I would like to finish today’s session with a summary and synthesis of why we must get HIV policy right for key populations – and how both national and municipal policy leaders can make a difference.
The Global Commission on HIV and the Law, hosted by UNDP, released its final report two weeks ago. The report synthesized overwhelming evidence that the law on the books as passed by parliamentarians, the law on the streets that is often enforced by police under municipal control, and access to justice all make an important difference to the AIDS response. Bad laws and bad legal environments undermine prevention and treatment efforts and make investments less cost effective.Good laws and good legal environments do the opposite, as shown in this slide. In and of themselves they can improve outcomes, and they can also multiply the impact of strong treatment and prevention programmes.
The legal environment is strongly associated with coverage and uptake of services. As you can see from these data, protection against discrimination increases HIV service coverage.
The Commission on HIV and the Law reached some conclusions and made some recommendations that cut across all key populations.Needless to say, key populations need access to services and programmes, yet they are disproportionately under-reached in many countries and cities.Even at current global funding levels, far more could be done by channeling a great proportion of resources to key populations most at risk.Laws do make a difference – as does law enforcement practice.And policy leaders need to go beyond law, law enforcement and financing: they have a key role in leading the broader effort against stigma and marginalization.
Of course, each key population has its own needs and its own epidemic dynamics, which means that each requires policy-makers attention and support. ‘Harm reduction’ for drug users refers to both the legal and policy framework and the provision of essential services. National parliamentarians must provide a legal framework for harm reduction while mayors and other municipal leaders must ensure that the police facilitate rather than block access to such services. Together, countries and cities must ensure funding. The contrast between countries that get this right and countries that get it wrong is dramatic.
The Commission report cites punitive laws and practices but also successes.Iran was an early adopter of harm reduction in the developing world and Indonesia and Malaysia have recently reformed some key provisions of relevant laws. Unfortunately, far too many countries stillcriminalise proven interventions such as syringe access and medication-assisted treatment for opioid dependence.In many Eastern European and Central Asian countries, people who use drugs are named on drug registers, which brand people who use drugs as sick and dangerous, sometimes for life. Far too often, drug users face police harassment, violence and incarceration; discrimination in health care, housing, employment and schooling; and political disenfranchisement. To meet arrest quotas, police officers seek out drug users as easy targets.
There is a clear agenda for policy leadership:From a criminal approach to a public health approachRecognizing that human rights and medical ethics are universal – and therefore apply to people who use drugs.Decriminalization of drug possession would reduce HIV related harm, radically reduce the size of the prison population and save government money in both cases. But there will always be some people in prison, and treatment and prevention services in such closed settings must also be improved.
The drug use related data I just showed demonstrated the power of combining the right laws, services and financing. But even the law alone seems to make a difference with key populations.These data contrast HIV prevalence rates amongst men who have sex with men in countries that criminalize such sexual relations with countries that have repealed punitive laws. The lesson is clear, which is that the law makes an important difference. In the Caribbean countries where homosexuality is criminalised, almost 1 in 4 MSM is infected with HIV. In the absence of such criminal law the prevalence is only 1 in 15 amongst MSM.To achieve even more dramatic gains, policy makers also need to ensure that the right LAWS are complemented by dramatically increasing the proportion of HIV funding that is targeted to MSM and other key populations.
From a human rights perspective alone, political leaders should repeal sodomy laws and assure that the police provide protection rather than harassment for sexual minorities.But for those politicians who need an additional rationale to convince their voters, look at how legal protections for sexual minorities over time protect heterosexual women. The bottom line is that laws against male homosexuality encourage MSM to marry women – which in turn increases the vulnerability of their wives to HIV as well.
MSM face harassment, arrest and police brutality in countries that outlaw their behaviour. Police raid educational forums and confiscate condoms and lubricants as evidence of sex crime and informational materials as “obscenity.” Even when there are no anti-sodomy laws, in far too many settings, police abuse MSM under overly broad “public safety” and “vagrancy” laws to harass and control MSM and theplaces where they may gather - HIV service centres as well asbaths and bars.
Parts of the policy agenda are very well known to all of you, in particular the repeal of all laws that criminalize consensual same-sex conduct between adults and the enactment of anti-discrimination laws.The Commission also identified other approaches that work in certain environments – in particular, for countries influenced by Islam or governed under Shari’a, the recognized right to privacy can be enforced with far more vigor.
Sex work is also criminalized in one way or another in most countries in the world, and as with MSM, such laws undermine effective programming.
One particularly important challenge is the deployment of anti-human-trafficking laws to conflate voluntary, consensual exchanges of sex for money with exploitative, coerced, and often violent trafficking of people for the purposes of sex.Indeed, often AIDS funds are predicated on this conflation. The US government’s PEPFAR compels governments to accept the conflation of human trafficking with sex work by conditioning the receipt of funds on the signing of its Anti-Prostitution Pledge.There are many other legal challenges.Municipal ‘public nuisance’ laws and zoning and health regulations give police wide latitude to arrest and detain sex workers.Some sex workers fear carrying condoms, which in too many jurisdictionsare used as evidence against them.Working in the informal sector reduces sex workers’ access to education and housing, thus increasing their dependence on others, including pimps.
When the state recognises the human and civil rights of sex workers, it can deploy the police in a radically different way. Rather than unleashing police to beat and arrest sex workers, it can put them to work alongside sex workers in enabling widespread safer sex practices. When this was done in India, condom use among sex workers rose from 27% to 85% from 1992 to 2001, and HIV prevalence among sex workers fell from over 11% in 2001 to less than 4 % by 2004.
The Commission also examined how bad laws make transgender people more vulnerable to HIV
And how good laws and law reform help transgender people protect themselves and their partners.
I want to conclude by briefly mentioning the special role of mayors and other municipal political leaders. The findings and recommendations that I have just shared from the Global Commission have a great deal of relevance at the urban level, particularly for those municipal governments that oversee police or prison services.While many of the laws themselves must be debated and enacted in national parliaments, cities have long been leading the way both to demonstrate the impact of protective rather than punitive approaches, and to push national leaders to change.In fact, two years ago, UNDP and the UNAIDS family adopted a global strategy towards universal access for men who have sex with men and transgender people that specifically emphasized policy leadership, service delivery and human rights protection at the municipal level.Most HIV infection amongst key population takes place in large cities, and most political courage and innovation on these issues comes from large cities.
Many thanks. I invite you to visit the Global Commission and UNDP websites for more information.
HIV Policy for Key Populations - Why does it matter (July 2012)
HIV Policy for Key Populations:
Why does it matter?
National Policy Priorities
Urban Policy Priorities
Director, HIV/AIDS Practice, UNDP
Secretariat, Global Commission on HIV & the Law
Modes of transmission in sub-Saharan
African countries, 2008-2009
Lesotho Kenya Swaziland Uganda Zambia Benin Burkina
Ghana Nigeria Senegal
Southern and East Africa West Africa
(measured only in
Distribution of new infections by sources of risk
Median percentage of population reached
with HIV prevention services within specified
sex with men
(UNGASS indicator 9)
Source: UNGASS Country Progress Reports 2008
UNDP African urban policy scan
Urban issues not understood and addressed sufficiently
HIV and AIDS not a priority of municipalities and city officials
Policy makers not providing guidance or strategies and donors not
providing focused resources.
Major donors and implementing agencies follow national strategy,
but local level leaders and AIDS Councils often not consulted.
A lot of monitoring but not enough co-ordinating.
Coordination capacity limitations in municipalities – human,
Challenges in addressing the needs of key populations in
improving access to justice, protection from sexual and gender-
based violence and access to services.
Civil society vs. government capacity – how can we develop
implementation and co-ordination capacity of different sectors?
Way forward – what do we expect from cities?
All cities could take action to:
• Integrate HIV in local development plans - own the response, identify targets
and establish accountability mechanisms.
• Know the epidemic and the response – produce evidence on size, prevalence,
behaviour and mapping of relevant population groups and high
transmission areas to mobilise and target prevention resources
• Develop evidence on specific urban dynamics - major drivers of epidemic such
as MCP, sex work and transactional sex, sero-discordancy , mobility,
migration routes, urban poverty, informal settlement, etc
• Advocate for enhanced urban responses (including for rural populations) – an important
and cost effective way to reach rural residents. Urban responses need investment to cater
for migrants and satellite communities.
• Provide leadership on rights based approaches -reduce harassment and increase
protection from law enforcement agencies.
• Support national resource mobilization efforts – generate “city” and extra resources e.g.
through partnership between public – private – community.
• Ensure accountability– monitor progress, evaluate, and provide political leadership.
Report of the Global Commission on HIV and
“Risks, Rights & Health”
available at: www.hivlawcommission.org