© UNICEF Serbia/2010/Maccak
Key populations: Excluded, stigmatized and criminalized
Towards an AIDS-Free Generation – Children and AIDS: Sixth Stocktaking Report, 2013
Worldwide, disproportionately high HIV prevalence is reported among adolescent males who have sex with males, adolescents who inject drugs and sexually exploited adolescents.122 In one of the few reports on the subject, more than 95 per cent of new HIV infections in adolescents in Asia and the Pacific were reported to occur in adolescents belonging to ‘key populations’ – people whose behaviours put them at considerable risk of HIV infection and whose young age renders them particularly vulnerable.123 In selected countries in Asia, the limited data available suggest that over 60 per cent of young key populations initiate sexual activity early in life (by 15–19 years old) and that HIV testing is low.124 Prevention programmes in Asia have been credited with containing HIV transmission resulting from sexual exploitation and commercial sex, although hot spots of concern persist.125 However, HIV transmission during unprotected sex between males appears to be an increasingly powerful driver of the epidemics in several countries. Where HIV incidence among men who have sex with men has been measured, it has been found to be very high. HIV prevalence exceeding 10 per cent has been found in cities in China,126 India,127 Thailand128 and Viet Nam.129 Epidemics driven by unprotected sex between males also predominate in the smaller Pacific nations, but HIV prevalence there is still low. Studies tend to be limited in scope and may include, but are not limited to, young men. Sharing contaminated injection equipment is an extremely efficient mode of HIV transmission, and the risk of infection increases dramatically the longer injecting continues. In a 2012 survey in
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Myanmar, HIV prevalence was 7 per cent among 15–19-year-olds injected drugs, and more than double that (15 per cent) among 20–24-year-olds.130 Studies suggest that injecting drug use accounts for more than two thirds of all new infections in Iran, 40 per cent of new infections in Eastern Europe and more than one third in the Philippines.131 In Pakistan, where injecting drug use is a key driver of the epidemic, studies indicate HIV prevalence more than tripled, from 11 per cent in 2005 to 38 per cent in 2011.132 Emerging evidence from Eastern Europe suggests that a small but important proportion of injecting drug use begins during adolescence.133 In addition to the factors that increase vulnerability for all adolescents, the vulnerability of adolescents in these key populations is profoundly compounded by severe social stigma, as well as harsh legal and policy settings and law enforcement practices that criminalize their behaviours and foster discrimination and violence, thereby hindering access to the few health services and other HIV prevention, treatment, protection, care and support interventions that target the needs of these populations.
Adolescents living with HIV: Shut out from testing, treatment and care Coverage of HIV testing and counselling is low among adolescents and especially low among key populations in most parts of the world. While access and coverage vary greatly by country, survey data from 2008 to 2012 in sub-Saharan Africa indicated that fewer than one in five adolescent girls aged 15–19 years were aware of their HIV status (see Figure 2.4).134 Guidance that testing should be strictly voluntary is clear. However, there are reports that testing of key populations in some settings is mandatory or coerced, and this is of great concern.135 Only a small proportion of adolescents who are long-term survivors born with HIV have access to ART, and most receive it through limited numbers of specialized centres in urban and peri-urban settings.136 Retention rates are also poor.