SITUATION OF ESPECIALLY VULNERABLE YOUNG PEOPLE IN LITHUANIA

SITUATION OF ESPECIALLY VULNERABLE YOUNG PEOPLE IN LITHUANIA VIDA MOCKIENE UNIVERSITY OF KLAIPEDA, LITHUANIA UNIVERSITY OF KUOPIO, FINLAND Abbreviations • • • • • • • • • • • • • • • • • • • • • • • • • • AA –Alcoholics Anonymous AC – Administrative Code AIDS – Acquired Immune Deficiency Syndrome ARV – Anti retrovirals CC – Criminal Code CCP – Code of Criminal Procedure EVYP – Especially Vulnerable Young People HAART – Highly Active Antiretroviral Therapy HAV – Hepatitis A Virus HBSC – Health Behaviour of School Aged Children HBV – Hepatitis B Virus HCV – Hepatitis C Virus HIV – Human Immune Deficiency Virus HRP – Harm Reduction Program IDU – Injecting Drug User IOM – International Organization of Migration LAC – Lithuania AIDS center LSD – Lysergic Acid Diethylamide NA – Narcotics Anonymous NSP – Needle and Syringe Exchange Programmes STD/STI – Sexually Transmitted Diseases/Sexually Transmitted Infections UNAIDS – United Nations HV/AIDS Program UNDP – United Nations Development Program UNFPA – United Nations Population Fund UNICEF – United Nations Children's Fund UNO – United Nations Organization 1. EPIDEMIOLOGICAL SITUATION ON HIV/AIDS, STIS AND SUBSTANCE ABUSE IN LITHUANIA • In 2004 United Nations Development Programme has published a report ―Reversing the Epidemic: Facts and Policy Options‖, where it stated that ―one out of every hundred adults walking down the streets of a city in Eastern Europe or the Commonwealth of Independent States (CIS) countries carries the HIV virus that causes AIDS‖. Injecting drug use has been the primary mode of transmission of HIV. The report has estimated the following numbers/percentages of people in Lithuania who are most at risk for HIV infection: • Prevalence of injecting drug users is about 0.2 – 0.3%; • Number of men having sex with men various from 17000 to 44000; • Number of sex workers both male and female – 5000 – 8000; • Number of prisoners – 11400; In Lithuania, as well as in the Baltic States, the main health problems facing young people aged 10 to 24 years identified by the epidemiological data are: • injuries and violence • high levels of alcohol and substance use, including injecting drug use (IDU); • dramatically increasing rates of HIV/AIDS and sexually transmitted infections (STIs); • poor mental health and high levels of suicide; • unwanted pregnancies and rather high levels of abortion. • There is also evidence for increased sexual abuse, sexual trafficking and domestic violence, especially for young women. • Studies by the International Office of Migration (IOM) in Lithuania indicate that girls who are being trafficked are of an increasingly young age. HIV/AIDS • Lithuania, for more than a decade since the first case of HIV in the country in 1988, is considered a country of low HIV prevalence. There was a total of 328 HIV cases registered by the end of 2001. • A HIV outbreak in one of Lithuanian prisons in May 2002 doubled the country statistics. As of December 31, 2003, a total of 845 people have been diagnosed HIV-positive. The numbers affected continue tosteadily increase. • In Lithuania injecting drug use is the main or a major mode of HIV transmission. Sharing or use of contaminated injecting equipment or needles is the most efficient way of transmitting HIV. The level of risk is much higher than from unprotected sexual intercourse since HIV infected material is injected directly into the bloodstream. • Injecting illicit drugs has increased rapidly worldwide in recent years. Moreover, the global experience of recent years reveals the fact that HIV can spread very quickly among IDUs and other especially vulnerable people. Therefore, special attention should be granted to these groups and prioritized actions should be directed to solve their health problems. • Until 2005 September 8, 1070 cases of HIV were provisionally reported in Lithuania. 947 of these were men and 123 were women. 108 persons were infected through heterosexual contacts, 69 men get infection having sex with men, 847 cases of HIV occurred among intravenous drug users (IDUs). • This reflects a tripling of HIV infections during a 3 year period! • AIDS was diagnosed in 92 cases. In total 40 died of AIDS and 53 HIV infected persons died from other causes not associated with HIV. HIV and AIDS registered cases in Lithuania: 1988 - 2004 • The predominant mode of HIV transmission is through injecting drug use (about 80%), followed by heterosexual contact (about 8.5%) and homosexual contact (about 7%). Nocases have been reported due to mother-to-child transmission or through HIV-contaminated blood products, although based on the pattern seen in other countries, we can expect cases among infants soon. • The largest number of new cases of HIV (about 35%) is diagnosed in the 30-39 year old age group. HIV INFECTION CASES BY AGE, 2004 (Males,Females,IDU,TOTAL) HIV INFECTION CASES BY AGE, 2005 Sexually transmitted infections • Levels of sexually transmitted infections are important indicator of risk or vulnerability to HIV. In addition to being a relatively good marker of unsafe sex, STIs facilitate thephysiological transmission of HIV. Sexually transmitted infections in Lithuania have increased dramatically over the past decade. • However, for the last five years incidence of STI has started to decrease slowly. Nonetheless, comparing to other new EU member states, Lithuania still has rather high number of STI cases diagnosed. • The same tendency is valid for young people in Lithuania. Incidence of sexually transmitted infections in population aged 15 – 19 (newly registered cases per 10000 relevant population) was 46.7 in 2002 while in Czech Republic this number was 29.9, Hungary – 16.3, Slovenia – 11.2 Slovakia – 1.7 • (UNICEF/MONEE, 2004). Viral hepatitis • Speaking of the infection risk of young people, acute viral hepatitis B and C cannot be overlooked. Many people with hepatitis B die from chronic liver diseases, cirrhosis and primary liver cancer. Approximately 80% of hepatitis C cases develop into a chronic form of infection and lead to cirrhosis or chronic liver cancer and death caused by these diseases. • In 2003, the largest rates of acute viral hepatitis B were reported among young people aged 20–24 and adolescents aged 15–19, viral hepatitis C – among people aged 25–29. On average, number of men infected with viral hepatitis B and C in Lithuania is double that of infected women. The largest differences are observed in the age group of 15–34 year olds. • The injecting drugs use is the most widespread in this age group. • As claimed by the World Health Organization, actual number of hepatitis B cases exceeds the officially reported statistics approximately by 6 times. • Lithuania is also not an exception. Psychoactive substance use • There is a lack of reliable statistics on the number of drug users in Lithuania and how this number is developing. The data collected by the State Mental Health Centre up to 2004 reflect only the numbers of persons who turned for help to mental health centres and centres for addictive disorders. • This number does not include large numbers of people counselled and treated in private healthcare institutions, in centres for addictive disorders anonymously, in rehabilitation centres operated by the state and NGOs, hospitalized at intensive care, internal and infection disease units due to drug overdosing and complications as well as those who turned to harm reduction programs, for example, to exchange syringes and needles. • For example, in 2003, Blue Bus project run by Vilnius Center of Addictive Disorders provided services to a total of 4,460 injecting drug users mostly using opioids, whereas, the official statistics on drug users in Vilnius City quoted 2,087 users in 2003. • Based on expert evaluations, the actual number of injecting drug users in Lithuania is from 7,000 to 11,000 users (UN Reference Group on HIV/AIDS Prevention and Care Among IDUs, 2004). • Number of people with substance dependence disorders applying to healthcare institutions is gradually increasing every year, despite the fact that people with substance dependence disorders often do not want to undergo treatment. And when they do turn for assistance, this often happens thanks to the efforts of their family or colleagues. • Some of those registered use multiple drugs and this number has increased compared to the earlier data. In 2003, treatment institutions recorded 576 persons using multiple drugs, of those seven persons were under 18 years old. • Based on the data provided by the State Mental Health Center, it can be claimed that the use of opioids is steadily growing. The use of tranquillizers and sedatives is going down slowly, while the number of persons using cannabis is almost unchanged compared to 2002 and 2001. The number of people using hallucinogens was also unchanged . • Additionally, more than one third of drug and toxic substances addicts is among young people aged 15 to 24 years old. It should not be forgotten that these statistics reflect official data, but estimated numbers are higher. 2. ESPECIALLY VULNERABLE YOUNG PEOPLE IN LITHUANIA • Especially vulnerable young people is a concept used to cover a broad range of populations at risk of developing health and other problems. • Especially vulnerable young people are phenomena existing world-wide and Lithuania is no exception. • It is however difficult to estimate the number of especially vulnerable young people and the magnitude of difficulties they experience as these populations are not adequately covered by national census, educational and health data. • In the Lithuanian context, we can distinguish various groups of especially vulnerable young people, each having specific characteristics and specific needs. • It is important to remember, however, that the individual young people who may be part of the groups noted below are not found in a particular or any one location. They will be residents, as anyone else in a city, town or village. They may be your neighbour, friend or relative. • While all young people are potentially at risk, there are some indicators that can be used to identify YP who are potentially at greatest risk. This includes: YP who do poorly in school, YP who are unemployed, YP who have lived in dysfunctional families, YP who have lived for many years in state boarding schools, YP who have been affected by domestic violence. • All these YP are at risk and requires the sensitivity of health workers—to hear their concerns and to prevent these risk factors in resulting in serious situations as noted below. • Belonging to the group of especially vulnerable young people indeed implicates some hazardous consequences on young people‘s health. • The WHO Rapid Assessment and Response guide on psychoactive substance use and especially vulnerable young people 5 has indicated that health concerns of especially vulnerable young people can be multiple, and that substance use and sexual or other risk behaviour can exacerbate existing conditions or induce new ones. Young injecting drug users • As mentioned above, Lithuania has a significant problem of injecting drug use. There are no reliable statistics on the number of young people involved in injecting drug use. • Since injecting drug users are often linked in tight networks and commonly share injection equipment, HIV can spread very rapidly in these populations through sharing of injection equipment and through risky sexual behavior. • Various factors make their issues unique and these have raised awareness for the need to have services, which target them specifically – one of these services are outreach services. Young sex workers • The changing economical and social conditions and growing unemployment are among significant factors increasing levels of prostitution in Lithuania. Under the these circumstances, some girls and women lose hope of stepping into the legal labour market and choose prostitution or are forced into prostitution. • However, it would be wrong to point out the economic difficulties as the only cause for prostitution in Lithuania. Micro social factors are also important here, such as cold family ties, socialization difficulties (especially with peers), as well as reluctance to learn and so on. • Sex work is often linked to substance abuse. For young female drug users, sex work can rapidly become a part of life as means of funding their drug habit. These girls are at high risk acquiring HIV and can serve as a transmission link of HIV to their casual and regular sexual partners, to their children and to the general population. Girls especially at risk for sexual abuse, rape and violence • As stated in the Country Reports on Human Rights Practices for Lithuania by the U.S. Department of State, child abuse, particularly in connection with parental alcohol abuse, was a problem; as of end of 2004, approximately 39,000 children lived in abusive and dysfunctional families. • The penalties for violence and cruelty against underage persons are prison terms of 1 to 2 years; however, the press reported cruelty to children, including sexual abuse, intentional starvation, beatings, and killings, was common. • The Penal Code provides for up to 13 years' imprisonment for sexual abuse of a child; however, sexual abuse was prevalent. • Trafficking in girls for the purpose of sexual exploitation is a problem . Exploiting children in the production of pornography is illegal; however, there were a few cases of this reported during the year 2004. For instance, the police detained a high school teacher suspected of distributing child pornography on the Internet. • Health Behaviour of School Aged Children (HBSC) report notes that school children in Lithuania demonstrate the highest rates of violence against each other in all of Europe!7 The growing number of sexual abuse, rape and violence among women shows that a big part of Lithuanian women falls at risk of vulnerability. • Additionally, high rates of pregnancy and high rates of abortion among young girls, compared to EU averages, indicate that young women need special support and services to promote their healthy growth and to reduce their vulnerability to other risky behaviours. • Females may need specialized services, such as those for pregnant or parenting adolescents. It has been shown that girls often experience more severe parental rejection and sexual or physical abuse than boys do. Weak family bonds are a precursor to substance abuse in Females. • The growing relevance of women trafficking issue in Lithuania becomes implicit from the data with an upward trend on young women extradited from foreign countries, however the actual scope of the problem is much bigger than suggested by official statistics. The country is a source, transit point, and destination for women trafficking. • Women from the country are primarily trafficked to Western Europe. Most women trafficked into or transiting the country are from Eastern Europe. According to Europol, every year approximately 1,200 Lithuanian women fall victim to trafficking or leave the country against their will. For instance, twenty women (3 under the age of 18) were reported to the police as victims of trafficking during 2004. • The most common age of victims of trafficking in human beings is about 18 – 24 years, but there is a significant proportion of minors among trafficking victims. A young woman, who is not studying, receives little support from the family, has no job and financial resources, is very much vulnerable to trafficking and prostitution. • It should be noted that the lack of stable family relations affect the development of a girl so that she consequently may become susceptible and vulnerable to various forms of human rights violations and trafficking. • Traffickers indeed particularly target the socially most vulnerable groups: Young females from poor, asocial, or unstable families. Traffickers also commonly target young women from ethnic minorities. Many are lured by deceptive offers of jobs such as household helpers, bar dancers, nannies, nurses, models, or waitresses, or through false marriage advertisements. • In many cases, close relatives or friends make the offers. Victims‗ compliance is ensured via threats and the withholding of their documents. Families often are unaware of their predicament and believed that they had been kidnapped. Boarding schools that also serve as orphanages are new targets of traffickers. Street Children • The street environment places street children in especially vulnerable categories. There is no unique or clear definition, what are ―street children‖ in Lithuania. • Usually these children are those living in a street, but having some (regular or irregular) relations with their families or kids living independently without any boundaries with their family members. Some part of such children are form care institutions and often they get back to these institutions or day care centres. • As indicated in the Report on Human Rights in Lithuania by the US Department of State, several thousand children lived on the street in 2004. Sixty regional government children's rights protection agencies, other institutions, and numerous NGOs routinely assist these children. • Street children had full access to free state services. There were no reports of police abuse against street children. • Substances (including illicit drugs) use is widely prevalent among street children all over Lithuania. • Often, substances are used as an escape from self-degradation and misery. Young people living on the street are keen to experiment, and therefore are more likely to try injection drug use. There is an increased risk of contracting HIV while needle sharing. • Service providers rarely understand the circumstances and specific needs of street children and their accessibility to health care services, particularly those related to substance abuse and HIV/AIDS/STIs is severely restricted. • Substance use, unsafe sex, illegal activity practiced by these young people may lead to particularly severe health complications – overdosing with alcohol and drugs, infection with HIV/AIDS, hepatitis and other sexually transmitted diseases, risk to become victims of violence and assault. • Illegal drugs and psychoactive substances are highly popular among street children in Lithuania. Even 81 percent of street children have tried at least one sort of drugs. Drugs became very popular and fashionable among the young people. • Legal psychoactive substances were extremely popular in 1995: among schoolchildren of 15-16 years 15.7 percent were using inhalants and 14.6 percent were using sedative and soporific drugs. • In 1999 their spread has somewhat decreased (to 9.7 percent and 12.4 percent respectively). However, above mentioned substances remain extremely popular among street children (the rates of use are 64.0 percent and 46.8 percent respectively). Young people in detention/prison • Studies in different parts of the world have indicated that overcrowded conditions, drug abuse and limited availability of adequate services in prisons may adversely affect the health of inmates. The same is valid for Lithuania. • Moreover, for young people in detention/prison there are risks considering that they are often physically (and also emotionally) weaker than other inmates are and may be forced to take part in drug related or sexually related activities. As noted previously, in one prison, over 250 cases of HIV infection were identified in 2002. Young men who have sex with men • It has been identified that young men who have sex with men engage more often in risky behaviour as compared to older men who have sex with men. • Moreover, studies have revealed that the frequency and variety of substances used by homosexual young men is greater than that of heterosexual men. The explanation for these findings usually involves the social and emotional isolation. These behaviours put them at special risk for HIV and other STI infection. Young people from Roma minority • The Roma is one the most vulnerable population throughout Central and Eastern Europe14. Lithuania is no exclusion. Around 3000 Roma people reside in Lithuania, concentrating in three biggest towns – Vilnius, Kaunas, Panevezys. • In Kirtimai encampment (Vilnius) Roma community lives in slum-like houses, have high unemployment levels, poor health care and lack access to public services. Many Roma living in Kirtimai settlement are uninformed about the risks associated with the needle sharing and unprotected sex. All these circumstances make them vulnerable to the risks of drug use and HIV infection. • Young Roma there are especially vulnerable. The mortality rate of Roma children and youth is higher compare to the indicators of the whole nation. A number of social and economic factors affect the situation of Roma people, especially those living in Kirtimai encampment. 3. MAIN HEALTH PROBLEMS OF ESPECIALLY VULNERABLE YOUNG PEOPLE Particular health problems that especially vulnerable young people may encounter includethe following: • Malnutrition and other disorders of diet. Specific nutritional deficiencies resulting in such disorders as anaemia and endemic goitre. • Infectious diseases: o Skin; o Respiratory tract; o Sexually transmittable infections, including HIV and hepatitis B; o Viral; o Parasitic; o Opportunistic; o Specific infections such as tuberculosis. • Oral health problems such as dental caries and gingivitis. • Intoxication overdose and dependency. • Unplanned pregnancies. • Skeletal and soft tissue injuries from accidents and violence. • Industrial and environmental poisoning. • Cognitive disorders and learning difficulties. • Mental Disorders: o Disorders of mood, such as depression; o Suicide and para suicide and other deliberate self-harm; o Anxiety and phobias; o Post-traumatic stress disorder; o Conduct and anti/dis-social personality disorders; o Substance use-related disorders, including psychoses and organic disorders; o Sleep disorders; o Eating disorders. • While other young people may have any or some of the above health problems, the risky behaviour and life styles of especially vulnerable young people may increase prevalence, morbidity and mortality with regard to the above mentioned health problems. THANK!