIV and other illnesses, and their protective behaviours. Current methods of gathering and reporting data make it impossible to calculate a reliable global estimate of the number of young people who inject drugs.13 Fewer than a quarter of the countries reporting in the 2010 United Nations General Assembly Special Session on Drugs provided age-disaggregated data on people under the age of 25 years who inject drugs.14 There are several reasons for this. In some countries there is simply no reliable data on drug use among young people in general. The criminalization and stigmatization of drug use in most countries forces many young people to hide their drug use. Legal and ethical constraints make it difficult to recruit children for studies, and the great majority of research therefore excludes participants under 18 years of age.13 Older survey participants do not always accurately recall the age at which they began injecting drugs, and rapid changes in drug-using practices may in any case make their information out of date.13 Girls and young women are also underrepresented in surveys of injecting drug use. Harm-reduction services can serve as important mechanisms for data collection,13 but the lack of such services, and age restrictions placed upon them, limit the amount of data they provide on young people.

HIV RISK AND VULNERABILITY

Compared to their age peers in the wider population, and to older people who inject drugs, young people who inject drugs are more vulnerable to HIV. This is due to specific risk behaviours – sharing non-sterile injecting equipment, and unprotected sex – which are linked to numerous individual and structural factors.

Sharing non-sterile injecting equipment: Exposure to HIV through use of contaminated injecting equipment is six times more likely to result in infection than exposure through unprotected vaginal intercourse.32 Many adolescents' first experience of injecting involves being given drugs by a friend, peer, sexual partner or other person and sharing their used injection equipment.33,34 Young people who inject drugs often do so in groups and are more likely to share equipment than their older counterparts, especially where rituals develop around injecting in social networks.2,35 Such practices may involve the young person being last to use the equipment.

Sharing equipment for the preparation of drugs is a common behaviour among young people who inject drugs, and it is an additional risk factor for transmission of HCV.36,37 In a study of people who inject drugs aged 15–30 years in five US cities, those who reported sharing equipment (cottons, cookers, rinse water) to prepare drugs for injection had a threefold increase in the risk of HCV seroconversion.38

Unprotected sex: Injecting drug use often occurs in the context of overlapping risks for HIV, such as sexual intercourse without the use of a condom. Factors including the young person's knowledge and their ability to gauge risk can influence choices to have unprotected sex. In addition, the use of certain substances – including alcohol – may increase sexual desire or lower behavioural inhibitions, further affecting risk perception. Apart from sexual contact with intimate partners, some young people may also exchange sex for drugs, or sell sexⁱ to obtain money for drugs, or may be at risk of sexual abuse.

“The main concern of young people who use drugs is their drugs. They do not think about diseases and have sex without protection.”

Young person, Mauritius11

Changes during adolescence: Adolescence is a period of rapid physical, psychological, sexual, emotional and social change. For some young people, drug use, like sex, is a way of experimenting with new forms of socialization and pleasure-seeking. The development of the brain in adolescence influences the individual's ability to balance immediate and longer-term rewards and goals, and to accurately gauge risks and consequences.39,40 This can make adolescents more vulnerable to peer pressure, or to manipulation, exploitation or abuse by older people, and therefore potentially to HIV. This is especially true for those who lack stable and supportive family environments.

Adolescents who inject drugs are more likely than older people to lack knowledge about safer injecting practices and HIV prevention and to be unaware of risks to their health. Many young participants in the consultations reported that when they began injecting drugs as adolescents they were unconcerned about HIV, other STIs, viral hepatitis or tuberculosis.11 Adolescents who inject drugs are also more likely than older people to be isolated from harm-reduction services, and to be unable to afford to buy injecting equipment,16,41 thus increasing their vulnerability to HIV.42

Social marginalization and discrimination: In many regions, injecting drug use is most prevalent among socially marginalized young people, including those who are orphaned, out of school, living in extreme poverty, or living or working on the streets.13 Each of these factors can contribute to a context of emotional or social disruption in which drugs may be both attractive and available, and where there are fewer deterrents to experimenting with them.

• In Albania, over one-quarter of males aged 15–24 years who inject drugs surveyed in 2008 had never been to school, and 30% were homeless.43
• A multi-city assessment of street youth in Ukraine (aged 15–24 years) found that nearly 1 in 5 was HIV-infected, with prevalence considerably higher among those who injected drugs (42%) and highest among those who shared needles (49%).22
• In a 2007 survey of children aged 12–17 years living or working on the street in Greater Cairo and Alexandria, Egypt, over half were currently using drugs, and 3% reported injecting. Only 5% were currently in school.44

Drug use is highly stigmatized in nearly all countries, and social, familial and religious disapproval can lead to discrimination against people who use drugs, further isolating them from individuals or systems that might support health-seeking behaviour. Young people who inject drugs are more vulnerable to these negative consequences because they depend on family and educational institutions for housing and other resources. Spending large amounts of time on the streets increases the chances that young people who inject drugs will interact with others engaging in risky needle use and higher-risk sexual behaviours, including older adults more likely to be infected with HIV. The social and economic isolation of young people who inject drugs only increases the likelihood that non-sterile injecting equipment will be used.45

“I was expelled from school and abandoned by my own family when they found out I was taking some [non-injecting] drugs. So I thought, Why not go all the way?”

Young person, Indonesia11

Racial and ethnic marginalization: In some regions, injecting drug use is disproportionately prevalent among young members of ethnic minorities. A study in Bucharest, Romania, found that more than one-quarter of people aged 10–24 years who injected drugs were Roma, a proportion three times higher than their proportion of the general population.46 Among people who inject drugs aged 13–19 years diagnosed with HIV in the United States in 2011, 61.7% were African American and 21.3% Latino, far higher than their proportion of the overall population.47 More research is needed to understand the reason for these disparities, though it has been suggested that the social isolation and discrimination suffered by some ethnic-minority youth may be linked to drug and alcohol use, lack of easy access to health services, and lack of knowledge about HIV prevention.48

Young women: Increased risk of injecting has also been noted among young females, who have additional vulnerabilities to HIV infection compared to their male peers who inject drugs.49,50 Consultations in Nepal and Nigeria with groups of young women who inject drugs indicated that many rely on their male partners to provide injecting equipment, and they are consequently less likely than young men to access harm-reduction services.11 They reported frequent sharing of syringes with their male partners and, in Nigeria, “flashblooding” – a technique of injecting oneself with blood extracted from another person who has recently injected a drug, usually heroin. 11

“When I was first introduced to injecting by my boyfriend I never knew anywhere to get needles because he was the one who used to inject me. So this was a major challenge for me.”

Young woman, Kenya11

Young females may also be more concerned than their male counterparts about being exposed as people who inject drugs because they face even stronger stigmatization.11 Young women who inject drugs in Kyrgyzstan said that sexual and reproductive health services were important to them, but they felt stigmatized when accessing them.11 Pregnant women who inject drugs are less likely than non-injecting pregnant women to have access to antenatal care and prevention of mother-to-child transmission services, thus increasing the risk of passing infection to their newborns.51

“It's harder for females to seek help, get tested [for STIs], or even talk about it.”

Young woman, Lebanon11

Selling sex: Some young people exchange sex for drugs, or sell sex to obtain money for drugs, and this may make them less likely to turn down a transaction or to insist that a client use a condom, thus increasing their risk of contracting HIV or another STI. They are also at risk of violence, including rape.

LEGAL AND POLICY CONSTRAINTS

The United Nations Convention on the Rights of the Child (CRC, 1989) is the global treaty guiding the protection of human rights for people under 18 years of age.1 One of its key principles is that the best interests of the child should guide all actions concerning children (Article 3), also taking into account children's evolving capacity to make decisions regarding their own health (Article 5). The CRC also guarantees the rights to non-discrimination (Article 2), life, survival and development (Article 6), social security (Article 26), an adequate standard of living (Article 27) and protection from all forms of exploitation and abuse (Article 34). Article 24 stresses “the right of the child to the enjoyment of the highest attainable standard of health and to facilities for treatment of illness and rehabilitation of health”.

International human-rights law is clear on the need to provide evidence-based and human-rights-compliant harm reduction, HIV prevention and drug dependence treatment programmes.52 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, and the rights of young people under 18 years 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.

Criminalization: Laws criminalizing use or possession of drugs or of injecting equipment can deter people from seeking services because of their fear of arrest and prosecution. In some countries, “aiding and abetting” or “encouragement” laws seek to protect those under 18 from people who incite or encourage drug use. These laws may deter harm-reduction service-providers from offering assistance, due to accusations that they are “facilitating” drug use and related concerns about their own legal liability.53 Criminalization of drug use also reduces the future employment prospects of those who have been convicted and can lead to economic instability.

Police enforcement: Young people who inject drugs may be targeted by the police for arrest or extortion, and carrying a needle or syringe may be taken as evidence of drug use, which is a disincentive to seek services such as needle and syringe programmes (NSPs).54 NSPs themselves may be targeted by police as a location to harass or arrest young people who inject drugs. Young people who exchange sex for drugs or sell sex to obtain money for drugs are also vulnerable to arrest or harassment by police.55,56,57

“Of course police choose those who are young [to arrest], and we know that police are always present in such places [NSPs].”

Young woman, Kyrgyzstan11

Incarceration: Imprisonment is a considerable risk for young people who use drugs, including children, despite the fact that Article 37 of the CRC specifies that imprisonment “shall be used only as a measure of last resort and for the shortest appropriate period of time”.1 The detention and forced treatment of adolescents who inject drugs is also a human-rights violation and public-health concern, because access to harm-reduction measures in places of detention is usually limited or non-existent. In addition, risk behaviours for HIV and hepatitis are more prevalent in such settings, and incarcerated young people are particularly at risk for sexual abuse by older prisoners.58 Human-rights violations in so-called drug detention or rehabilitation centres are now well documented, leading the UN system, including the World Health Organization, to call for these centres to be closed down.59

Legal minority status: For those under the legal age of majority, access to harm-reduction services is more complicated. Child protection laws and policies must be factored in and appropriately understood and applied to the situation.

Access to services can be legally restricted. For those below the legal age of majority, access to NSPs is often limited because of moral or ethical concerns that these programmes may inadvertently encourage or condone the use of drugs by children. Age restrictions exist for NSPs in 18 of 77 countries surveyed by Harm Reduction International in 2012, showing that while such restrictions are not the norm they still present an important barrier.60 A more common scenario is where the legal and policy situation is unclear or not sufficiently supportive. This is a considerable gap considering the widespread moral or ethical concerns among service-providers themselves about how to appropriately intervene with young people who use drugs, and fears about being seen to condone or facilitate drug use.

Opioid substitution therapy (OST) to treat opiate dependency is far less common among people under 18 years than among adults, partly because many young people who inject do not use opiates, and also because in many cases if dependency develops, most are of an age to fall under adult treatment protocols for OST. Nevertheless, in at least 29 of the 74 countries where OST is available, age restrictions are placed upon it. This hinders clinicians from making decisions in the best interests of the individual client.53

Even in countries with no legal age restrictions, other requirements, such as mandatory parent/guardian consent requirements, or evidence of previous failed attempts at detoxification or other drug treatment modalities, limit or complicate young people's access to crucial harm-reduction services.53

Policy and research: At a broader policy level, attitudes towards drug use influence what research is funded and what questions are asked. When the political goal is to reduce drug use overall among young people, research tends to focus on lifetime prevalence of drug use among this age group, rather than drug-related harms among those that use drugs.17 Straightforward “don't do drugs” messaging may be politically popular, but it is ineffective in changing the behaviour of vulnerable young people61,62 and obscures the need for research into preventing harm for those who do use and inject drugs.

“[Under-18s] can go [to harm-reduction services], but only with their parents – their father or someone who is over 18 must go with them. They cannot go by themselves.”

Young person, Mexico11

SERVICE COVERAGE AND BARRIERS TO ACCESS

Funding of programmes for young people who inject drugs is inadequate, despite their disproportionate risk of acquiring HIV. A 2010 systematic review found that worldwide coverage of HIV prevention, treatment and care services for all people who inject drugs, although increasing, is still very low.63

Need for additional services for young people: While the harm-reduction approach has been proven to reduce HIV infections among people who inject drugs, as a rule such programmes are not designed with the specific needs and vulnerabilities of young people in mind. In addition to the core package of harm-reduction services and overdose prevention, many young people who inject drugs also require basic medical and psychological services, housing, food, social protection benefits and services, and access to education or to employment opportunities.

Lack of youth-friendly and youth-focused services and programmes: Most services specific to people who inject drugs, such as NSPs, are designed for adults and do not operate in a way that is engaging or friendly to younger people. Many younger people do not like to access services alongside adult clients because they feel they have little in common with them, or feel unsafe around them. Service-providers often lack the skills to work with vulnerable adolescents. Furthermore, unless outreach is directed specifically at young people who inject drugs through their social networks and the media they use, they are unlikely to be aware that services exist.

SERVICES AND PROGRAMMES ADDRESSING THE NEEDS OF YOUNG PEOPLE WHO INJECT DRUGS

Around the world, programmes with young people who inject drugs are being implemented by governments, civil-society organizations and by organizations of people who use drugs. Relatively few have been fully evaluated, but the elements of a number of promising programmes are presented briefly here, as examples of how the challenges in serving young people who inject drugs may be addressed. These examples are illustrative and not prescriptive. They may not be adaptable to all situations, but they may inspire policy-makers, donors, programme-planners and community members to think about effective approaches to programming in their own contexts.

APPROACHES AND CONSIDERATIONS FOR SERVICES

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United Nations Population Fund and Youth Peer Education Network (Y-PEER). Youth peer education toolkit: standards for peer education programmes. New York (NY): United Nations Population Fund; 2005. [16 June 2014]. http://www​.unfpa.org​/webdav/site/global/shared​/documents/publications​/2006/ypeer_standardsbook.pdf .

69.

United Nations Educational, Scientific and Cultural Organization; United Nations Population Fund; Joint United Nations Programme on HIV/AIDS; United Nations Development Programme. Young people and the law in Asia and the Pacific: A review of laws and policies affecting young people's access to sexual and reproductive health and HIV services. Bangkok: United Nations Educational, Scientific and Cultural Organization; 2013. [16 June 2014]. http://unesdoc​.unesco​.org/images/0022/002247/224782e.pdf .

70.

United Nations Office on Drugs and Crime. From coercion to cohesion treating drug dependence through health care, not punishment. Vienna: United Nations Office on Drugs and Crime; 2009. [16 June 2014]. Discussion paper. http://www​.unodc.org​/documents/hiv-aids/publications​/Coercion_Ebook.pdf .

71.

Family Health International in collaboration with Advocates for Youth. Youth participation guide: assessment, planning, and implementation. Research Triangle Park (NC): Family Health International; 2005. [16 June 2014]. http://www​.unfpa.org​/webdav/site/global/shared​/documents/publications​/2008/youth_participation.pdf .

ACKNOWLEDGMENTS

This technical brief series was led by the World Health Organization under the guidance, support and review of the Interagency Working Group on Key Populations with representations from: Asia Pacific Transgender Network; Global Network of Sex work Projects; HIV Young Leaders Fund; International Labour Organisation; International Network of People who use Drugs; Joint United Nations Programme on HIV/AIDS; The Global Forum on MSM and HIV; United Nations Children's Fund; United Nations Development Programme, United Nations Office on Drugs and Crime; United Nation Educational, Scientific and Cultural Organization; United Nations Populations Fund; United Nations Refugee Agency; World Bank; World Food Programme and the World Health Organization.

The series benefited from the valuable community consultation and case study contribution from the follow organisations: Aids Myanmar Association Country-wide Network of Sex Workers; Aksion Plus; Callen-Lorde Community Health Center; Egyptian Family Planning Association; FHI 360; Fokus Muda; HIV Young Leaders Fund; International HIV/AIDS Alliance; Kimara Peer Educators and Health Promoters Trust Fund; MCC New York Charities; menZDRAV Foundation; New York State Department of Health; Programa de Política de Drogas; River of Life Initiative (ROLi); Save the Children Fund; Silueta X Association, Streetwise and Safe (SAS); STOP AIDS; United Nations Populations Fund Country Offices; YouthCO HIV and Hep C Society; Youth Leadership, Education, Advocacy and Development Project (Youth LEAD) ; Youth Research Information Support Education (Youth RISE); and Youth Voice Count.

Expert peer review was provided by: African Men Sexual Health and Rights; AIDS Council of NSW (ACON); ALIAT; Cardiff University; Family Planning Organization of the Philippines; FHI 360; Global Youth Coalition on HIV/AIDS; Harm Reduction International; International HIV/AIDS Alliance; International Planned Parenthood Federation; Joint United Nations Programme on HIV/AIDS Youth Reference Group; Johns Hopkins Bloomberg School of Public Health; London School of Hygiene and Tropical Medicine; Mexican Association for Sex Education; Office of the U.S. Global AIDS Coordinator; Save the Children; Streetwise and Safe (SAS); The Centre for Sexual Health and HIV AIDS Research Zimbabwe; The Global Forum on MSM and HIV Youth Reference Group; The Global Network of people living with HIV; Thubelihle; Youth Coalition on Sexual and Reproductive Rights; Youth Leadership, Education, Advocacy and Development Project (Youth LEAD) ; Youth Research Information Support Education (Youth RISE); and Youth Voice Count.

The technical briefs were written by James Baer, Alice Armstrong, Rachel Baggaley and Annette Verster.

Damon Barrett, Gonçalo Figueiredo Augusto, Martiani Oktavia, Jeanette Olsson, Mira Schneiders and Kate Welch provided background papers and literature reviews which informed this technical series.

INTRODUCTION

Young people aged 10–24 years constitute one-quarter of the world's population,6 and they are among those most affected by the global epidemic of human immunodeficiency virus (HIV). In 2013, there were an estimated 5 million people aged 10–24 years were living with HIV, and young people aged 15–24 years accounted for an estimated 35% of all new infections worldwide in people over 15 years of age.7

Key populations at higher risk of HIV include people who sell sex, men who have sex with men (MSM), transgender people and people who inject drugs. Young people who belong to one or more of these key populations – or who engage in activities associated with these populations – are made especially vulnerable to HIV by widespread discrimination, stigma and violence, combined with the particular vulnerabilities of youth, power imbalances in relationships and, sometimes, alienation from family and friends. These factors increase the risk that they may engage – willingly or not – in behaviours that put them at risk of HIV, such as frequent unprotected sex and the sharing of needles and syringes to inject drugs.

Governments have a legal obligation to support the rights of those under 18 years of age 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 or criminalize 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.

The global response to HIV largely neglects young key populations. Governments, international agencies and donors fail to adequately fund research, prevention, treatment and care for them. HIV service-providers are often poorly equipped to serve young key populations, while the staff of programmes for young people may lack the sensitivity and knowledge to work specifically with members of key populations.

Among young MSM, high rates of HIV infection are due in part to unprotected anal sex with an HIV positive partner, but the social and structural factors already noted also play an important role. Use of drugs or alcohol and selling sexⁱ contribute to HIV risk and represent overlapping vulnerabilities that some young MSM share with other young key populations. Young MSM are often more vulnerable than older MSM to the effects of homophobia – manifested in discrimination, bullying, harassment, family disapproval, social isolation and violence – as well as criminalization and self-stigmatization. These can have serious repercussions not only for their physical health and their ability to access HIV testing, counselling and treatment, but also for their emotional, social, educational and economic well-being.

This technical brief is one in a series addressing four young key populations. It is intended for policy-makers, donors, service-planners, service-providers and community-led organizations. This brief aims to catalyse and inform discussions about how best to provide services, programmes and support for young MSM. It offers a concise account of current knowledge concerning the HIV risk and vulnerability of young MSM; the barriers and constraints they face to appropriate services; examples of programmes that may work well in addressing their needs; and approaches and considerations for providing services that both draw upon and build to the strengths, competencies and capacities of young MSM.

YOUNG MSM

The HIV epidemic among young MSM is not well defined. There is a lack of global data on the number of young MSM, their levels of risk for HIV and their protective behaviours. This is due in part to a lack of research and surveillance, and also to the difficulty of reaching young MSM who may fear disclosing their same-sex behaviour.

Estimates of lifetime prevalence of sex between males in some low- and middle-income countries range from 3–20%.12 However, virtually no data is available for all of Africa, the Middle East, and the Caribbean. Similarly, isolated studies indicate wide variation in the reports of same-sex behaviour or sexual orientation among young people, and the glimpse they provide of the numbers of young MSM is not globally representative:

• A study of 857 street children aged 12–17 years in Greater Cairo and Alexandria, Egypt, found that among the sexually active street boys, 44.2% reported having had sex with a male partner in the previous 12 months, and 15% reported being raped by a male partner.13
• In Canada, a study of 11 000 secondary-school students in three grades (aged about 12, 14 and 16) found that up to 1.7% of the boys reported being attracted exclusively to the same sex, and up to 3% to both sexes.14
• In New Zealand, of 8 000 secondary-school students (of both sexes) surveyed anonymously, 0.9% reported exclusive attraction to the same sex and 3.3% to both sexes.15

One of the challenges in reaching young MSM with sexual health education and other services is the stigmatization of same-sex behaviour. MSM may have sex with other males in secret and may be reluctant to disclose such activity to others. Some MSM are married to or partnered with women. A further factor is that some young people, particularly adolescents, have fluid and changing understandings of their sexual identity and behaviours and may not accept the categories used by research and surveillance, particularly if they perceive these as stigmatizing within their particular social context.16,17

Nevertheless, it is clear that young MSM are often at greater risk of acquiring HIV than young heterosexual males or older MSM.18,19,20,21 Despite this, there is relatively little funding for HIV prevention and treatment programmes specifically targeting this population.20

Where data are available, HIV prevalence and incidence are consistently found to be higher among MSM than in the general population, especially in some urban areas. In much of Central and South America and in multiple settings in high-income countries, sex between males is the predominant mode of HIV transmission, but even in contexts where the epidemic is driven primarily by heterosexual sex or by injecting drug use, HIV prevalence among MSM may also be high.22

Data also indicate that young MSM have a greater HIV risk than heterosexual young people and older MSM:

• In the Russian Federation, HIV prevalence among young MSM in 2010 was 10.79%.
• In China, a meta-analysis of studies published between 2006 and 2012 estimated the HIV prevalence among young MSM to be 3.0–6.4%.23
• In urban sites in the Democratic Republic of Congo, HIV prevalence among MSM aged 15–19 years in 2012 was 4.5%.24
• In Bahamas, HIV prevalence among young MSM in 2010 was 24%.25
• Among adolescent males aged 13–19 years in the USA, 92.8% of all diagnosed HIV infections in 2011 were attributed to male-to-male sexual contact.26,27

Data on sexual orientation and sexual behaviours are generally less well correlated with other sexually transmitted infections (STIs) than with HIV, but available data suggest high rates of some STIs among MSM. For example, MSM account for nearly three-quarters of all syphilis cases (among both sexes) in the USA, and incidence rose from 1.3 cases per 100 000 MSM (aged 15–19) in 2003 to 6.0 cases in 2009.28 Rates of syphilis, gonorrhoea and chlamydia among MSM in Africa, Latin America and Asia are much higher than in the general population.29 For example, in a study in four cities in China, 8.4% of MSM aged 16–20 years were infected with syphilis,30 and at a sexual health clinic in Bangkok, Thailand, syphilis prevalence was 10.4% among MSM aged 15–21 years.31

Since syphilis facilitates transmission of HIV and there is evidence that gonorrhoea may also do so, rising infection rates among MSM are of particular concern. MSM diagnosed with rectal gonorrhoea are more likely to be HIV-infected, use recreational drugs, and have partners whose sero-status is unknown to them.32

MSM are also at increased risk of viral hepatitis. Some studies suggest high prevalence of hepatitis B virus among MSM.33 Similarly, rates of human papillomavirus, which can cause anal carcinoma, are high among MSM,34,35 but prevalence among young MSM is not known.

HIV RISK AND VULNERABILITY

Compared to their age peers in the general population, and to older MSM, young MSM are often more vulnerable to HIV. This is due to numerous individual and structural factors that are linked to specific risk behaviours – inconsistent condom use and greater use of drugs or alcohol.

Unprotected sex: Transmission of HIV is 18 times more likely to occur through unprotected receptive anal sex (between MSM or between heterosexuals) than through unprotected vaginal intercourse.36 Frequency of unprotected sex increases risk of exposure to HIV, and some younger MSM are more sexually active than their older counterparts. For example, in Cairo, Egypt, 25.9% of MSM aged 15–25 years reported having sex more than once per day, compared to 6.7% of MSM aged 25 years and above.37 Young MSM have also been found to be more likely than older MSM to report unprotected anal intercourse with partners of unknown HIV status.38

The community consultation revealed that many young MSM remain unaware that unprotected anal sex can transmit HIV and other STIs, and do not know the importance of condom-compatible lubricants in HIV prevention.9 A study of MSM and transgender persons in northern Thailand found low rates of consistent condom use in both insertive and receptive anal sex (33.3% and 31.9%, respectively).39 Community consultation participants in Albania noted that condoms and lubricant were not always available.8 In other places, cost prevents some MSM from obtaining them.

Drug and alcohol consumption: Adolescence may be a time of experimentation with alcohol and drugs. Some MSM seek out social spaces such as gay-identified bars, clubs or private parties to socialize without fear of being subjected to homophobia. Such environments may also tolerate or normalize the consumption of alcohol or drugs, which can lower sexual inhibitions and affect risk perception.40 Young MSM who are uncertain about their sexual orientation may be more likely to use alcohol or drugs during sexual contact with men.17 Use of stimulants, inhalants, cocaine or hallucinogens by adolescent males studied at clinical care sites in the USA was found to be a direct predictor of sexual risk behaviour.41 A study in Los Angeles found that MSM using crystal methamphetamine were three times more likely to have HIV than non-drug-using MSM.42 In Thailand, the use of amphetamine-type stimulants by MSM during their most recent sexual encounter increased from less than 1% in 2003 to 5.5% in 2007.43

Changes during adolescence: Adolescence is a period of rapid physical, psychological, sexual, emotional and social development. It is often a time of experimentation, which may involve alcohol or other drugs, and the period when sexual activity with other people may begin. The development of the brain in adolescence influences the individual's ability to balance immediate and longer-term rewards and goals, and to accurately gauge risks and consequences.44

Sexual orientation is often clarified and articulated during adolescence. For some young MSM, the awareness of an attraction to people of the same sex may be disconcerting and confusing, especially if they do not see their same-sex attraction modelled or reflected in positive ways in the wider culture. Regardless of their sexual orientation, adolescent males may also be vulnerable to sexual abuse or exploitation by other males, and therefore potentially to HIV. This is especially true for those who lack stable and supportive family environments. In United Republic of Tanzania, consultation participants said they want the police to arrest political and religious leaders who take advantage of them sexually.8

Homophobia, stigma and discrimination: Stigmatizing attitudes towards homosexuality, and discriminatory behaviour towards people with a homosexual orientation, are major obstacles affecting the lives and health of young MSM, particularly when reinforced by criminalization and violence. Most school-based sex education programmes do not acknowledge or address issues of sexual orientation.22 Sexual minority stigma is associated with high-risk sexual behaviour by young MSM,45 who may also be discouraged from seeking voluntary HIV testing and counselling and other essential prevention, care and treatment services.

Stigmatization related to being HIV positive can be an additional burden: a study of 40 young MSM living with HIV found that those who experienced high levels of HIV stigma were significantly more likely to engage in unprotected sex while high or intoxicated.46

Young MSM are often aware of incomprehension and hostility around issues of same-sex behaviour. Understandably, many choose to keep their sexual behaviour or orientation hidden from others, but this may reduce their access to guidance and information about HIV and the risks of unprotected sex – especially if they fear stigma and discrimination from health-care providers – and may make them more likely to engage in risk-taking behaviours.47

Studies in a number of countries show that young people are more likely to experience homophobic bullying at school than in the home or the community.48 This can have serious psychological repercussions and also undermine learning opportunities, educational achievement, and therefore access to employment opportunities.49,50

Anxiety, loneliness, and fear of rejection affect the self-perception and sense of worth of young MSM and can lead to self-stigmatization – feelings of depression, low self-esteem and anger, or self-harming acts.9 Self-stigmatization is also linked to HIV risk behaviour.51 However, in many countries few services are available to address the mental-health needs of young people. In the consultation in Pakistan, several young MSM said that friends of theirs had committed suicide because of the stigmatization from their families or communities, especially after their identity as MSM who sold sex was disclosed by health-care providers.11 Consultation participants in Cambodia said they often felt lonely and needed a place where they could meet to enjoy recreational activities with their peers.11

Research shows that men who accept their sexual orientation are more psychologically healthy, have higher self-esteem, are more likely to disclose their HIV status with casual sex partners and are less likely to engage in sexual risk-taking. 52 However, for those who identify as gay, the decision to come out can be a stressful one, and the process of doing so may bring a mixture of responses ranging from acceptance and support to severe social and legal censure. They are more likely than heterosexual youth to face family disapproval, bullying, harassment, social isolation, discrimination and violence, including sexual violence. 53,54,55,56

“Nobody recognizes me as MSM, as I don't show any sign that links me with gay behaviour. However, if outside of this room I behave differently, then opinion about me and my life would change dramatically.”

Young MSM, Albania8

“Young MSM are often unable to respond effectively to homophobia because of their age – they have no income, no employment, and they are dependent on family for housing. If they get kicked out, and they often do, they end up on the street where they may be forced to trade sex for food, shelter or protection.”

Young MSM advocate, Jamaica57

Lack of information and misconception of risk: There is evidence that young MSM begin having sexual intercourse at an earlier age than previous generations of MSM.58,59 Many are unaware of the risks of infection and of how to protect themselves.60 Sex education in schools often provides inadequate information about HIV and generally does not address sexual health risks relevant to MSM.22 Objective information related to same-sex behaviour is usually not available from family or friends.

In Mozambique, consultation participants said that many young MSM were unaware of the risks of unprotected anal sex and did not know the importance of water-based lubricants in HIV prevention. They wanted specific sexual and reproductive health information provided through the media, health services and peer educators; easier access to prevention commodities; and informed, friendly health-service providers.8

Young MSM in Albania said that their main sources of information about safe sex, HIV and STIs were textbooks, but these were mostly in foreign languages and hard to understand. Information about HIV in the media was often incorrect. None of the consultation participants in Albania had received information on STIs from public institutions, but some had received clear information through NGOs serving MSM. 8

Uptake of HIV testing and counselling is particularly low among young MSM. Many who do not realize they are infected believe they are at low risk for HIV, making them more likely to engage in behaviours that could transmit HIV to their partners.61 For example, in a study of 122 MSM in Togo, where the average reported age of first sex with another male was around 17 years, about one-third reported having two or more concurrent partners. Only about half said they had been tested for HIV, and only one-fifth reported regular condom use with their regular male partner. Some thought that HIV infection could be transmitted only through sex with women, not with men.62

We are virgins because we've never slept with women, so we cannot catch the sickness [HIV].

Young MSM, Togo63

By contrast with such misconceptions, in contexts where HIV risk is widely understood and there is easy and affordable access to antiretroviral therapy, MSM may feel less concerned about the risks and consequences of HIV infection, and thus may increase their risk behaviours. This effect may be greater in countries where the worst period of the epidemic lies too far back for young MSM to remember, especially if they are unaware of having known anyone with HIV.64

Relationship status: MSM, like heterosexuals, practise unprotected intercourse more often in steady than in casual relationships,20 and this trend is particularly pronounced among young MSM: in one study, considering the relationship to be “serious” was associated with a nearly eightfold increase in the rate of unprotected sex.65 Where there is a high turnover of primary partners, the risk of HIV transmission is even higher.66 Younger MSM are also significantly more likely than older MSM to engage in unprotected anal intercourse with casual partners while also being in a steady sexual relationship.67

Some young MSM in the Asia-Pacific consultation reported unprotected sex as a way to express their love for their boyfriend or partner (as well as for increased sexual pleasure).9 Not using a condom was seen as an act of trust in the other person, even if their HIV status or relationship history was unknown.9 Young MSM in relationships with older partners are more likely to have unprotected sex than those in relationships with partners of the same age,68 and are more likely to be HIV positive.69 Some young MSM with older partners said they sometimes lacked the confidence to insist that their partner use a condom.9

Selling sex: In some contexts of social marginalization a significant proportion of young MSM engage in selling sex. A 2001 study in St Petersburg, Russian Federation, found that 22.7% of MSM reported selling sex.22 In Paraguay, 29% of MSM (median age 21 years) indicated that they were currently engaging in selling sex, and more than half of these reported having begun to do so when they were younger than 18 years.70 Among MSM, selling sex is often associated with an increased likelihood of being younger, unemployed, having less education, using drugs, engaging in high-risk sexual practices and being raped, compared to MSM who do not sell sex.22,71,72,73,74

Selling sex can lead to higher rates of HIV among young MSM. A study among MSM and transgender people aged 15–24 years in Thailand found that HIV prevalence was 13% for the group as a whole, but even higher (15%) among those that sold sex. Among males aged 15 years and above engaged in selling sex in Ho Chi Minh City, Viet Nam, those aged 15–24 years were less likely than older MSM to understand sexual and reproductive health, reduce their risk behaviours or take an HIV test.74

“Clients are too ashamed to purchase a condom and we are too scared to buy a condom.”

Young MSM who sells sex, Pakistan11

Loss of basic social protections: Young MSM are more vulnerable than older MSM to the negative consequences of stigma and discrimination because they depend on family and educational institutions for housing and other resources.57 Young MSM who are disowned and thrown out of the family home may end up living or working on the streets. Loss of stable housing makes it harder to access health and other services and is associated with increased vulnerability to violence, including sexual violence, as well as to HIV risk behaviours including unprotected sex and selling sex.75,76

Forced displacement and refugee settings can increase the pressure on young people to exchange sex for material goods or protection. This is frequently a direct consequence of gaps in assistance, failures of registration systems or family separations.77

Migration: Some adolescent males who migrate from rural to urban areas in search of work may sell sex to other males for economic survival, regardless of their sexual orientation. For example, among 237 young male migrants from villages to Shanghai, China, who were selling sex to other males, about one-fifth of the group self-identified as non-gay and the rest as gay. More than half had left home before the age of 20 and many before the age of 15, suggesting initiation of same-sex behaviour at a young age. The gay-identified group was more likely to engage in anal sex and less likely to use condoms. There was a high prevalence of depression among the young MSM and low knowledge about HIV, and only half of them had ever been tested for HIV, even though free testing was available.78

Racial and ethnic marginalization: Ethnic and racial disparities in HIV infection rates among young MSM have been noted in some countries. More research is needed to understand the reason for these disparities, though it has been suggested that the social isolation and discrimination suffered by some ethnic-minority youth may be linked to lack of knowledge about HIV prevention, lack of easy access to health services, and drug and alcohol use.79

Among MSM aged 13–24 years diagnosed with HIV in the USA in 2011, an estimated 58% were African American and 20% were Latino, far higher than their proportion of the overall population.80 Another US survey found a strong correlation between being African American or Latino and not knowing that one was HIV positive. One in five young Roma, Ashkali and Egyptian men in Podgorica, Montenegro – many of whom are refugees from Kosovo – reported having had sex with men, typically unprotected and sometimes involving rape. Most had their first anal intercourse before age 18.79

LEGAL AND POLICY CONSTRAINTS

The United Nations Convention on the Rights of the Child (CRC, 1989) is the global treaty guiding the protection of human rights for people under 18 years of age.1 One of its key principles is that the best interests of the child should guide all actions concerning children (Article 3), also taking into account children's evolving capacity to make decisions regarding their own health (Article 5). The CRC also guarantees the rights to non-discrimination (Article 2), life, survival and development (Article 6), social security (Article 26), an adequate standard of living (Article 27) and protection from all forms of exploitation and abuse (Article 34). Article 24 stresses “the right of the child to the enjoyment of the highest attainable standard of health and to facilities for treatment of illness and rehabilitation of health”.

In practice, significant legal and policy constraints limit the access of young MSM to information and services affecting their health and well-being. In some countries, legal discrimination against MSM is reinforced or encouraged by conservative religious institutions or attitudes or by laws criminalizing same sex behaviour.81,82 The rights of young people under 18 years 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.

Criminalization of same-sex behaviour: As of January 2014, 78 countries had criminal penalties for homosexual acts between consenting adults (or anal sex more generally) or prosecuted such behaviour under other laws.83 In seven of these countries, such acts are punishable by death. The criminalization of homosexuality or homosexual sex pushes young MSM further underground and makes it difficult for them to obtain condoms, lubricants and much-needed counselling, and for service-providers to provide services and commodities. In regions like the Caribbean, it has been documented that countries with such laws have significantly higher rates of HIV among MSM.84,85 Research suggests that MSM with a history of arrest and incarceration are more likely to engage in high-risk sexual behaviours.86

In some countries, laws against sexual violence do not criminalize the sexual assault of men and transgender individuals. The community consultation with young MSM in United Republic of Tanzania revealed that the police often do not respond to complaints of abuse or violence affecting MSM.8

“There should be some changes in the law so that people like us can be saved from abuse and torture.”

Young MSM, Pakistan52

In some jurisdictions where homosexuality or homosexual sex is not illegal, the age of consent for homosexual sex is higher than for heterosexual sex.87 This makes younger MSM more vulnerable to arrest for their sexual behaviour than their age peers who engage in heterosexual sex.

In Lebanon, advocacy by medical experts and psychologists has recently succeeded in ensuring that laws criminalizing “unnatural sex” are no longer applied to homosexual sex.88

Young MSM in Uruguay said that the promotion of human-rights activities and campaigns, including laws approved recently on the recognition and protection of LGBT people's rights and citizenship, must be implemented at the community level and in educational settings.8

Police enforcement: In countries where homosexual sex is criminalized, MSM have no recourse to the police if they are the victims of sexual violence. Young MSM may also be targeted by the police for arrest, extortion or sexual abuse, sometimes in the guise of enforcing laws against “public nuisance” or obscenity.87 Even in countries where homosexual sex is not illegal, the threat of exposure gives police tremendous power over young MSM, many of whom have no awareness of their legal rights. Participants in the Asia consultation pointed out that community members doing prevention outreach work, for example, distributing condoms, may also be targeted for harassment and arrest.11

Legal obstacles to outreach to young MSM: Laws that criminalize homosexual sex make it extremely difficult for organizations offering services for sexual health and HIV prevention, treatment, care and support to do effective outreach to young MSM, since their work can bring them into conflict with laws banning same-sex behaviour or underage sex.

While the United Nations Secretary-General has explicitly stated that human rights apply to all people, including people who identify as lesbian, gay, bisexual or transgender,89 sexual orientation and gender identity are not explicitly a protected status in any binding international human-rights instrument. Some states have incorrectly justified the criminalization of homosexual sex by claiming that they are fulfilling their obligations under Articles 6 and 34 of the CRC (the right to grow up healthy, and the protection of children from sexual abuse and exploitation). National laws banning specific sexual acts between members of the same sex may be used to effectively shut down public-health campaigns targeting MSM or to prevent health workers and others from providing relevant information to young MSM.87

Restricted access to services: The access of legal minors to sexual and reproductive health and other services, including harm reduction for those who use drugs, may be restricted by laws and policies requiring the consent of parents or guardians for testing or treatment. This is a particular problem for minors who live away from their parents. The principle of the evolving capacity of people under 18 years (Article 5, CRC) is not always observed, even though this is particularly important for “mature minors” – a term used in some national policies to describe those under 18 years who are living independently, have no parents/guardians or no contact with them, or have abusive parents/guardians. Parental consent is a particular concern for MSM under the legal age of majority who fear disclosing their sexual behaviours or orientation to their parents.

One of the biggest barriers we face while accessing health services is that the doctors demand that we bring our guardians, which is not possible for us.

Young MSM, Pakistan11

Employment discrimination against MSM: Many countries provide no legal protections against discrimination in hiring, or against dismissal from employment, on the basis of actual or perceived sexual orientation or HIV status. This has the potential to increase the economic vulnerability and dependence of young MSM, and lack of income is a predictor of HIV infection.57 The International Labour Organization has ruled that there should be “no discrimination against or stigmatization of workers, in particular job-seekers and job applicants, on the grounds of real or perceived HIV status or the fact that they belong to regions of the world or segments of the population perceived to be at greater risk of or more vulnerable to HIV infection,”90 and its supervisory bodies have interpreted this clause as applying to key populations.

SERVICE COVERAGE AND BARRIERS TO ACCESS

There are limited data on the proportion of young MSM reached by HIV prevention, treatment and care programmes. Mean coverage of prevention programmes reported by 20 countries in 2012 for all MSM was 54%. However, one international review concluded that globally, fewer than one in ten MSM receive a basic package of HIV prevention services.91

Availability and accessibility: In a 2012 survey, MSM under the age of 30 years reported significantly lower levels of access to low-cost STI testing and treatment, MSM-focused sexual health education and HIV educational materials, and risk-reduction programmes for MSM.57,92 There is frequently a disparity between services available in urban and rural areas.

• Young MSM in the community consultation in United Republic of Tanzania reported that clinics that provided services were often too far from home to reach easily.8
• In Albania, consultation participants said that sexual health clinics in public hospitals were cramped and not private, unfriendly to MSM, and did not provide prevention commodities.8
• It was reported that young MSM in Laos PDR sometimes cannot find condoms. Some young MSM in Nepal were unaware of the benefits of lubricants, and in many cases did not know where to obtain lubricants.9

“There is a severe lack of general sexual health services in the Middle East and North Africa, let alone those which are equipped and sensitized to cater to the needs of young MSM, who do not have the social or financial support to consult a private care-provider. Young MSM need access to information and services to keep themselves healthy.”

Young MSM advocate, Lebanon57

“We do want to participate and attend the institutions and services [that are provided] for all the people; we do not want specific things because we´re LGBT. That's why we need a real homophobia-free dynamic. Without that there is no effective social integration.”

Young MSM, Uruguay11

Funding: Recent reports indicate that less than 2% of global HIV prevention funding is directed towards MSM.93 International funding vastly outweighs domestic spending on focused prevention services for MSM globally, including in all regions except the Caribbean.94 Funding for HIV prevention services for MSM is especially limited in East Asia, the Middle East and North Africa, and across sub-Saharan Africa.94 In response, outreach in some of these regions is led primarily by civil-society organizations rather than the government. While this means that they can apply international guidelines to their outreach, finding adequate support and legal coverage for their work is challenging.

Uptake of HIV testing and counselling: Perceived low risk for infection is one of the reasons that young MSM delay testing. In a survey of MSM aged 15–22 years in seven metropolitan areas of the USA, almost 6 out of 10 respondents thought they were at low risk of being infected.61 However, low uptake of testing can also be because those who do perceive themselves at high risk of HIV fear learning that they are HIV positive.95 Many young MSM delay getting tested for HIV until they become symptomatic.96 Migrants face obstacles to getting tested if services are available only to country nationals.

Uptake of antiretroviral therapy (ART): Young MSM living with HIV are more likely than older MSM to be identified later in the course of their infection and to delay entry into clinical care.97,98 In one study of 126 MSM living with HIV below 30 years of age, more than 40% did not know their viral load or could not access viral load testing, only 56% of those who met the WHO's guidelines for recommended treatment reported taking ART, and only 38% were virally suppressed, compared to 73% of older MSM living with HIV.57 Reasons for delaying or forgoing entry into mainstream services may include self-stigma and shame, fear of disapproval and discrimination from health-care providers, lack of health-care insurance, or poor service availability, accessibility and affordability.99,100

The limited data that exist suggest that adherence to ART among young people is poor, although the reasons are not well understood. In one study among MSM aged 17–25 years living with HIV in Chicago, USA, HIV stigma and discrimination by peers and family emerged as important factors driving non-adherence: of the respondents, 50% indicated that they had skipped doses because they feared family or friends would discover their seropositive status. Participants also described depressive symptoms as barriers to taking medications consistently.101

Lack of services targeted to young MSM: Sexual health counselling provided by clinicians frequently addresses only heterosexual behaviour, in part because training curricula do not include issues around same-sex behaviours and homosexuality. A survey of paediatricians in the USA found that while most discussed sexual activity during preventive care visits, they rarely or never discussed homosexuality (82%) with their patients. Only about 30% prescribed condoms, and just 19% provided condom demonstrations.102 Among young MSM in New York City, USA, who had received a general sexual health screening in the prior six months and who reported any receptive anal sex in their lifetime, just 16% had ever had a rectal screening. A combination of linked factors (e.g., provider discomfort with talking about same-sex behaviours, and the patient's discomfort about revealing these behaviours) may be responsible.103 Young MSM in the consultation in Albania said that public-health facilities were often cramped, offered little privacy, and did not provide condoms and water-based lubricants.8

Stigma and discrimination by service-providers: Insensitivity or discrimination on the part of health-care providers, exacerbated by lack of training and awareness, can deter young MSM from seeking not only HIV testing and counselling but also treatment for other STIs, especially if they feel they will need to disclose their same-sex behaviour to service-providers.91 This reluctance may be especially strong for MSM who do not identify as gay.104 Young MSM may fear that revealing their HIV status to family and friends will also mean disclosing their sexual orientation.105 In the consultation with young MSM in Albania, half the respondents mentioned that despite being aware of public-health services, they did not make use of them because of discrimination from health-care providers and fear of being “outed” as gay.8 Young MSM in Asia reported judgmental attitudes from doctors or nurses, who suggested they should “stop” their sexual behaviour. This contributed to feelings of low self-esteem and discouraged them from returning to health services.9 In the consultation in Pakistan, more than half of the young men who sold sex said that they had been raped by a health-care provider when they went to seek services.8

“One day with a friend of mine I went for general health check-up in a public hospital. At first everything was fine. Once my friend started to explain his problems (I guess the doctor realized that he is gay), then [the doctor] started smiling, making inappropriate jokes about [being] gay and his health problems.”

Young MSM, Albania8

Service-providers also often fail to recognize that as adolescents living with HIV grow up, sexual orientation and sexual practices must be addressed as part of the support offered around sexual and reproductive health and HIV. Often paediatricians are unprepared to discuss same-sex relationships or to provide appropriate comprehensive information, commodities and services for adolescents living with HIV as they become sexually active.

Competing priorities: For many young MSM, taking care of their health is not always their top priority. The need to find shelter, food, alcohol or drugs may take precedence over seeking out services for sexual health, particularly if those services are inadequate or discriminatory. The lack of provision for basic social needs is thus a barrier to accessing sexual health services.

SERVICES AND PROGRAMMES

Around the world, programmes with young MSM are being implemented by governments, civil-society organizations and organizations of MSM themselves. Relatively few have been fully evaluated, but the elements of a number of promising programmes are presented briefly here, as examples of how the challenges in serving young MSM may be addressed. These examples are illustrative and not prescriptive. They may not be adaptable to all situations, but they may inspire policy-makers, donors, programme-planners and community members to think about effective approaches to programming in their own contexts.

APPROACHES AND CONSIDERATIONS FOR SERVICES

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