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HIV Moves In on Homeless Youth

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Science  09 Jul 2010:
Vol. 329, Issue 5988, pp. 170-171
DOI: 10.1126/science.329.5988.170

Studies have discovered shockingly high HIV prevalence rates in kids who live on the streets of Russia and Ukraine; nongovernmental organizations are trying to give them new leases on life.

Mean streets.

Stas Fedorov (center) and his friends have risky lifestyles that HIV easily exploits.

CREDIT: MALCOLM LINTON

ST. PETERSBURG, RUSSIA, AND ODESSA, UKRAINE—Russians frequently boast that St. Petersburg is the most beautiful city in the country, and Ukrainians say the same about Odessa. Both feature well-preserved architecture in Italian and French styles that date back to the 18th century, stunning monuments, and lots of water, be it the canals that wind through St. Petersburg pouring into the Neva River or the majestic Black Sea that laps Odessa's shores. Yet both cities have a dark underbelly that has caught the attention of HIV/AIDS researchers: Large numbers of youths living on the street who, as a group, are at as high a risk of becoming infected by the virus as any vulnerable population ever studied. “They're hard to reach and invisible for HIV statistics and often for HIV prevention programs,” says Dmitry Kissin, an obstetrician/gynecologist who works for the U.S. Centers for Disease Control and Prevention (CDC) in Atlanta. “No one knows how many street youth there are because no one's counting them. And when you don't know about something, you don't pay attention.”

Kissin, who is originally from St. Petersburg, has worked for the past 4 years with colleagues in both countries to bring attention to this underappreciated high-risk group. Estimates suggest that up to 3 million youths are living on the streets in Russia and 150,000 in Ukraine. They live in city shadows, sleeping in basements of apartment buildings and abandoned buildings, taking odd jobs and panhandling, and constantly dodging police. “You don't see them unless you look for them,” he says.

Kissin has been trying to do just that. Along with CDC's Susan Hillis and co-workers from HealthRight International—a nongovernmental organization (NGO) formerly known as Doctors of the World-USA and founded by pioneering AIDS researcher Jonathan Mann—he launched a study in St. Petersburg in 2006. The researchers identified 41 different train stations, metro stops, street markets, and other sites where groups of teens gathered. They picked half of the sites at random and started enrolling youths in the study. In the end, they signed up 313 teenagers between the ages of 15 and 19, two-thirds of them male, who lived at least part-time on the street, were not cared for by their families, and did not regularly attend school. They questioned the participants in detail about their lifestyles and tested each one for HIV. When they first saw the results, says Konstantin Zakharov, the project coordinator for HealthRight, “it was a shock.” A staggering 37.4% were infected.

Highs and lows

Shortly before dark one March night, three young men hanging out together on a canal near the center of St. Petersburg approach a mobile van operated by HealthRight and greet Zakharov. In the wake of their first study, which was published in the 12 November 2007 issue of AIDS, HealthRight started to send the van out on the streets twice each week to do HIV testing and counseling of street youth. The group also opened an overnight shelter, organized a drop-in center for counseling with psychologists, and helped connect youths in need of medical care with the appropriate doctors. The oldest of the three young men, Stas Fedorov, 23, has received vocational training and leads informal, HIV-prevention workshops with others in his situation. His two friends are drinking vodka from a soda bottle, but he seems sober, the wise elder of the group. “My dream is to live like a normal person,” he says. “Start working and restore my documentation, which somebody stole.”

Fedorov is infected with HIV—“My girlfriend gave me that present,” he says—but he is relatively healthy, which is remarkable given his history. He says he started smoking cigarettes at 6. His friends took him to the big city, St. Petersburg, at 7, and he was dazzled by the bright lights and stayed, sleeping in basements or in abandoned buildings. Like many of the youths, Fedorov was an orphan and got into inhalants and injecting drugs, but he says he is clean now. “I've seen people do anything for the dose,” he says.

Kissin, Zakharov, and their colleagues have attempted to tease out the risk factors that lead to such high infection rates among street youth—information that is key to tailoring prevention programs to each vulnerable population. Some behaviors are well known to fuel HIV's spread: an astounding 78% of the youths who injected drugs tested positive, as did 70% who had another sexually transmitted infection (an indicator that they did not use condoms). But they also linked HIV infection to social forces particular to street youth. The death of both parents more than tripled the risk of becoming infected, and having no place to live raised it 2.4-fold.

Shelter from the storm.

Inna Nikiforova (above) and The Way Home offer street youths a nourishing environment, including a chance to rebuild self-esteem playing sports and winning medals.

CREDITS: MALCOLM LINTON

Although many studies have found that people who learn they are infected take precautions not to infect others, in this group, teens who came into the study knowing they were HIV positive were more likely to share needles and inconsistently use condoms. “Maybe there's just a sense of hopelessness among them,” says Kissin. “HIV may not be your first priority when you need to negotiate survival on the street and find food, drugs, alcohol, and some place to sleep.”

Odessan odyssey

“Dima! Dima! Dima!”

Inna Nikiforova is crouching down and yelling through an iron grate that covers an opening to the dirt-floored basement of a downscale apartment building not far from Odessa's swank downtown. Nikiforova, a former injecting drug user (IDU) herself who lost an arm after a suicide attempt as a teen, is an outreach worker with The Way Home, an NGO that helps street youth, and Dima is one of the teens she has become closest to over the years. This Saturday afternoon, she has brought him a plastic crate filled with food, but he is not in his usual haunt, which is strewn with filthy mattresses, trash, cigarette butts, and burnt-out candles.

Nikiforova soon finds Dima at a nearby busy intersection approaching cars, hat in hand. He has clubbed feet, the result of nerve damage from injecting an ephedrine-based drug called baltushka, and he hobbles over and gives her a long hug, closing his eyes. He has few teeth left. He is 18 but looks much younger. Dima also is HIV infected, as are 27% of the street youth here, according to a study conducted in 2008 by HealthRight and the U.S. CDC. And like many teens who live on the street, he is difficult to help—and is in dire need of assistance. “We found his father in Moldova and said, ‘Here's your kid, he wants to come home,’” says Nikiforova. “The father had a new wife and family and said, ‘He's not my son until he stops using drugs.’”

The Way Home runs a shelter that houses two dozen street youth, and Nikiforova, who lives with them in the well-kept dorms, brought Dima in. He lasted only 3 days. But clean for a time, joining a soccer team and winning a medal that Nikiforova hangs from a mirror in her bedroom. To return to his father, all he needed was proper documentation—like many street youths, he had none—and The Way Home tried to help him obtain them. Then Dima relapsed. “He just got drunk and left, and since then …” says Nikiforova.

Attempts to help the street youth are even more complicated when it comes to HIV prevention and care. As Sergey Kostin, the head of The Way Home, explains, they are not allowed to distribute clean needles to the youths. “It's against the norms,” says Kostin, a geologist and former IDU himself. “It's hypocritical.” Nataliya Kitsenko, a clinician who directs the HIV/AIDS program for the charity, says they have had many difficulties accessing anti-HIV drugs for the youths, too. “It's very hard because they don't have parents to give consent,” says Kitsenko. “It's a big problem, and we don't know how to solve it.”

Although NGOs such as The Way Home and HealthRight have joined with international groups to address the often-ignored epidemic of HIV/AIDS in street youth, Kitsenko doesn't expect her own economically challenged government to step up its efforts anytime soon. “The government doesn't do much of anything for the so-called normal people, and at such times, how can they think of programs for the marginalized?” she asks.

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