Overview and analysis of harm reduction approaches and services for Children and Young People Who Use Drugs Produced by Graham Shaw Consulting Ltd for the ICF “International HIV/AIDS Alliance in Ukraine” This material has been prepared within the Harm Reduction for children young people who use drugs in Ukraine: Reaching the Underserved, 2015. Project implemented with financial support from the Elton John AIDS Foundation. Copyright 2015 © ICF “International HIV/AIDS Alliance in Ukraine Acronyms AdjHR Adjusted Hazard Ratio(s) AFEW AIDS Foundation East-West AHR Adjusted Hazard Ratio AOR Adjusted Odds Ratio ART Antiretroviral Therapy ARYS At-Risk Youth Study ATS Amphetamine Type Stimulant(s) BBV Blood Borne Virus(es) BiH Bosnia and Herzegovina CBT Cognitive–Behavioural Therapy CEE Central and Eastern Europe CFA Confirmatory Factor Analysis CFI Comparative Fit Index CI Confidence Interval CIS Commonwealth of Independent States CISHRWIN Civil Society on Health & Right of Vulnerable Women and Girls in Nigeria CM Crystal Methamphetamine CPCS Child Protection Centres and Services CRC United Nations Convention on the Rights of the Child CYP Children and Young People CYPUD Children and Young People who Use Drugs DUST Drug Use Screening Tool EFA Exploratory Factor Analysis EHRN Eurasian Harm Reduction Network EMCDDA European Monitoring Centre for Drugs and Drug Addiction ESPAD European School Survey Project on Alcohol and Other Drugs EU European Union EVA Extremely Vulnerable Adolescent(s) EVYP Extremely Vulnerable Young People FFI Frequent Former Injector(s) FUS Frequency of Use Score HBV Hepatitis B virus HCP Health Care Practitioner HCV Hepatitis C virus HR Hazards Ratio(s) HRI Harm Reduction International (formerly IHRA, the International Harm Reduction Association) IATT Inter-Agency Task Team IAWG Inter-Agency Working Group IDPC International Drug Policy Consortium IDU Injecting Drug Use(r) IFI Infrequent Former Injector(s) IQR Interquartile Range IVDU Intravenous Drug Use(r) KP Key Population(s) LGBTQ Lesbian, Gay, Bisexual, Transgender and Queer LMICs Low and Middle Income Countries LSD Lysergic acid diethylamide, also known as lysergide and colloquially as 'acid' MA Methamphetamine 2 MARA Most-At-Risk Adolescent(s) MI Motivational Interviewing MSF Doctors Without Borders MSM Men who have Sex with Men NTASM National Treatment Agency for Substance Misuse (UK) NEP Needle Exchange Programme NGO Non-Governmental Organisation NIDU Non-Injecting Drug Use NIROA Non-Injecting Routes Of Administration NIU Non-Injecting Users NSP Needle and Syringe Programme OHCHR United Nations High Commissioner for Human Rights OR Odds Ratio(s) OST Opioid Substitution Therapy OTC Over The Counter PCB Programme Coordinating Board (of UNAIDS) PDS Polydrug Use Score PrEP Pre-Exposure Prophylaxis PSI Population Services International PWID People Who Inject Drugs PWUD People Who Use Drugs PYAR Person-Years-At-Risk RISE Resource, Information, Support, Education, as in the organisation Youth RISE RTI Route Transition Intervention SEE South East Europe SG Shooting Gallery SIBA Safer Interventions and Broader Acceptance SSS Sensation Seeking Scale STI Sexually Transmitted Infection TB Tuberculosis UK United Kingdom of Great Britain and Northern Ireland UN United Nations Organisation UNAIDS Joint United Nations Programme on HIV/AIDS UNCTs United Nations Country Teams UNFPA United Nations Population Fund UNICEF United Nations Children's Fund UNODC United Nations Office on Drugs and Crime UNSCR United Nations Security Council Resolution WHO World Health Organization WLDAS West Lothian Drug and Alcohol Service WMD Weighted Mean Difference YKP Young Key Populations YPWID Young People Who Inject Drugs 3 Contents Acronyms ................................................................................................................................................ 2 Preface .................................................................................................................................................... 5 Executive Summary ................................................................................................................................. 6 1. Introduction .................................................................................................................................. 8 1.1 How to use this report ........................................................................................................ 8 1.2 Definitions .......................................................................................................................... 9 2. Methodology .............................................................................................................................. 10 3. Analysis of studies of harm reduction for CYPUD....................................................................... 12 4. Analysis of methodologies, approaches and experiences in the delivery of harm reduction services in the Americas and Europe, including countries of the Former Soviet-Union, for CYPUD ......................................................................................................................................... 14 5. Analysis of data on existing harm reduction services for CYPUD ............................................... 24 6. Analysis of international experience on prevention of transition from non-injecting to injecting by CYPUD .................................................................................................................................... 28 ANNEX A References to studies of harm reduction for CYPUD ....................................................... 38 ANNEX B References to methodologies, approaches and experiences in the delivery of harm reduction services for CYPUD ..................................................................................................... 41 ANNEX C References to data for existing harm reduction services for CYPUD ............................... 84 ANNEX D References to international experience on prevention of transition from non-injecting to injecting by CYPUD ..................................................................................................................... 87 ANNEX E Harm reduction services for CYPUD ............................................................................... 128 Endnotes ............................................................................................................................................. 139 Table 1 Agencies identified that provide some form of drug use interventions for CYPUD aged 10-18 years 25 Figure 1 A schema for route transition interventions (RTIs) 34 4 Preface It is only in relatively recent years that harm reduction for children and young people who use drugs (CYPUD) has begun to see the light of day as a crucially important intervention for the continuum of prevention to care and treatment for communicable diseases, especially HIV/AIDS, tuberculosis and viral hepatitis. Although well intentioned, a lengthy period of time has been taken by international agencies, such as those in the United Nations - particularly UNICEF, UNAIDS, WHO and UNODC - and international NGOs, in discussing, debating and arguing over the age range and the terminology to be used for those who are not legally adults in their own country or territory. Whilst the legal basis for such health and related service interventions is important, it has somewhat distracted such well- meaning organisations from moving rapidly forward with specific guidance on how to assess the unique needs of CYPUD and how to establish and scale-up harm reduction services for such young members of the population. As with 'adults' who use, or inject, drugs, there can be multiple risk behaviours facing CYPUD including sex work, domestic violence which may, or may not, include sexual abuse, as well as young people/adolescents who are in the process of becoming aware of their sexual orientation and gender identity. Regardless of age or 'label' used to describe them, at-risk CYPUD cannot be protected from communicable diseases by simply waving legislation in the air that results in them being unable to access the health and related services that they need. Rather, practical steps that are evidence- based and implemented in a manner that is acceptable to the target populations within the CYPUD- community are needed, and urgently. And those interventions are already well known and referred to as 'harm reduction', of which global guidance has been available from WHO, UNODC and UNAIDS since 2007 (update in 2012). As Fisher notes, "it is not the substance use, but rather the physical, psychosocial, emotional, and often legal consequences of use that lead to terrible consequences among adolescents."1(1) Even with the advent of the UN Convention on the Rights of the Child (CRC), little practical progress has been made around the world in recognising, implementing, evaluating and taking to scale harm reduction interventions for CYPUD in direct violation of the CRC. Many articles published since the late 1990's cannot even bring themselves to consider harm reduction as a viable intervention for CYPUD, preferring instead to focus on drug use prevention and abstinence-based approaches, especially those in schools which, overall, have been an abject failure around the world. Although there have been many lessons learnt in the realm of drug demand reduction and drug use prevention that unanimously show that such approaches fail badly, there continues