ASSESSMENT OF GAPS IN POLICIES, POLICY IMPLEMENTATION AND PROGRAMS FOR KEY POPULATIONS IN BURKINA FASO

ACTION FOR WEST AFRICA REGION II (AWARE II)

Submitted to: USAID/West Africa Regional Mission Office of Health, Population and Nutrition American EmbassyNo. 24 Fourth Circular Rd. Cantonments Accra, Ghana P. O. Box 1630 Accra, Ghana

CONTRACT GHS-I-05-07-00006-00

Suggested citation: Duvall, S., K. Beardsley, C. Compaor, P. Sanon and D. Bassonon. 2012. Assessment of Gaps in Policies, Policy Implementation and Programs for Key Populations in Burkina Faso. Accra, Ghana: Action for West Africa (AWARE II).

ASSESSMENT OF GAPS IN POLICIES, POLICY IMPLEMENTATION AND PROGRAMS FOR KEY POPULATIONS IN BURKINA FASO

March 2012

CONTENTS

Background ............................................................................................................................................................... 5 Objectives and Methodology .................................................................................................................................... 5 Assessment Findings ................................................................................................................................................. 5 Key Populations HIV Policy Assessment ............................................................................................................... 12 Methodology and Steps of the AWARE II Key Populations Policy Analysis........................................................ 12 Challenges and Limitations..................................................................................................................................... 14 Key Populations and HIV in Burkina Faso ............................................................................................................. 15 Framework .............................................................................................................................................................. 16 Community Partnership .......................................................................................................................................... 17 Legal Environment.................................................................................................................................................. 18 Intervention Design, Access, and Implementation ................................................................................................. 24

This report represents initial findings from a rapid assessment of available policy documents and a limited number of interviews with individuals in their professional or official capacity. Due to time and budget constraints, the findings have not been validated or prioritized with stakeholders in Burkina Faso. The authors recommend that further interviews be undertaken with individuals of these Key Populations and that these data be confirmed and corroborated before making any assumption or taking action on them.

ACKNOWLEDGEMENTS
The authors would like to thank Christian Fung and Laurent Kapesa at USAID for commissioning this assessment and for their commitment to its completion. We also highlight with appreciation the continued support and encouragement of Issakha Diallo, Director of AWARE II, from the early planning stages of the assessment through submission of the final report. Ron MacInnis, Deputy Director for HIV on the Health Policy Project at Futures Group, and Modibo Maiga, Senior Policy Advisor at AWARE II, joined the assessment team in Ouagadougou to meet with key stakeholders and organize the key stakeholder workshop and provided invaluable technical input, management oversight and feedback. Regional Technical Advisor Demba Diack was instrumental in identifying in-country management solutions, facilitating contact with government officials and key stakeholders and providing technical input on data analysis and reports. We thank the research assistants, Celestin Compaor and Patrice Koblavi, for their insight and their persistence in obtaining key documents. We are also grateful for the notable contributions from colleagues at USAID, AWARE II and Futures Group, including Martine Laney, Alpha Ba, Ginny Gordon and Marie-Paule Gbedjrou, with a special thanks to Laura McPherson whose constant support, input and work behind the scenes was fundamental in the initiation and completion of the assessment. Finally, this assessment could not have been conducted without the support of the Permanent Secretary of the National Council for the Fight Against AIDS and STIs (CNLS-IST), Dr. Joseph Tiendrebeogo, the members of the Burkina Faso MARPs (most-at-risk populations) Intervention Monitoring Committee, key informants, and the generous advice, assistance and coordination from Dr. Marcel Lougu and his team at the Support Program for Associations and Communities (PAMAC).

ACRONYMS
AIDS ART ARV AWARE II CAMEG CBO CD4 C/L CCM CEDAW CMLS/Sant CNLS/IST CSLS CSO DAF/MS DAP DGPML DHS EPT FP GBV GFATM GoBF HAV HBV HIV HCT ICESCR IEC MoH acquired immune deficiency syndrome antiretroviral treatment antiretroviral Action for West Africa Region II Central Purchasing Agency of Generic Essential Drugs and Medical Commodities community-based organization cluster of differentiation 4 (cell count) condoms and lubricants country coordinating mechanism Convention on the Elimination of All Forms of Discrimination against Women Ministerial Committee for the Response to HIV, AIDS and STIs of the Ministry of Health National Committee for the Response to HIV and STIs National Strategic Framework in the Response to HIV and STIs civil society organization Directorate of Administration and Finance, Ministry of Health Pharmaceutical Supply Department Department of Pharmacy, Medication and Laboratories Demographic and Health Survey expedited partner therapy family planning gender-based violence The Global Fund to Fight AIDS, Tuberculosis and Malaria Government of Burkina Faso Hepatitis A vaccine Hepatitis B vaccine human immunodeficiency virus HIV Counseling and Testing International Covenant on Economic, Social and Cultural Rights Information, Education, Communication Ministry of Health

MARPs M&E MSM NASA NHDP NGO OI OVC PAMAC PEPSE PLHIV PMTCT PNDS PPN PPT PSM PSN PWID DM R2P RH SCADD SP/CNLS STI SW TB TG UN UNAIDS UNDAF UNDP UNGASS UNODC WBL WHO

most-at-risk populations monitoring and evaluation men who have sex with men (or males who have sex with males) National AIDS Spending Assessment national health development plan non-governmental organization opportunistic infection orphans and vulnerable children Assistance Program for the Associative and Community Sphere post-exposure prophylaxis person/people living with HIV prevention of mother-to-child transmission of HIV National Health Development Plan National Pharmaceutical Policy periodic presumptive treatment (used to manage STIs) procurement-and-supply management National Health Policy person/people who inject drugsDecision Model Research to Prevention reproductive health Accelerated growth and sustainable development strategy Permanent Secretariat of the National Council for the Fight against AIDS and STIs sexually transmitted infection sex worker tuberculosis transgender United Nations Joint United Nations Program on HIV/AIDS United Nations Development Assistance Framework United Nations Development Program United Nations General Assembly Special Session on HIV/AIDS United Nations Office on Drugs and Crime water-based lubricant (used with condoms) World Health Organization
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EXECUTIVE SUMMARY
Background
Like many countries in West Africa, Burkina Faso has a mixed HIV epidemic with a sustained level of HIV transmission in the general population, coupled with an elevated level of transmission among key populations, including sex workers (SW), men who have sex with men (MSM) and detainees. Among countries in the region, Burkina Faso can be seen as a relative success story in terms of national HIV response. HIV levels in the general population have been reduced from 6.44 percent in 1999 (UNAIDS 2000) to 1 percent in 2010 (INSD 2011) and estimated levels among SW have come down from 20.8 percent in 2003 (CNLS-IST/UNAIDS 2010) to 16.5 percent in 2010 (BASP96 2011). However, data regarding key populations is scarce and existing qualitative research points to relatively high levels of stigma and discrimination for SW and MSM (Drabo et al. 2010. Moreau and Compoar 2010. Niang et al. 2004). An adequate response to the epidemic in countries like Burkina Faso should focus prevention efforts on key populations among whom the majority of new HIV infections are likely to occur (Wilson and Halperin 2008; Wilson and Challa 2009. Sarkar, Menser et al. 2009. UNAIDS 2007). Availability and accessibility of prevention, care and treatment services for these populations are affected by policies, including laws, codes, directives and operational procedures. Policy in Burkina Faso has seen a number of positive changes in recent years and lessons can be extracted for other countries in the region while documenting remaining gaps in policy and barriers to increasing access to services for key populations incountry.

Objectives and Methodology

A previous USAID Action for West Africa Region (AWARE II) regional assessment uncovered policy challenges in West African countries that may hinder effective HIV prevention, care and treatment of key populations (Dutta and Maiga 2011). The current assessment was designed as an in-depth policy analysis of the legal, regulatory, and policy environment related to sex workers (SW), men who have sex with men (MSM), and prison populations in Burkina Faso to uncover gaps in policy and practical challenges to policy implementation. Beginning in February 2012, the AWARE II principal investigator and a team of local consultants conducted a document review and assessment. The team collected an inventory of source policy and program documents and previous policy and program research related to HIV and/or key populations. Upon completion of the inventory, the AWARE II team conducted key informant interviews to examine the policy environment and assess dissemination and implementation of current policies, particularly gaps in dissemination and implementation that pose barriers to service access for key populations.

Assessment Findings
The AWARE II policy analysis and key informant interviews confirmed that the government of Burkina Faso has made HIV prevention, care, and treatment a priority. Vital steps have been taken to develop policies that recognize key populations and aim to improve access to services for them. Moreover, significant opportunities exist, including a Global Fund grant under round 10 with a strong focus on key populations and open support from the President of Burkina Faso and the Permanent Secretary for CNLS. Burkina Faso is also in the unique position of having a handful of strong community-based organizations already working with key populations that can provide lessons learned and successful activities for scaleup.

Although many current policies follow international best practices, critical gaps remain. Where supportive policies exist, policies are often unknown or not effectively and consistently implemented. Gaps and barriers in policy and implementation in Burkina Faso include the following: A lack of recognition of and strategies for addressing HIV among key populations beyond the CSLS 20112015 (National Strategic Framework in the Response to HIV and STIs) and a few additional policy documents Insufficient dissemination of many policies and policy documents A lack of detailed mechanisms, such as operational guidelines or standards, to support policy implementation A lack of inclusion of key populations in key committees and consultative bodies A lack of awareness and acceptance of legal protections for vulnerable groups and professional codes of conduct among key stakeholder groups, including law enforcement, healthcare providers and key populations

Table 1 presents a synopsis of the current policy environment in Burkina Faso as it relates to key populations. Please note that check marks do not necessarily indicate 100 percent achievement in the relevant category but rather an indication of progress. Areas of relatively weak or absent progress have been noted.
Policy Category Number of relevant policies1 examined Evidence of engagement of stakeholders in policy development2 Evidence of ongoing data collection related to policies No data Government endorsement of policy Implementation mechanism outlined Policy implementation3 Evaluation of policy implementation

Framework: Multisectoral response and linkages Community Partnership

65

None

Limited

Limited

None

15

Limited inclusion of key populations None

Weak data

Limited

Limited

Authorization4

22

Weak data

Limited

Strong, but with gaps Strong, but with gaps Strong, but with gaps

None

Informed Consent Privacy and Confidentiality

49

None

No data

Strong, but with gaps Strong, but with gaps

None

38

None

No data

None

Policy Category

Number of relevant policies1 examined

Evidence of engagement of stakeholders in policy development2

Evidence of ongoing data collection related to policies No data

Government endorsement of policy

Implementation mechanism outlined

Policy implementation3

Evaluation of policy implementation

Registries5

13

None

Inconsistent and barriers exist None

None

HIV and MARPsrelated Stigma and Discrimination Criminalization6

21

Unknown

Weak data

New policies being developed

None

None

43

None

Weak data

Unclear

N/A

Inconsistent and barriers exist Inconsistent and barriers exist

None

Gender-Based Violence

22

None

Weak data

Strong, but with gaps

Limited

Limited

Monitoring and Enforcement of Human Legal Rights Procurement and Supply Management Overarching Services Design

32

None

Weak data

Strong, but with gaps

Limited

Significant barriers

Limited

29

None

Weak data

New policies being developed Strong, but with gaps

New policies being developed

Inconsistent and barriers exist

Limited

21

Limited inclusion of key populations Limited inclusion of key population Limited inclusion of key populations Limited inclusion of key populations None

Weak data

Limited

Inconsistent and barriers exist

None

HIV Counseling and Testing

18

Weak data

Programs operating, but barriers exist Programs operating, but barriers exist Inconsistent and barriers exist

Limited

Antiretroviral Treatment

Collection ongoing

Limited

Sexually Transmitted Infections Condoms and Lubrication Information, Education and Communication

13

Weak data

None

Weak data

Strong, but with gaps

Limited

Inconsistent and barriers exist Programs operating, but barriers exist

None

Limited inclusion of key populations

Weak data

Limited

None

Policy Category

Number of relevant policies1 examined

Evidence of engagement of stakeholders in policy development2

Evidence of ongoing data collection related to policies Weak data

Government endorsement of policy

Implementation mechanism outlined

Policy implementation3

Evaluation of policy implementation

HIV Prevention Outreach

Limited inclusion of key populations N/A

Limited

Programs exist, but barriers exist

None

Alcohol Harm Reduction7 Family Planning/ Reproductive Health

1

N/A

N/A

N/A

N/A

N/A

N/A

None

Weak data

Limited

Programs operating, but barriers exist

None

Burkina Faso tends to have wide, overarching laws with separate articles, additional decrees, and policy documents of a similar nature. Moreover, similar or even conflicting policies are found in different laws or policy documents. For the purposes of this table, each individual legal article, legal decree, policy, etc. was counted as a separate policy. This column describes the number of separate policies reviewed under each separate subject or category (column one) and under which issues relevant to key populations could have been, should have been or were addressed. SW, MSM, detainees, and organizations serving these populations are considered stakeholders for purposes of this analysis. At this time, only organizations serving key populations are engaged in policy decisions.
2

For purposes of this table, policy implementation was defined as implementation of policies that are favorable to key populations. This was measured by analyzing whether or not policies favorable to key populations, where they exist, are currently being implemented and whether or not barriers exist. Data for this analysis came from key informant interviews. For example, in the case of consent there are 49 policies that address consent but for purposes of implementation, we were only interested in implementation of policies that are favorable to key populations and their access to services.
3

Authorization refers to the agency authorized to implement services for key populations, e.g. public health officials, law enforcement or judicial agencies. Authorization can have a major impact on policy implementation and access to services.
4

Registries are used in public health for epidemiological purposes and at the health clinic or provider level to record patient information. Government sex offender registries exist in many countries and are used to keep records of individuals involved in and/or accused of sexual activities prohibited under current laws. Policies can prohibit use of certain types of registries or inclusion of certain information, explicitly lay out regulations for data protection and confidentiality, or remain vague with few or no guidelines to protect patients.
5

Criminal law establishes definitions and parameters of behavior that reflect a criminal justice perspective and identify options for enforcement and remedy. Criminalization here addresses criminal law related to HIV transmission, sexual behavior and sex work.
6 7

There are currently no programs in place in Burkina Faso for alcohol harm reduction. Policy is silent on this issue.

This report presents key findings on a wide range of policy areas that impact key populations access to HIV services. Specific gaps and barriers identified through this assessment include the following:
Framework, including multisectoral response and linkages: Burkina Faso is in the first stages of organizing a multisectoral national response to HIV. At this time, ministry and program policies are not always aligned with the Strategic Framework in the Response to AIDS (CSLS) 20112015, and policies in many sectors lack implementation strategies. Other than the CSLS 20112015, policies, including national development strategies and ministry action plans, are generally silent on SW and MSM. For

detainees, policies regarding access to HIV and STI services are misaligned, and interpretation of penal code has led to denial of FP/RH services in prison settings.
Community partnership: While policy supports the establishment of community organizations serving SW and MSM, it fails to mention non-governmental organizations comprised of SW, TG, or MSM. MSM-specific non-profit organizations that have applied for official status have never been recognized. Although organizations serving key populations are included in the CCM and have been invited to other policy discussions, policy does not define or require involvement of SW, TG, and MSM in HIV, STI or FP/RH decision-making, policy design, and evaluation of policy implementation. Authorization: Public health officials have oversight and coordination of HIV prevention programs and other services for SW and MSM. However, law enforcement training is needed to clarify policy, including laws, that affect SW and MSM and to ensure their cooperation. In addition to lack of funding, prison authority oversight of prison health services presents an obstacle to access to HIV services for detainees. Consent: Misaligned policies regarding parental consent of minors for HCT and access to medical services represent a potential barrier for young SW, MSM and street youth. For adults, consent laws allow health care practitioners to test for HIV without counseling or consent if it is part of an overall health screening in ill patients. This policy is aggravated by the lack of specific guidelines to determine when HIV testing can or should be included in a battery of tests. Implementation of consent policy also poses a barrier, particularly in the case of pre-natal exams when testing is sometimes conducted for PMTCT without patient consent. Privacy and confidentiality: While strong privacy and confidentiality policies exist, gaps remain in the implementation of these policies. Breaches of confidentiality exist, but to date, no cases have been brought before the agency commissioned with reviewing and sanctioning them. Finally, disclosure of medical data of a minor to parents/guardians, sanctioned under Burkinabe law, does not allow for prioritization of the childs best interest. Stigma and discrimination: Stigma and discrimination of key populations in Burkina Faso pose a major barrier to service access. Although strong policies exist to prohibit discrimination based on HIV status, protect patient confidentiality, and guarantee equal rights for people living with and affected by HIV, no specific mention is made of sexual orientation or sex work. Religious and customary beliefs and laws create a highly stigmatic environment for SW and MSM. Policies are urgently needed to actively measure and address stigma and discrimination among key populations (SW, MSM, TG, and prisoners) and to provide legal remedies for customary laws, teachings, or practices that are used to affect the status and treatment of SW, TG, or MSM. Criminalization: While sex work itself is not illegal, soliciting on public streets and pimping are illegal, and loitering laws specifically mention solicitation. SW and MSM are commonly victims of a misinterpretation of these texts. NDjamena-type HIV laws exist with specific codes on HIV transmission rather than application of general criminal codes. Moreover, these laws criminalize non-disclosure of HIV status and exposure without transmission. Gender-based violence (GBV): Sexual violence against sex workers, male and female, is common. Sexual violence against SW reduces their ability to negotiate condom use and access adequate health care and increases risk of HIV transmission. Although SW in Burkina Faso have rights to pursue rape or sexual abuse in court, all victims of GBV must pay related court costs, including attorneys fees and official court stamps, and many SW do not know their rights. As such, most cases go unreported and victims are unable to access related services, including post-exposure prophylaxis (PEPSE).

Monitoring and enforcement of human legal rights: Burkina Faso has ratified major international conventions related to human rights, and the constitution guarantees rights for all citizens. However, these rights are not specific to SW, MSM, and detainees and are often limited in their application. The implementation of policies that ensure protection of human rights and the development of policies that put an end to police abuse and enlist police support to protect key populations would help ensure HIV prevention, care, and treatment efforts are able to reach these key populations. Procurement and supply management (PSM): Stockouts of HIV testing and laboratory materials, lubricant, and medicationsincluding ARVs and STI kits, present major barriers for key populations.

The currently unsigned new national PSM policy generally follows best practices, although there are no CSOs included in the oversight body and policy does not identify mechanisms for SW, TG, or MSM to be involved in product selection or other decisions.
Overarching services design: HIV and STI services tend to be clustered in urban centers, with most services for SW and MSM based in Ouagadougou and Bobo-Dioulasso. Border towns where transportation routes exist and demand for SW is relatively high generally face an absence of services. Barriers to service access could also be addressed through proper training of law enforcement and health care providers. HIV policy provides for standardized basic training in multiple work sectors, but implementation of this law appears to be weak. HIV counseling and testing (HCT): To increase SW and MSM access to HCT, barriers to HCT including addressing frequent stockouts of testing materials and taking measures to decrease stigma and discrimination, should be addressed. Additionally, although it identifies SW and MSM as vulnerable groups to which providers should offer HCT, current policy does not identify mechanisms for SW, TG, or MSM to be involved in the development of HIV testing and counseling protocols. Antiretroviral therapy (ART): Major obstacles to achieving the policy goal of universal access to ART currently exist. Related or required services to access ART, such as CD4 count testing, provider fees and medications for OIs, are generally not provided free of charge and can be costly. Decentralization of services for CD4 count testing and ART delivery is limited at this time. ART stockouts and lack of second and third line ARVs pose additional barriers. Sexually transmitted infections (STIs): Policies for STIs generally follow best practices, but implementation of policies is limited by frequent stockouts of STI kits and a shortage of specialized clinics for key populations, particularly outside of major urban centers. Gaps in policies are present, including a failure to specifically identify free services for SW, TG, and MSM. Condoms and lubrication (C/L): Policy in Burkina Faso fails to guarantee free C/L services for SW, TG, and MSM and fails to direct provision of water- and/or silicone-based lubricants in condom programs. Reported stockouts of lubricant pose a major barrier to effective HIV prevention among key populations. Information, education and communication (IEC): While current policy guarantees public funding of IEC programs, it does not guarantee access to IEC information specific to SW, TG, or MSM. Although IEC adapted to SW can be found in Burkina Faso, MSM-specific IEC is unavailable. Culturally appropriate IEC for MSM could improve HIV prevention efforts and increase access to services for this population. Outreach: Recent policies developed to address outreach in Burkina Faso follow international best practices. Stigma and discrimination are reported to be the greatest barriers to outreach among key

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populations in Burkina Faso. However, criminalization of soliciting, which is used to harass SW and MSM and causes some SW to go underground, stockouts of lubricant, and lack of MSM-specific IEC materials are also barriers to outreach.
Alcohol harm reduction: Access to alcohol harm reduction approaches for key populations is essential to HIV prevention efforts. However, current policy in Burkina Faso does not address alcohol consumption, except among minors, and alcohol harm reduction programs do not exist. Family planning/reproductive health (FP/RH): Service integration in HIV/STI policy is not entirely harmonized in FP/RH policy. Full integration of HIV and STI services with reproductive health programs can ensure more SW and TG, who may avoid HIV and STI clinics due to stigma and discrimination, are reached. Misaligned policies exist between RH law, which guarantees the reproductive rights of all citizens under all conditions, and interpretation of penal code that denies detainees the right to reproductive health care or family planning.

Establishment of the Ministerial Committee for the Response to HIV, AIDS and STIs (CMLS) in 2007 and the recent development of HIV policy within each sector are major first steps towards a nationwide multisectoral response to HIV. Burkina Faso has also incorporated a number of policies based on international best practices, including some that facilitate access to services for key populations. The recent inclusion of MSM in the National Strategic Framework in the Response to HIV and STIs (SP/CNLS-IST 2010) for the first time and new efforts to develop policy to address stigma and discrimination point to the commitment of the Burkinabe government to improve access to services for key populations. This level of government support facilitates new possibilities to close policy gaps and develop effective mechanisms to support the implementation and enforcement of HIV-related policy.

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INTRODUCTION AND METHODOLOGY

Key Populations HIV Policy Assessment
Policies, including laws, codes, directives, and operational procedures, affect the availability and accessibility of HIV prevention, care, and treatment services for men who have sex with men (MSM), sex workers (SWs), and detainees. While effective policies can create a framework that supports HIV objectives and addresses the needs of key populations, they can also adversely affect access to services for MSM, SW, and detainees. Policies determine legal rights and recourse, affect funding, and authorize or block public health services. Government laws and policies in several West African countries criminalize same-sex sexual relations and sex work, making it more difficult for MSM and SW to access HIV prevention and treatment services. Even in countries that have not formally criminalized same-sex sexual relations and sex work, public health authorities and policymakers have largely ignored the needs of MSM, SW, and detainees. While policy silence may be necessary early in a countrys policy evolution in order to avoid codification of a punitive or criminal approach, it also poses a barrier to sustainability and scale-up of high-quality prevention, care, and treatment services. USAIDs Action for West Africa Region (AWARE II) Project conducted an assessment in Burkina Faso focusing on the current legal, regulatory, and policy environment and practical challenges associated with the implementation of policies and regulations related to MSM, SW, and prison populations. Several projects funded by donors and nongovernmental organizations (NGO) have addressed these key populations. The AWARE II assessment builds on earlier AWARE II regional policy assessments that uncovered policy challenges to effective HIV prevention, care, and treatment in the region. Policy in Burkina Faso has seen a number of positive changes in recent years and lessons can be extracted for other countries in the region while documenting remaining gaps in policy and barriers to increasing access to services for key populations in-country. The assessment is timely as Burkina Faso has just completed its 20112015 National Strategic Framework in the Response to HIV and STIs (CSLS) (SP/CNLS-IST 2010), which includes MSM for the first time. The AWARE II assessment also complements other studies currently underway in Burkina Faso. The United Nations Development Program (UNDP), in collaboration with the World Health Organization (WHO) and local NGOs working with key populations, has just completed a first draft of services available for key populations in Ouagadougou. R2P (Research to Prevention), funded by USAID and led by the Johns Hopkins Center for Global Health, will conduct a study in Burkina Faso to estimate the size of the MSM and SW populations and to implement integrated HIV serological and behavioral surveillance. This country-specific assessment, the first of its type conducted in Burkina Faso, is designed to help public health officials and organizations working in Burkina Faso better understand the policy barriers to effective public health programming for key populations. The lack of synthesized information on legal and regulatory issues and on gaps between policy and implementation for key populations in Burkina Faso poses challenges as advocates and policymakers work to introduce essential reforms to improve public health programming.

Methodology and Steps of the AWARE II Key Populations Policy Analysis

The AWARE II assessment team traveled to Ouagadougou in February 2012 to collect documents and conduct key informant interviews to complete an in-depth inventory and assessment of policy, law, and regulation development and implementation affecting access to HIV prevention, care, and treatment services among MSM, SW, and detainees in Burkina Faso. Before beginning the assessment, a team of local

12

consultants underwent training in data collection methods and assessment procedures. Throughout the assessment, the assessment team coordinated and collaborated closely with PAMAC (Assistance Program for the Associations and Communities, a joint program of SP/CNLS and UNDP). The team also coordinated with SP/CNLS and collaborated with the Burkina Faso MARPs (most at-risk populations) Intervention Monitoring Committee and key stakeholders through a workshop to Assessment Team Technical Skills present the assessment protocol and solicit 1 HIV field research specialist feedback and through a follow-up presentation of preliminary findings. 1 regional HIV public health advisor The assessment team consisted of the AWARE 1 lawyer, experience with key populations II/Futures Group Principal Investigator, one regional consultant, three local consultants, and 1 key populations technical advisor two local research assistants. The team conducted a desk review and analysis of 102 documents and 1 sociologist, key populations research available data related to key policies and programs affecting access to HIV prevention, care, and 1 research assistant, MSM project treatment, with particular focus on MSM, SW, and coordinator detainees. The documents subjected to review 1 research assistant, SW project included constitutional provisions, laws, coordinator regulations, national guidelines, other key policy documents, and earlier studies (Annex 2). The team used the Policy Assessment and Inventory data collection tool developed by the Health Policy Project (Annex 3) and based on international human rights frameworks and best practices to complete an inventory of relevant documents and to conduct an assessment of laws, regulations, and other policies affecting MSM, SW, and detainees. The inventory includes instruments and procedures for compiling and classifying a reference library of country documents. It also has an analytic framework that permits a comparison of current policies against international best practices and an assessment of the extent to which such policies enable or restrict implementation of HIV prevention, care, and treatment interventions for key populations (Beardsley et al. forthcoming). Following completion of the inventory, the assessment team conducted 17 key informant interviews with government officials, judges, service providers, and civil society organizations (CSO) representing MSM, SW, and detainees as well as with representatives from the media. Most interviewees were national actors, with a few CSO interviews at the regional level. The interview guide developed for the study complemented the inventory tool, followed international best practices, and focused on understanding the legal, policy, and program environment for MSM, SW, and detainees. It was designed to collect the opinions and experiences of key informants in order to assess the dissemination and implementation of Burkina Fasos current policies and programs, with a focus on gaps between policy language and implementation. It also addressed related barriers to service access for key populations, including stigma and discrimination and human rights violations. As part of the overall analysis, the assessment team reviewed the interview transcripts and analyzed statements linking the interviews to the analysis of the policy, legal, and regulatory documents and policy/program implementation. The assessment team completed written documentation of the inventory by using the data collection tool and prepared a separate written synthesis of the policy assessment and another synthesis of the key informant interviews for each subject area (policy, program, and legal). The assessment team conducted further analysis of the inventory, data, and reports collected in-country to complete the

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gap/opportunity analysis of existing policies and determine barriers to service access among the key populations.

Challenges and Limitations

The main challenge facing the assessment team was the inaccessibility of certain key policy documents. In the absence of a national repository of all policy documents related to HIV, the team was unable to determine the existence and location of policy documents in some ministries and experienced considerable difficulty in gaining access to documents, particularly law enforcement and prison policy. Given Burkina Fasos relatively recent move to a multisectoral approach to HIVcoupled with the bureaucratic nature of the countrys governmentseveral policy documents are still being developed or have yet to be signed. Other key policy documents have been signed but not distributed, making their existence unknown to other than a select few. For example, the only signed version of a pharmacy policy dates to 1996. Although the assessment team obtained a copy of the updated pharmacy policy currently under revision, it had not been signed and made official. While interviews with clients of programs would have shed further light on gaps in policy implementation and barriers to HIV service access from a consumer perspective, the assessments limited time frame ruled out such interviews due to the time involved in securing approvals for the participation of human subjects. Nonetheless, the assessment team compensated by undertaking key informant interviews with CSO representatives working with the populations of interest and by reviewing study reports featuring data from interviews with MSM, SW, and detainees. Finally, not all policies and laws are appropriate to and applicable in all countries. International standards must reflect country context. The standards identified in the inventory are based on the language and context of international documents and best practices and are not intended to be either restrictive or comprehensive (Beardsley et al. forthcoming). The inventory and analysis of country policy documents enable the identification of policies that require additional attention. After the identification of such policies, a broad range of local stakeholders must identify country-specific policies that best meet the needs of local key populations. The assessment team and the Burkina Faso MARPs Intervention Monitoring Committee recommend in-country validation of the findings in this assessment report.

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ASSESSMENT OF FORMAL POLICIES AND POLICY IMPLEMENTATION FOR KEY POPULATIONS IN BURKINA FASO
Key Populations and HIV in Burkina Faso
In contrast to many countries in Southern and Eastern Africa where HIV infection occurs at relatively high rates among the general population, West African countries tend to exhibit evidence of either concentrated epidemics, in which the vast majority of HIV infection occurs among specific populations, or mixed epidemics, in which a significant portion of HIV infections occurs among specific populations with some sustained level of HIV transmission in the general population (Dutta and Maiga 2011). Biological, behavioral, and structural factors place key populations at higher risk for HIV transmission than other individuals. Research in West African countries with mixed epidemics suggests that transmission between key populations, which include MSM, SW, and detainees, and sexual partners from populations at lower risk of infection represents a significant proportion of new infections in the general population. For example, 81 percent of new infections among the general male population in two towns in Senegal were attributable to sexual contact with a sex worker (Wilson and Fraser 2011). Moreover, evidence suggests that stigma, discrimination, and violence against key populations may cause members of these populations to hide their occupation, gender identity, or behavior. Stigma and discrimination may also result in fear and distrust around health services, hindering HIV prevention, care, and treatment (Larmarange 2010; Fay, Baral et al. 2010; OSI 2006; WHO 2011a; WHO 2011b; UNAIDS 2009b). HIV prevention spending per capita is lower in West Africa than in other subregions of sub-Saharan Africa, and the efforts of individual countries have generally not targeted the key populations from which most new HIV infections are likely to emerge. Yet, in concentrated and mixed epidemics, focusing prevention efforts on these key populations is accepted as both necessary and cost-effective (Wilson and Halperin 2008; Wilson and Challa 2009; Sarkar, Menser et al. 2009). Given the regions scarcity of resources, strategically focusing supportive HIV policy and resources on key populations will enable the regions countries to efficiently and economically attenuate HIV rates and improve health outcomes. Like many countries in West Africa, Burkina Faso is experiencing a mixed epidemic, with HIV prevalence in the general population at 1 percent (INSD 2011). The total population of Burkina Faso is estimated at 17,275,115 (CIA 2012), with the MSM population estimated at 3,174 (GFATM 2010), the female SW population estimated at 31,000, and an average 12,000 detainees at any one time (APA 2008). The MSM and SW populations may be significantly higher as population estimates for MSM and SW derive from size targets for the Global Fund to Fight AIDS, Tuberculosis, and Malaria grants. To date, there have been no definitive studies of MSM or HIV prevalence among MSM in Burkina Faso. Although data are unavailable for MSM, including male sex workers, comparison data from countries with similar epidemics in the region point to potentially high levels of HIV prevalence among MSM (Wade, Larmarange et al. 2010; IRIN 2011). Data collected for 2008 from community organizations in Ouagadougou revealed a rate of 19 percent among tested MSM (SP/CSLS-IST 2010). In contrast to the general population, current HIV prevalence among female sex workers is estimated at 16.5 percent (BASP96 2011). Among West African countries, Burkina Faso is a relative success story in terms of its HIV response. HIV levels in the general population dropped from 6.44 percent in 1999 (UNAIDS 2000) to 1 percent in 2010 (INSD 2011), and estimated levels among SW declined from 20.8 percent in 2003 (CNLS-IST/ UNAIDS 2010) to 16.5 percent in 2010 (BASP96 2011). The Government of Burkina Faso (GoBF) has

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made HIV prevention, care, and treatment a priority and has moved to follow international best practices. Unlike the case of many countries in the region, the 2010 UNGASS report for Burkina Faso included indicators for MSM and SW, and the president of Burkina Faso recently spoke out regarding the importance of including MSM in HIV prevention efforts. On the other hand, anecdotal evidence indicates that MSM and SW in Burkina Faso face high levels of stigma, discrimination, and violence (Drabo et al. 2010; Niang et al. 2004), potentially undercutting HIV intervention efforts among these populations. For example, 86.95 percent of female sex workers interviewed in a recent study (N = 69) reported police harassment (Drabo et al. 2010), causing many SW to go underground and thereby potentially impeding outreach and access to HIV services. Moreover, Burkina Faso faces a deficit of current population, epidemiologic, and behavioral data regarding SW in Burkina Faso, with virtually no data regarding MSM.

Framework
International guidelines highlight the need for a coordinated, participatory, transparent and accountable approach to HIV prevention, care, and treatment services (Beardsley et al. forthcoming) in which programs are integrated across all branches of government and align with international standards (UNAIDS 2006). Support of international initiatives and dissemination of knowledge and information are also indicated. In keeping with international guidelines and a UNDP-supported initiative, the GoBF has initiated a multisectoral HIV response. Accordingly, the National Committee for the Response to HIV and STIs (CNLS-IST) has issued an edict to ensure the involvement of all stakeholders from all sectors in HIV decision making. In 2007, the government of Burkina Faso created the Ministerial Committee for the Response to HIV, AIDS, and STIs (CMLS) to develop and implement cross-ministerial programs against STIs, HIV, and AIDS in collaboration with focal points in cooperating ministries and decentralized structures. However, ministry and program policies do not always align with CSLS policies, and, as in many countries, policies in some sectors are merely declarations of theoretical policy goals or intended outcomes and lack strategies for access to evidence-based interventions (Annex 1). Several ministries that have recently promulgated an HIV policy have not disseminated their policy and therefore have not begun policy implementation. In general, policies supporting HIV response are more fully developed than those addressing sexually transmitted infections (STIs) or reproductive health (RH), which in some sectors do not exist at all. While Burkina Faso has taken the regional lead in including SW and MSM in HIV policy, misaligned policies are in place that may affect access to services for these populations. The National Response Guide for Sex Workers (2006) set out a service package that lacks clarity with respect to service activities and implementation, and the CSLS-IST 20112015 (SP/CNLS-IST 2010) is distinguished by the absence of specific implementation mechanisms for services to SW. The CSLS-IST 20112015 does, however, mention key populations and follows several international best practices, such as identifying services; providing guidance on monitoring and evaluation with data disaggregated for SW, MSM, prisoners, people living with HIV (PLHIV), and drug users; and describing mechanisms to identify, monitor, and evaluate the results of programs for SW. Detainees in Burkina Faso represent a population seriously affected by conflicting policy in the response to HIV. 43 percent of inmates interviewed in 2007 reported that sexual relations exist in prisons in Burkina Faso with 2.6 percent of male detainees stating that they have had same-sex sexual relations (APA 2008). Key informant interviews confirmed the occurrence of sex work and same-sex sexual relations within prison populations. The CSLS 20112015 identifies detainees as a priority population because of its higher HIV prevalence than that of the general population (SP/CNLS-IST 2010). The framework also promotes the use of male and female condoms and targets 100 percent access to HIV prevention, care, and treatment information for detainees. Moreover, the law on reproductive health states

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that access to RH services is a fundamental right for all citizens under all conditions (MoH. 2005). At the same time, prison authorities have interpreted penal code denying civil rights of detainees as a prohibition of sexual relations in prison (GoBF. 2005) and applied the code to restrict in-prison provision of family planning (FP) services, including condom and lubricant distribution. Although key informants revealed that condoms may be purchased on the in-prison black market, they cost up to 10 times as much as outside prison. These policies clearly conflict with each other and create a serious barrier to HIV and STI prevention and to provision of RH services in prisons. Despite no written policy specifying methods for generating budgets for MSM, SW, and clients of SW proportional to the objectives for HIV and STI service coverage, CNLS/IST recently defined these packages using estimate-based projections calculated with the Resource Needs Model (RNM) and Spectrum model software (SP/CNLS 2010). Even though mechanisms are not in place to ensure the allocation of resources, the implementation of best practices in forecasting budgets preceded official policy development. To address the HIV epidemic, it is essential to codify use of the models for estimating populations and budgets in official policy and to create mechanisms that ensure the allocation of resources to key populations in need of adequate funding The specification of strategies in the CSLS 20112015 to address key populations is clearly a major advance. However, other major policy documents, such as the National Health Development Plan (NHDP) (MoH 2007), the United Nations Development Assistance Framework (UNDAF) (UN 2010), and the Accelerated Growth and Sustainable Development Strategy (SCADD) (2010), and individual sector strategies for gender, education, labor, commerce, transportation, immigration, prisons, and military/uniformed forces make no mention of key populations. Although some policies refer to vulnerable or at-risk groups in general or mention global access for the entire population without discrimination, they do not specify MSM, SW, clients of SW, or detainees. The inclusion of MSM in policy is new to the latest CSLS, and it will be important to align various policy documents across sectors and to ensure inclusion of key populations in all relevant policy documents. In the most recent United Nations General Assembly Special Session on HIV/AIDS (UNGASS) report (2010), Burkina Faso provided indicators for MSM and SW. However, data on SW and MSM in Burkina Faso are limited, and there are very few policies on data use. The only available data for MSM derive from prevalence data obtained by CSOs during HIV counseling and testing (HCT) and from an ongoing UNDP/PAMAC study in Ouagadougou (Soulama. Draft 2011). SW data are not current, and data on clients of SW are extremely limited. Data on sexual violence in prison are unavailable.

Community Partnership
Human rights and intervention guidelines emphasize the importance of engaging priority populations in policy and program design, implementation, and evaluation (Beardsley et al. forthcoming). Moreover, there is strong evidence of a positive correlation between community engagement and health outcomes (Green et al. 2006.Manandhar and Osrin 2004. Barnett and Whiteside 2006). The World Health Organizations HIV program guidelines (2011) call on governments to include MSM and transgender people (TG) in the development of health plans as supported by medical ethics and human rights models. The UNAIDS Advisory Group (2011) has highlighted the crucial role of SW and their organizations in HIV prevention, care, and treatment efforts. The government of Burkina Faso signed the UNGASS Declaration of Commitment that includes guidelines for the participation of stakeholders in the HIV response. Nevertheless, the GoBF has not established any formal mechanisms for engaging key populations in government decision making or policy development. The development and adoption of the CSLS-IST 20112015 identified MSM, SW, and clients of SW as key populations, and while it does not expressly exclude these populations from

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participation in the decision-making process, it does not identify formal mechanisms for regular and active participation. . . . [I]n practice beneficiaries do not participate in program decisions. . . . We have never had an SW or MSM representative in a national decision making meeting. (Key Informant, NGO) Although beneficiaries have never been invited to participate in policy and program development, key informant interviews revealed that CNLS-IST has invited NGO representatives working with key populations to participate in meetings. Additionally, the Country Coordinating Mechanism (CCM) includes three NGOs serving key populations. The CSLS 20112015 identifies the role of CSOs, including NGOs, and includes policies that specifically support NGO work with SW and MSM in the community. A limited number of organizations provide services to these populations, including some that count MSM and/or SW as members, yet public authorities appear reluctant to recognize MSM or SW organizations. For example, MSM-specific nonprofit organizations that have applied for official status have yet to gain recognition. They have neither been denied nor granted official status, but their applications have been under review indefinitely. The failure to accord such organizations official recognition has potential implications for HIV prevention, care, and treatment. Some key informants believed that official recognition of the organizations would enable them to apply for funding that could be used for advocacy and outreach. Community-based NGOs have a strong presence in Burkina Faso and participate in HIV prevention, care, and treatment activities. In December 2011, 20.06 percent of patients on antiretroviral treatment (ART) received treatment through the eight community-based NGOs mandated to provide ART services (CMLS 2012). Just under 1 percent of PLHIV on ART received treatment through seven private health care facilities mandated to deliver ART.

Legal Environment
Authorization Policies can authorize oversight and coordination of programs, laws, and/or services by public health agencies, law enforcement, and/or judicial agencies, which can in turn profoundly affect implementation (Beardsley et al. forthcoming). In Burkina Faso, policy empowers public health authorities to provide a comprehensive range of prevention and treatment services for FP/RH, STIs, and HIV (MoH 2007.MoH 2001). Policy also explicitly grants public health agenciesrather than law enforcementthe authority for oversight and coordination of MSM and SW services. For example, rather than law enforcement, public health authorities carried out a public health campaign to improve conditions in brothels in Ouagadougou.
HIV Law 030 AN/2008, Article 22 Notwithstanding the prohibitions in Article 21 above, the application of HIV testing is authorized when diagnosis is needed to inform the health professional in the provision of medical care.

Policy that grants health care decision-making authority for detainees to law enforcement, prison, or detention officials rather than to health care providers can adversely affect detainees health. Public health policy in Burkina Faso does not explicitly mention responsibility for health services in prison and does not provide for independent health provider decisions in prisons. The assessment team was unable to obtain prison policy documents beyond laws and codes applicable to prison settings. Key informant interviews revealed that health care in prison does not receive the same level of funding or human

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resources as community health services and that healthcare providers in prisons do not have the same level of education and training as those in the community. Materials and treatment are generally unavailable, and health providers appear to lack decision-making authority. A prison nurse once told us that everyone is treated using paracetamol or sedatives . . . it is all they have as available medications. (Key Informant, NGO) Consent Informed consent and counseling are two of the three Cs of HIV testing, along with confidentiality of test results (WHO 2007). Obtaining a patients informed consent is a prerequisite for any medical intervention under the declaration on the promotion of patients rights in Europe, adopted by the European Meeting on Patient Rights, Amsterdam (WHO 1994). Obtaining informed consent is particularly important for pregnant women, including pregnant SW who may avoid prenatal care if they fear HIV testing without consent, as well as for MSM and SW who may self-medicate or avoid treatment altogether, at least in the early stages of illness. Although some aspects of consent policy in Burkina Faso follow international best practices, other policies and lack of proper implementation may pose barriers to HIV outreach efforts targeted not only to key populations but also to the general population. Official policy requires consent for HCT and identifies the key elements required for consent (MoH 2008). However, official policy does not identify the right to refuse or withdraw from testing or treatment at any time. The policy also allows a health care practitioner to test for HIV without counseling or consent if such testing is part of an overall health screening to determine the cause of illness. No specific guidelines determine when HIV testing can or should be included in a battery of tests for ill patients. In practice, consent is not always obtained from healthy adults, particularly in the case of prenatal examinations when testing for the prevention of mother-to-child transmission of HIV (PMTCT). Even though Burkina Faso does not mandate testing among SW, exemption from consent is allowed in studies that collect data on seroprevalence among SW, and courts may mandate testing in criminal cases such as alleged rape or willful transmission of HIV. RH law in Burkina Faso guarantees access to information and counseling as well as the right to reproductive health irrespective of a childs age and regardless of parental/caregiver consent (MoH 2005). HIV policy guarantees access to information and medical services (MoH 2008). The age of consent in Burkina Faso is 21 (GoBF 1989, article 554), and HIV law dictates that HCT may not be delivered to a minor without parental or guardian consent and that results should be disclosed to the parent or caregiver without any consideration of the childs wishes or best interests (MoH 2008). In stark contrast, the HCT Health Provider Reference Manual (SP/CNLS 2008b) states that the age of consent for HCT is 18. It further states that providers can conduct HCT on youth between 14 and 18 if the person is deemed sufficiently 'mature'. Key informants reported that parental/caregiver consent may be written and that providers are not required to check the validity of a signature. Even so, age of consent policy is potentially a major barrier to HIV outreach for vulnerable youth. Fear of abuse, stigma, and discrimination may discourage MSM and SW youth from seeking parental/guardian consent. Street youth in Burkina Faso who report high-risk behavior, including sex work, same-sex sexual relations, and unprotected sex (Yaro et al. 2007), are difficult to reach even without this additional barrier. Confidentiality As with consent, the policy guaranteeing patient confidentiality specifies exceptions that are potential barriers to HIV outreach among key populations. For example, the law directs health care providers to disclose HIV test results to the parent/guardian of anyone who is under 21 or incapacitated (MoH 2008). Anecdotal evidence from key informant interviews pointed to breaches in confidentiality when physicians revealed results to adult patients family members. Even though the government established an office to

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address breaches of confidentiality, no citizen or health care facility has yet to file a complaint. For MSM and SW who are already stigmatized, fear of disclosure of their HIV status may prevent participation in HCT and subsequently pose a barrier to care and treatment. Registries Registries are used in public health for epidemiological purposes and at the health clinic or provider level to record patient information, including sensitive health records (Beardsley et al. forthcoming). Whenever data are linked to personal identifiers, such as name or address, it is essential to adhere to regulations that protect data and confidentiality. Burkina Fasos policy on public health data and patient registries and data spells out strict rules covering data protection and confidentiality (MoH 2008). Breaches in confidentiality have been reported (see Confidentiality). In many countries, government sex offender registries compile records of individuals involved in and/or accused of illegal sexual activities. In countries where sex work and same-sex sexual relations are illegal, the registries can maintain records on MSM and SW; in extreme cases, law enforcement can use the information in the registries to remove children from their custodian and deny the offending party access to state services such as housing, education, and employment (Beardsley et al. forthcoming). The assessment team was unable to obtain policy information about Burkina Fasos registries, although newspaper articles and contact with law enforcement indicate that law enforcement maintains nonmedical registries of some type, possibly even unofficial registries. Detailed information was unavailable. The assessment team did not identify any policy related to registries and found no reports of registries used to deny access to state services. Stigma and Discrimination Policies that address stigma and discrimination are particularly important in a country such as Burkina Faso where religious beliefs, customs, and laws, including gender norms for men and women, create a highly stigmatized environment for MSM and SW. Even though Burkina Fasos policy documents recognize stigma and discrimination as a problem (SP/CNLS 2010), and the government has adopted policies intended to protect all citizens, including PLHIV, from all forms discrimination (GoBF 1991. MoH 2005. MoH 2008), policy documents make no specific mention of sexual orientation or sex work. The assessment team was unable to find any policies that actively measure or address stigma and discrimination among key populations (MSM, SW, TG, and prisoners) or any policies that provide legal remedies for customary laws, teachings, or practices that affect the status and treatment of MSM, SW, or TG. According to key informant interviews and research reports (Drabo et al. 2010; Niang et al. 2004; Moreau et al. 2010), society in Burkina shuns same-sex sexual activity. In addition, strong anecdotal evidence points to verbal and physical aggression against MSM, including beatings and public humiliation by family members. The key informant interviews confirmed the anecdotes and highlighted accounts of health care providers violation of their code of ethics (MoH 1997) by refusing to deliver care to MSM and/or insulting MSM, along with episodes of families forcing MSM to marry to cure them and reports of verbal and physical aggression against MSM. Each [health care] provider decides to ignore this group [MSM] on behalf of his/her personal and moral beliefs. (Key Informant, NGO) As in other countries in West Africa (World Bank/NACA 2008), stigma and discrimination in Burkina Faso lead to heterosexual marriage as a social cover among MSM. A 2008 study in Burkina Faso revealed that 17 percent of MSM are married (Soulama. 2008). While 60 percent in the same study self-identified as bisexual, some of these marriages may represent a response to stigma and discrimination.

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Stigma and discrimination of MSM and SW influence their migration and affect access to HIV services. Key informants reported that, to avoid exposure, many MSM migrate between major urban centers in the regionAbidjan, Bamako, Ouagadougou, Bobo-Dioulassoevery three to six months. They also stated that MSM migratory behavior makes outreach and care more difficult, thus increasing risk/vulnerability. SW migration follows a different pattern. Based on key informant interviews with CSOs that work with SW and according to studies in Burkina Faso (Nagot et al. 2002. Kahn et al. 2008), many SW in brothels or in other forms of organized sex work are immigrants from neighboring countries. In addition, key informants noted that Burkinabe SW, particularly those working in their town of origin, experience higher stigma, are more likely to solicit, are more likely to hide their occupation from health care providers and others, and are more difficult to reach, thus greatly increasing their vulnerability. Burkina Fasos media continue to propagate stigma and discrimination. Until recently, public television broadcast the faces of SW and SW work locations during police raids. In another instance, a media interview on the rights of MSM was cut short because of content. On the other hand, key informants in the media reported that MSM are reluctant to take part in television broadcasts due to stigma and discrimination. . . . He [MSM]. . .subsequently pulled out, notifying me that he was afraid of the retaliation that could result from his participation in a televised emission in which his face was shown. (Key Informant, Media) Key informants reported that, in response to stigma and discrimination, MSM and SW often hide their occupation, sexual behavior, or sexual orientation from health care providers. In addition, they frequently forgo health care and/or self-medicate. It is important to note that self-medication is particularly dangerous in Burkina Faso, where medications on the black market have often expired and may be unsafe. Key informants revealed that loss of employment or remunerative activities as a result of stigma and discrimination have forced some MSM to take up sex work for survival, further increasing their HIV risk. International best practices suggest that policies related to national FP/RH, STI, and HIV programs should identify and measure the causes of stigma and discrimination among key populations. Approaches to reducing stigma and discrimination can include programs that sensitize health workers to the needs of MSM and SW and that recruit sympathetic health mediators to accompany MSM and SW to health care facilities, as pioneered by some CSOs in Burkina Faso. Just prior to Article 423, Burkinabe Penal Code publication of this report, the assessment team was informed that the government of The punishment is imprisonment for 15 days Burkina Faso is developing a new document to 2 months and a fine of 50,000 to 100,000 to address stigma and discrimination. francs or either of these two penalties for Inclusion of specific measures for key any person engaged regularly in prostitution populations and detailed implementation by solicitation on public roads. mechanisms will be critical to decreasing stigma and discrimination and improving access to services. Criminalization Unlike many West African countries, Burkina Faso does not criminalize homosexuality and sodomy, although policy remains largely silent regarding same-sex sexual relations. For the most part, politicians are unwilling to address the issue, and key informant interviews revealed a preference for policy silence in lieu of the probable backlash that could follow changes to current law on same-sex relations.

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In a fairly hostile environment, like in Burkina Faso, it is better that. . . there is no law; they remain anonymous, in a silence that can be interpreted as a tacit tolerance. (Key Informant, CSO) Although sex work is not illegal, soliciting on public streets and pimping are criminalized under Burkinabe law (GoBF 2004). According to key informants, MSM and SW are commonly victims of misinterpretation and misuse of these laws. For example, the police routinely harass and detain MSM citing solicitation as the reason. Reports of police violence and extortion among SW also exist. Although key informant interviews and research studies indicate that rape of sex workers is common (Drabo et al. 2010), these sources also revealed that sex workers do not press charges because they are embarrassed, unaware of their rights, and afraid of law enforcement. With regards to trafficking, policy is unclear as to whether individuals who have been trafficked or coerced into transactional sex are immune from prosecution for soliciting, thus placing potential barriers for victims who wish to report abuse. Criminalization of solicitation and subsequent police harassment of MSM and SW reduce the probability that victims of abuse will file police complaints, discourage MSM and SW from accessing HIV services, and put SW in unsafe and exploitative working conditions that make condom negotiation more difficult while legitimizing general stigma and discrimination. As in other West African countries with NDjamena-type model HIV laws, Burkina Faso provides for criminalization of willful transmission under its current HIV law (MoH 2008). This law demonstrates conflicting policy as willful transmission of HIV only exists under HIV law and not under Burkinabe penal code. To date, there have been no prosecutions under the law, which includes a number of articles, including abstaining from unprotected sexual relations with another person. Although the law has not been employed, it poses potential problems for MSM, who might not have access to water-based lubricants (WBL), and for SW, who may not have sufficient agency to negotiate safe sex even if they are aware of their HIV status. Per WHO guidance, criminalization of HIV transmission should be only a last resort in response to the failure of prevention efforts and then only in a manner that protects human rights (WHO 2006; Beardsley et al. forthcoming). The WHO guidance also raises the issue of the potential link between criminalization and greater stigma and discrimination for PLHIV. Even though Burkina Faso has not prosecuted PLHIV for willful transmission, the HIV Law 030 AN/2008, Article 26 prospect of prosecution may deter key populations from partaking of HIV testing or Anyone who knows of his/her condition public health services. Experience elsewhere regarding HIV infection and who does not has shown that prosecution of MSM, SW, or take necessary and sufficient precautions to PLHIV can be a major barrier to prevention protect his/her partner (s) is subject to penal efforts, the adoption of safe sex behaviors, and sanctions. Anyone who knows he/she is access to support and care services. Service infected with HIV and does not take the referral in lieu of prosecution can ensure that necessary precautions sufficient for the key populations obtain needed services. protection of his or her partner (s), shall be punished by a fine of one hundred thousand Medical Testing (100 000) CFA francs to one million Burkina Fasos public health code includes two (1,000,000) francs CFA. In the event of a sections that require SW to submit to subsequent HIV infection, he/she incurs the appropriate medical supervision (MoH 1994), penalty of attempted murder under the although policy fails to specify the conditions, provisions of the Criminal Code. such as how, where, or by whom. While the code could subject SW to testing or treatment

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without consent, this has not been the case. Instead, several projects, including SIDA 3, and several organizations, such as Yerelon in Bobo-Dioulasso, have called for medical visits and requiring SW to carry medical cards. Yerelon has successfully involved local police such that law enforcement officers, even in instances of solicitation, do not harass SW who carry an up-to-date medical card. SW must be tested and treated for STIs and, if infected, obtain a signature on the card attesting to treatment. While policy states that the cost of STI treatment, including treatment for SW, is subsidized through distribution of free STI treatment kits, stockouts are common, and SW must often pay for treatment. Key informant interviews with CSOs working with SW reported positive attitudes toward health cards and STI testing among SW due to the subsequent decrease in police harassment and improved health status among SW. However, steps should be taken to ensure that outdated cards do not lead to increased harassment and testing without consent. Moreover, it is essential to avoid stockouts of STI kits so that treatment may be offered at no charge. Gender-Based Violence Reporting and prosecution of rape is influenced by how rape is defined under the law and in policies addressing rape victims and their perpetrators. Although laws in many countries are expanding to cover any gender of victim and attacker, they typically consider victims as female and perpetrators as male. In countries where physical resistance is required, the law may not cover instances in which the victim is incapable of giving consent due to the influence of drugs, alcohol, or age. Some laws may limit the definition of insertion and penetration to specific body parts (e.g., penis and vagina) or recognize other forms of rape. Policy in Burkina Faso follows international best practices such that rape is defined as an act of sexual penetration of any nature that is committed on another person using violence, force, or surprise (GoBF. 2005). Sexual violence against SW is common and may be perpetrated by, for example, clients, pimps, members of the community, or members of law enforcement. In a study in Burkina Faso, 68 percent of interviewed SW reported that they were victims of recurrent theft and rape (Drabo et al. 2010). Sexual violence against SW may reduce sex workers ability to negotiate condom use and increase the risk of HIV transmission. In Burkina Faso, SW have the right to pursue rape or sexual abuse in court (GoBF 2004), but, according to key informants, most are afraid or embarrassed to report the incidents to the police or are not aware of their rights; as a result, cases go unreported. In addition, all plaintiffs in Burkina Faso must pay legal costs, including attorney fees and official court stamps, thus further discouraging legal action. Although policy states that post-exposure prophylaxis (PEPSE) is available to all rape victims (MoH 2008), key informants report that, in practice, most SW do not come forward with their case and therefore do not benefit from the available services. A major concern with any harm reduction program aimed at MSM, SW, and other detainees is to address sexual violence in detention and prison settings; such violence represents additional opportunities for human rights violations and disease transmission (Beardsley et al. forthcoming). The assessment team was unable to obtain prison policy documents and found no evidence of policy to address sexual violence in prisons. Monitoring and Enforcement of Human and Legal Rights Burkina Faso has ratified major international conventions related to human rights, including the Universal Declaration of Human Rights; International Covenant on Economic, Social and Cultural Rights (ICESCR); and Convention on the Elimination of All Forms of Discrimination against Women (CEDAW). Burkina Faso law states that these conventions or treaties supersede any contradictory laws or policies in place in the country. Two laws developed in relation to the declaration of the UN General Assembly on AIDS in 2001 address human rights and the prevention of stigma and discrimination against PLHIV as essential components of the HIV response (MoH 2008).

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In addition, Burkina Faso has promulgated several policies to protect womens and girls rights, including legal mechanisms for womens full inheritance of property, equal distribution of assets for women in divorce, compulsory education for all children, continued schooling for pregnant girls or re-admission to schools after pregnancy, and free access to primary education (GoBF 1989. MESSRS/MEBA1996). According to key informants, citizens in Burkina Faso do not always adhere to these policies such that religious or customary law often governs inheritance and divorce. At the same time, many women are not aware of their rights. As a practical matter, many children, particularly girls, are unable to attend school because families cannot afford uniforms, books, and transportation or need help in the home or fields. Even though Burkina Fasos constitution and HIV and RH law guarantee the rights of all citizens, neither the constitution nor the laws makes specific mention of MSM, SW, and prisoners and therefore are often limited in their application. Stigma, discrimination, and outright verbal and physical abuse of MSM, SW, and street children are common (Drabo 2010; Niang et al. 2004; Yaro et al. 2007). According to key informants, even when MSM and SW are aware of their rights, fear of stigma and discrimination prevent them from demanding their rights, including access to essential services and housing. While the Ministry for the Promotion of Human Rights and Ministry of Justice offer legal assistance to protect human rights, including stigma and discrimination, a plaintiff must pay legal costs to assert his or her rights, effectively discouraging legal action. Other than the relatively new CSLS HIV policy (see Framework section), Burkina Faso has enacted no laws or policies addressing sexual orientation. At this time, most key informants agree that any attempts to enact laws to protect sexual orientation in the near future could produce a backlash. In fact, the lack of laws is preferable to the prohibitive or criminal laws enacted by other West African countries. Instead, the implementation of policies that ensure protection of human rights and the development of policies that put an end to police abuse, enlist police support to protect key populations from abuse and violence, and provide legal aid to abused MSM, SW, and TG can help ensure that HIV prevention, care, and treatment efforts reach key populations.

Intervention Design, Access, and Implementation

Procurement and Supply Management of Medicines and Medical Commodities Although the policy was not signed at the time of data collection, Burkina Faso had initiated a policy to increase the affordability and accessibility of medications, encouraging the use of essential generic medications and other health products to manage HIV and STIs and improve the health of the population. The new policy aims to improve Burkina Fasos pharmaceutical supply system using processes that ensure quality assurance, pharmaceutical regulation, information management, promotion of rational drug use, and inventory management (MoH/DGPML 2011). Previous policy dates to 1996, and according to key informants, was not widely disseminated or implemented. Once in place, the new policy will generally follow best practices, although CSOs are not represented on the oversight body, and the policy does not identify mechanisms for involving MSM, SW, or TG in product selection or other decisions. It remains to be seen whether the policy will address the numerous barriers to accessing STI and HIV services as related to the procurement and supply management of medicines and medical commodities. A 2007 evaluation identified stockouts and expiration of stock as a major problem (MoH/DGPML 2007). Key informants and a CMLS report (2011) underscore the issue of stockouts of HIV testing and laboratory materials and medicationsincluding antiretrovirals (ARV), STI kits, and lubricantparticularly outside Ouagadougou and Bobo-Dioulasso. In addition to stockouts, few modern medicines are produced locally, and regulations restricting procurement and distribution of certain medications by CSOs offering HIV testing, care, and treatment create barriers to integrated services for key populations.

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Overarching Service Design Best practices in intervention design and the protection of human rights can mitigate obstacles to accessing services for key populations (Beardsley et al. forthcoming). Integrating STI and HIV services into FP/RH and other health services and developing referral mechanisms can increase access to services, including STI and HIV screening. Addressing domestic and sexual violence is also an important component of the HIV response, particularly for MSM, SW, and TG, who are often at high risk for such violence. Although service integration and referral mechanisms are mandated through HIV policy in Burkina Faso, FP/RH policy to incorporate these best practices is not well developed. Moreover, the assessment team was unable to identify any policy identifying domestic and sexual violence risk assessment protocols for MSM, SW, or TG. HIV and STI services in Burkina Faso tend to be clustered in urban centers, with most services for MSM and SW based in Ouagadougou and Bobo-Dioulasso. By contrast, key informants revealed that border towns, often crossed by transportation routes, experience relatively high demand for SW and face an absence of services. Although HIV services are available outside urban centers, particularly through mobile units, services for MSM are largely non-existent outside of major cities. In addition, key informants reported that, even in urban centers where services for MSM are available, some MSM, particularly married heads of households and men of higher socioeconomic status who do not care to be identified as MSM, choose not to access these services, thereby creating a major challenge for prevention, care, and treatment efforts. Burkina Fasos health system follows regular business hours that may not meet the needs of key populations. However, a rotation system makes services available at night, during weekends, and on holidays. More important, several CSOs offer services via mobile units and during non-standard operating hours. According to key informants, service barriers attributable to geographic distance and inconvenient opening hours, particularly with respect to ARV services, are more formidable outside major urban centers or geographic areas served by community-based organizations (CBO) mobile units. Finally, prison detainees generally do not have access to health care services. Key informants disclosed that budgets for prison health care are significantly lower than budgets for general community health care. To compound matters, health care providers serving prisons often lack training and higher education while medications, other than over-the-counter pain and fever medications, are generally not available. Although detainees living with HIV may obtain care outside prison through CBOs, the lack of general care has serious implications for HIV and STI testing, care, and treatment. A perceived lack of medical confidentiality, coupled with fear of stigma and discrimination, frequently prevents key populations from seeking out needed services. Research in Senegal (Larmarange 2010) and Botswana (Fay, Baral et al. 2010) indicates that MSM delay or neglect medical treatment, including treatment for STI symptoms, because of a supposed lack of medical confidentiality and a fear of stigma and/or abuse. Anecdotal evidence in Burkina Faso suggests that such fears are warranted, owing to reports of breaches of medical confidentiality and illegal arrests and harassment among MSM and SW (Drab et al. 2010). Key informants reported that health care providers refuse to treat MSM and SW on moral or religious grounds. UNAIDS and WHO recommendations call for training prison staff, law enforcement, and health care providers in ethics and various aspects of human rights, including informed consent, confidentiality, and avoidance of stigma and discrimination. With proper policies and training, police can be enlisted to protect MSM, SW, and TG from abuse and violence. Policies and programming to sensitize health care workers can be a first step in reducing stigma and discrimination while supporting integrated services in reaching more MSM, SW, and TG. Article 6 of the law regarding the HIV response (MoH 2008) states that standardized basic training to correct misconceptions about HIV should be provided to all state employees, local authorities, private
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sector employees, informal sector workers, members of the armed forces and law enforcement, prisoners, and sex workers. For the most part, implementation of Article 6 appears to be weak. The assessment team was unable to identify standardized training guides or guidelines. The training provided to health workers in Ouagadougou, which addressed ethics and human rights and avoidance of stigma and discrimination, did not appear to have been delivered in other parts of the country. PROMACO has provided such training to the armed forces, but local authorities and law enforcementthose with direct contact with key populationshave generally not received such training other than that delivered in Bobo-Dioulasso on the issues facing SW. Training modeled on these discreet projects as well as on programs in other countries could be scaled up to address key populations barriers to access. HIV Counseling and Testing Policy in Burkina Faso guarantees state funding for HCT services, specifically for MSM and SW, and authorizes a model for integrated services (SP/CNLS-IST 2010). Although policy does not permit salivabased rapid testing, it does allow rapid testing algorithms to diagnose HIV infection in community settings, but not in prison settings (SP/CNLS-IST 2008a). Policy guarantees that HCT services, including receipt of test results, are available on a confidential and anonymous basis (other than cases listed under Confidentiality) (MoH 2008). Although there are no restrictions on the frequency of HIV testing, testing is not usually free. It costs 500 F CFA, or approximately US$1, which may discourage some key populations, particularly street youth, from testing. A recent CMLS report points to insufficient providerinitiated opt-in HCT and frequent stockouts of testing materials as barriers to HCT (CMLS 2012). With regard to key populations, policy does not identify mechanisms that involve MSM, SW, or TG in the development of HIV testing and counseling protocols, although it identifies MSM and SW as vulnerable groups to which providers should offer HCT. The latest framework (CSLS-IST 20112015) identifies mechanisms for monitoring HCT outcomes for MSM and SW but does not identify mechanisms for involving MSM, SW, or TG in monitoring and evaluating HIV testing and counseling programs. Among the most significant barriers to HCT are stigma and discrimination. Key populations may fear increased stigma and discrimination if they are found to be HIV-positive. For example, anecdotal evidence indicates that SW in border towns and other small urban or rural zones in Burkina Faso prefer to travel to undergo testing in a town where they are not known or forego testing altogether, for fear of losing clients. Key informants reported frequent cases of SW loss-to-follow-up following an HIV-positive test result. Involvement of MSM, SW, and TG in the development of HIV testing and counseling protocols can ensure that HCT meets the needs of key populations, encourages HCT uptake, and ensures PLHIV access to care and treatment services. Antiretroviral Treatment Since January 1, 2010, the policy authorizing ART has guaranteed free ART for all citizens. However, policy implementation has faced serious challenges, particularly for key populations. In particular, the services related to or required for ART, such as CD4 count testing, provider fees, and medications for opportunistic infections (OI), are generally not provided free of charge and can be costly. Key informant interviews revealed that the charges pose a serious financial barrier to ART access for many patients. Some services are not free. This is the case of certain laboratory tests and medications for opportunistic infections. So if the person does not have financial means, he/she cannot access them. (Key Informant, Health Care Provider) In addition, stockouts of HIV testing materials, CD4 testing materials, and ARVs, along with broken equipment, have limited uptake (CMLS. 2012). Only first-line ARVs are available for the vast majority of the population. Newly eligible patients are not initiating ART at this time, with approximately 2,598 eligible patients waiting to begin treatment (CMLS 2012).

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Only 1,776 children (under 14 years of age) are currently on ARVs, accounting for approximately 16.6 percent of eligible children living with HIV based on EPP Spectrum estimates (CMLS 2012). The implications for orphans and vulnerable children (OVC) are seriousparticularly for street youth, MSM, and SW who are minors. Many of the barriers, such as cost and stockouts, most directly affect these groups. Decentralization of ART is even more limited for childrens ARVs while issues such as parental consent and mistrust of health care providers create additional barriers among these vulnerable populations that have especially limited access to appropriate IEC and HIV protective measures and face higher exposure to rape and at-risk behaviors (Yaro et al 2007). ART delivery and follow-up, particularly for key populations, is supported by eight CBO health care facilities (20.06 percent of all PLHIV on ART) and seven private clinics (under 1 percent of all PLHIV on ART) (CMLS 2012). However, current policy limiting procurement and administration of certain laboratory testing and medications (MoH 2011), such as those for IOs, pose a barrier to service integration for some of these CBOs. Decentralization of services for CD4 count testing and ART delivery is currently limited. As with specialized services for MSM and SW, ART services are generally offered in centralized locations (CMLS 2012) such that, according to key informants, many patients, particularly those residing in rural areas and border towns, must travel long distances, generally expending their own financial resources for travel. For many MSM and SW, particularly those living outside major urban centers, free ART services may be financially out of reach owing to travel and other expenses related to ART. Although ART policy regarding eligibility does not specifically list categories of eligible individuals or populations, it does state that anyone infected with an STI and/or HIV is eligible without discrimination (SP/CNLS-IST 2010). Policy is silent on detainees eligibility for ART but does not restrict their access. According to the ART policy, all citizens are considered eligible, and, in practice, inmates who inform prison staff of their HIV serostatus are transported to an appropriate service point to receive ART. Sexually Transmitted Infections Although the pharmacy policy currently undergoing development has not yet been signed, it states that medications for treating STIs are subsidized while ARVs are free (MoH/DGPML 2011). In practice, stockouts of STI kits are common, and individual medications in kits are often removed and sold for cash (CMLS 2012). There are frequently stockouts of STI kits. And when they are available, since they are free, people remove the medications from inside to go sell them. Often, even health staff does it. (Key Informant, Health Care Provider) As a result, key informants report that clients with STIs, particularly SW who elect health cardrelated medical examinations, must often pay the full cost of treatment. Sex workers may avoid STI testing if they know that they will be unable to pay for the treatment needed for updating their health card. In keeping with international best practices, current policy authorizes HCT services through STI clinics, syndromic STI management services, periodic presumptive treatment (PPT), and expedited partner therapy (EPT) for cases of gonorrhea and chlamydial infection (SP/CNLS/IST 2008). The assessment team was unable to identify any policy specifying that testing for STIs should include oral, vaginal, and anal testing, directives that would enable more appropriate testing, care, and treatment of MSM, SW, detainees, and street youth. While policy covers treatment of STIs, it does not cover provider costs, which may exceed the means of some populations, and it fails to guarantee free access for Hepatitis A and B vaccinations for key populations and others (SP/CNLS-IST 2008a). Overall RH policy guarantees the reproductive health of

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all citizens without discrimination (MoH 2005), but STI policy fails to identify free services for MSM or SW or provide for specialized clinics to serve such populations. Key informant interviews indicated that stigma and discrimination pose barriers to service uptake among key populations and that relatively few specialized services for these populations are available as part of a concentration of services in major urban centers. Condoms and Lubrication HIV prevention must be evidence-informed based on proven methods (UNAIDS 2009a). Consistent use of condoms and WBL has a direct effect on reducing HIV risk and transmission (UNAIDS 2011a; UNAIDS/UNFPA/WHO 2009). Prevention efforts cannot succeed without guaranteed, uninterrupted access to reliable and affordable high-quality condoms and water-based lubricants. Sex workers sometimes cite lack of availability of free condoms as a reason for unprotected sex (WHO 2011a), and 40 percent of SW interviewed in Burkina Faso reported problems with torn condoms (Drabo et al. 2010). Focus group discussions with MSM in Burkina Faso that were part of ongoing research by UNDP/PAMAC revealed access to WBL as an impediment to prevention (Soulama. Draft 2011). Policy in Burkina Faso fails to guarantee free C/L services for MSM, SW, or TG and fails to direct distribution of water- and/or silicone-based lubricants in condom programs. Moreover, there are currently no policies regarding commodity procurement or distribution of lubricants, and lubricants are not mentioned in the CSLS 2011-2015. Key informant interviews noted frequent stockouts of lubricant, except in a limited number of CBOs, and in pharmacies, which stock large tubes of lubricant that are difficult to conceal and too costly for most MSM and SW. Programs that focus on empowering SW to negotiate condom use and on increasing client acceptance of condoms have succeeded in increasing condom use in many communities (UNAIDS Advisory Group 2011). Condom programs for SW in Burkina Faso provide support and guidance but allow SW to retain control over their decision regarding condom use. In keeping with international best practices, public health authorities rather than law enforcement monitor the uptake and effectiveness of condom programs. Information, Education, and Communication Basic IEC activities for MSM, SW, and clients of SW must include focused communication and education efforts adapted to the needs of these populations (UNAIDS 2011a. WHO 2011a. WHO 2011b), which can be extremely heterogeneous. Studies in West Africa, including Burkina Faso, indicate that some MSM work in the sex industry (Mah and Dibba 2008; World Bank/NACA 2008) while others have sex with women, are married and/or have children (Larmarange 2010; Larmarange, Wade et al. 2010; CCM Burkina Faso 2010; Soulama 2008). Studies in the region also point to heterogeneity among sex workers and their clients with respect to country of origin, location of sex work, frequency of sex work, and client types (Lowndes, Alary et al. 2008; WHO 2011a). Street youth in Burkina Faso report sex work, consensual and non-consensual same-sex sexual relations, and other high-risk sexual behaviors coupled with a lack of HIV and STI IEC (Yaro et al. 2007). Access to IEC must be specific to a given population and stipulate protocols for delivery of IEC services (WHO 2011b), including relevant information on HIV transmission. Although current policy guarantees public funding of IEC programs, the assessment team was unable to find any policy that guarantees access to IEC information specific to MSM, SW, or TG. While Burkina Faso has adapted IEC to SW, key informant interviews revealed that MSM-specific IEC is not available and that many MSM may not know that HIV transmission can occur during same-sex sexual relations. Outreach Outreach activities increase the impact of basic programs (UNAIDS 2011a), and outreach through networks, communities, and peer-educators is often the best or even the only way to reach populations

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that may be forced to hide their behavior or are afraid to access services. Policies that guarantee access to tailored protocols for outreach services (CHALN 2007) and that ensure the safety and engagement of key populations are needed. Recent policies developed to address outreach in Burkina Faso follow international best practices. For example, the CSLS 20112015 guarantees access to outreach that meets the needs of MSM and SW and that documents types of sex work, maps establishments where sex work takes place, maps places of socialization for MSM and SW, and estimates the population size of MSM and SW (SP/CNLS-IST 2010). The CSLS 20112015 also mandates documentation of the health-seeking behaviors of MSM and SW and aims to align types of outreach (drop-in center, mobile clinic, and so forth) with the health-seeking behaviors and context identified for a given population in a particular geographic area. New policy also directs that peer-leaders and outreach workers be compensated for their work. It also calls for the participation of police as partners and authorizes outreach in prisons. It stipulates that outreach workers should be provided with condoms, lubricants, and a dildo for demonstration as well as with information materials on harm reduction and available services. As many of these policies are relatively new, the assessment team was unable to ascertain whether the policies are undergoing proper implementation. CBOs working with key populations are particularly active in Burkina Faso, and the team received no reports that current policy, government practices, or opposition by law enforcement discouraged or impeded outreach. Among key populations in Burkina Faso, the greatest barriers to outreach are stigma and discrimination. However, key informants also noted the following barriers: criminalization of solicitation, which drives some SW underground; stockouts of lubricant; lack of MSM-specific IEC materials; and barriers to HIV and STI care and treatment. Among minors, including street youth, MSM, and SW, age of consent laws that require parental or guardian consent for HCT represent a potential barrier for members of key populations who are minors. When asked about potential barriers, one key informant mentioned safety concerns for outreach workers trying to access both street youth and SW who solicit. Alcohol Harm Reduction Alcohol use among SW and their clients is common. Focus group discussions among male SW in Burkina Faso revealed that stigma, discrimination, and poor work conditions influence alcohol and drug use (Soulama Draft 2011). Among all populations, alcohol use hampers condom negotiation skills and adversely affects sexual decision making and judgment (WHO 2011a). Although the CSLS 20112015 recognizes alcohol as a behavioral risk factor for HIV transmission, current policy in Burkina Faso does not address alcohol consumption, except among minors. In fact, the assessment team was unable to identify any harm reduction programs. Reproductive Health and Family Planning Access to FP/RH services structured around approaches specific to SW and TG is not only essential to human rights and health but can also be a point of entry for HIV prevention, care, and treatment. Integrating HIV and STI services into reproductive health programs can help expand FP/RH service delivery to SW and TG who may avoid HIV and STI clinics due to stigma and discrimination. Moreover, service integration has been shown to reduce HIV infection significantly (IPPF/UNFPA/Young Positives and the Global Coalition on Women and AIDS 2007). In Burkina Faso, public financing of reproductive health is guaranteed through contracting with CSOs, and policy authorizes STI and HCT services in FP/RH health centers as part of service integration in health centers (SP/CNLS-IST 2010). Although RH law guarantees the reproductive rights of all citizens under all conditions (MoH 2005), detainees are generally denied FP/RH services. Street youth, often victims of sexual exploitation and violence, face exceptional barriers to accessing FP/RH services. Stigma and discrimination, financial barriers, maladapted services, and distrust of health care providers pose challenges for reaching these youth (Yaro et al. 2007).

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RH law guarantees the reproductive rights of all citizens regardless of age. However, Burkina Faso does not permit abortion except in cases of rape or incest, when continued pregnancy puts a pregnant womans life or health in danger, or when diagnostic testing reveals a strong probability that the child will be born with a specific, serious condition (MoH 2005). Transgender People Policy documents in Burkina Faso make no mention of TG; no data on TG have been collected. Key informant interviews revealed that, despite rare cases of men (who may or may not self-identify as women) publicly dressing as women, Burkina Faso has no recognized cases of TG. In two newspaper articles (Sidwaya 2003. Sidwaya 2004) about the arrests of two potentially TG people (one in which the persons face was revealed, and the other in which the person, a minor, was hidden), both denied being transgender and cited external reasons for dressing as women, possibly due to fear of stigma and discrimination.

CONCLUSION
The GoBF commitment to the AIDS response and the countrys recent policy changes incorporating international best practices have set Burkina Faso on course for improving access to services for key populations, potentially positioning Burkina Faso as a model for other West African countries. While the country clearly faces several barriers to meeting its commitment, Burkina Faso can also capitalize on wide-ranging opportunities not available to other countries in the region. Burkina Faso is the recipient of a Global Fund grant under round 10, which includes a strong focus on key populations. The president of Burkina Faso and Permanent Secretary for CNLS have publicly expressed support for and acknowledged the need to address key populations. Burkina Faso is also in the unique position of reaping the benefits of a handful of strong community-based organizations that work with key populations and can point to lessons learned and successful activities for scale-up. Although policies are not always known or implemented, current policy in Burkina Faso supports human rights, and the country has incorporated many international best practices into official policy related to HIV and key populations. Nonetheless, the GoBF will not be able to manage the HIV epidemic among key populations without further pro-active formal measures aimed at protecting and providing prevention, care, and treatment to key populations. Critical gaps in policy remain, particularly as related to SW, TG, MSM and detainees, and the discrepancy between written policy and policy implementation needs to be addressed. Removing barriers to service access for key populations is essential to ensure that HIV prevalence continues to decrease or remains stable For a multisectoral approach to work, increased harmonization of CMLS policy and other policy documents across key sectors will be needed, along with widespread dissemination, availability, and implementation of new policies issued by each ministry. Misaligned policies should be harmonized, particularly RH, HIV, and prison policy affecting HIV prevention for detainees. Implementation mechanisms, adequate funding, and human resources are also needed. Although laws do not criminalize same-sex sexual relations or all types of sex work, much of official policy is silent regarding MSM and SW. Fear of backlash among government officials and those working with these key populations stems from societal, religious, and customary beliefs. Although many elected government officials and other authorities may fear public opinion, several supporting policies lend themselves to quiet implementation or modification without attracting the attention that changes to major laws could precipitate.

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For example, formal mechanisms can be put in place for engaging key populations in government decision making, policy development, monitoring and evaluation, and developing HCT and ART guidelines for key population, thus improving service uptake by ensuring that services address the needs of the populations of interest. Although policies are developed following international guidelines, members of key populations and/or their representatives should be invited to participate in all stages of development, monitoring and evaluation to ensure that impediments particular to the local context are addressed. International guidelines and best practices should inform policies, but they must be adapted to the needs of key populations in the particular context of Burkina Faso by modifying them or including additional directives to ensure open access to services. For example, standard protocols for ART should be followed. However key populations may have barriers to accessing ART unknown to technical teams developing the guidelines and that require additional directives or minor modifications to current protocols. For policy to have a positive impact on access to services, Burkina Faso will need to identify specific activities for key populations, design minimum service package guidelines, and develop implementation mechanisms for relevant policies and services. A policy and program focus on SW clients will balance efforts to manage HIV among SW. Policy impact will depend on adequate funding and human resource allocation for proposed activities. Scale-up will require increased government activities for key populations or the creation and implementation of policies that assist CBOs with scale-up, including access to all medications and procedures in on-site laboratories and pharmacies. Data collection and policies that mandate data use in decision making are instrumental for ensuring accurate forecasting and appropriate planning, along with mechanisms for measuring and documenting success. Upon the signing of a new policy on procurement and management of medications and medical supplies (MoH/DGPML 2011), Burkina Faso should address improved coordination, forecasting, and distribution of medication and medical supplies, including female condoms, testing materials, and medications. Moreover, policies should be updated to address and safeguard commodity procurement and distribution of water- and/or silicone-based lubricants. Reallocation of funds and policy to support horizontal checks and cross-stocking for redistribution of medicines and medical commodities are instrumental in preventing stockouts, overstock, and expiration. If CBOs are to scale up testing, care, and treatment services, policy will need to address CBO access to prescription medications, including those for OIs, thereby removing barriers to integrated service access for key populations. HIV prevention can be supported with policy to ensure free C/L services for MSM, SW, and TG and by avoiding stockouts of lubricants with a focus on small, individual packets to assist uptake and use. These policy recommendations align with and bolster plans under the Global Fund Round 10 to provide CBOs with C/L for SW and MSM. To meet policy objectives for free ARVs and subsidized STI treatment, order quantities must be based on reliable estimates of need, with budgets set accordingly. To identify and reach more HIV-positive youth and children with ART services, research into the causes for low service uptake, including a focus on street children, will be essential. To protect the rights of citizens and increase voluntary HCT uptake and informed consent, Burkina Faso must guarantee confidentiality for all clients, including sick and pregnant patients. All health care providers authorized to conduct HIV testing should undergo training in HIV counseling and confidentiality. Parental consent laws must undergo revision to ensure that they do not pose a serious barrier to HCT and HIV care and treatment, particularly among street youth, adolescent SW, and MSM. At the very least, the age of consent should be significantly reduced to concur with the HCT Reference Manual (SP/CNLS-IST 2008b). Willful transmission laws can constrain HCT uptake and increase stigma and discrimination among PLHIV. Replacing those laws with service referral for key populations may remove barriers to HCT and ensure that key populations obtain needed services. Barriers to ART, such as cost of HIV-related testing and distance to services, can be addressed by increasing the number of locations offering free or subsidized services. Access to services for key populations can also be
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addressed by engaging sympathetic health mediators to accompany key populations to health care facilities that offer services unavailable in CBO clinics. Finding ways to address stigma and discrimination of key populations is crucial in countries such as Burkina Faso. Policies that call for actively measuring and addressing stigma and discrimination can be a critical step in addressing HIV among key populations. Offering comprehensive training and sensitizing health care providers, members of law enforcement, judges, and educators can increase access to services that meet the needs of key populations, improve service coordination, and decrease stigma and discrimination. Formal coordination among health care authorities, health care providers, and law enforcement, accompanied by police support to protect key populations from abuse and violence, can reduce stigma. For example, the use of performance indicators can provide incentives for responding to reports of violence against MSM, SW, and TG. Changing norms can be addressed through the media and, where possible, by working with willing religious and traditional leaders to recast perceptions. Quietly providing legal recognition of MSM and SW associations and networks can enable such bodies to access funding and other assistance that can be used for HIV prevention efforts, including condom and lubricant distribution, population-specific IEC, and condom negotiation training as well as for advocacy efforts to address stigma and discrimination. As formulation of a national policy on stigma and discrimination is currently underway, engaging experts and stakeholdersincluding community organizations serving key populationsand including international best practices will ensure the appropriate mix of policies will be adopted and implemented. The involvement of key populations in the development of population-specific IEC that takes the heterogeneity of populations into account can help ensure the availability of appropriate prevention outreach materials. Even a country such as Burkina Faso that severely stigmatizes MSM can and should develop IEC relevant to MSM. For example, prevention information should point out that transmission can occur during same-sex sexual relations and anal sex, and that condoms with lubricants can minimize transmission. MSM can be invited to help develop materials that meet their needs and respond to the local culture, ensuring that materials are socially acceptable, but accurate and useful. Such an approach should be possible in Burkina Faso as policy places no restriction on IEC content related to sexual orientation or gender identity. Although prisons prohibit sexual relations, evidence indicates that consensual and non-consensual sexual relations are common in Burkina Fasos prisons and that detainees must have the right to protect themselves from HIV and STIs. Moreover, given that many detainees leave prison and re-integrate into the community, HIV prevention efforts must include detainees to curb the spread of HIV in the general population. For detainees, the key issues are access to condoms and lubricant as well as access to general health care, HCT, and in-prison care and treatment. Other than youth education campaigns, Burkina Faso currently has no policies or programs in place to reduce alcohol consumption or address alcoholism. Given the reported prevalence of alcohol use among key populations (Soulama Draft 2011) and the negative impact of alcohol on sexual decision making and condom negotiation skills (WHO 2011a), the addition of alcohol harm reduction outreach/programs would benefit key populations. Burkina Faso has incorporated several policies based on international best practices that facilitate access to services for key populations. Addressing the remaining gaps and challenges outlined in this report could have a significant impact on Burkina Fasos HIV policy environment for key populations and potentially remove barriers to service access. Clearly, key stakeholders in Burkina Faso must decide which issues are the most critical to them. The findings of this assessment can help facilitate dialogue and identify priority issues.

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WHO. (1994). A declaration on the promotion of patients' rights in Europe. European consultation on the rights of patients. Amsterdam. 28 - 30 March 1994. Retrieved August 1, 2011, from http://www.who.int/genomics/public/eu_declaration1994.pdf WHO. (2006). Basic principles for treatment and psychosocial support of drug dependent people living with HIV/AIDS. Retrieved from http://www.who.int/substance_abuse/publications/basic_principles_drug_hiv.pdf WHO. (2007). Guidance on provider-initiated HIV testing and counselling in health facilities. Retrieved from http://www.who.int/hiv/pub/vct/pitc2007/en/ WHO (2011a). Preventing HIV in sex work settings in sub-Saharan Africa. Geneva, World Health Organization. WHO. (2011b). Prevention and Treatment of HIV and Other Sexually Transmitted Infections Among Men Who Have Sex with Men and Transgender People. Retrieved from http://www.who.int/hiv/pub/populations/msm_mreport_2008.pdf Wilson, D. and S. Challa (2009). Ch.1 HIV Epidemiology: Recent Trends and Lessons. The changing HIV/AIDS landscape: selected papers for the World Banks agenda for action in Africa, 2007-2011. E. Lule, R. Seifman and A. C. David, World Bank Publications. Wilson, D. and N. Fraser (2011). Mixed HIV epidemic dynamics: Epidemiology and program implications. PEPFAR Technical Consultation on HIV Prevention in Mixed Epidemics, Accra, AIDSTAR-One. Wilson, D. and D. T. Halperin (2008). Know your epidemic, know your response : a useful approach, if we get it right. Lancet 372(9637): 423. World Bank/NACA (2008). Nigeria Epidemiology and Response Synthesis Report. Abuja, The World Bank and the National Agency for Control of AIDS. Yaro, Y., C. Compaor, et al. (2007). La Problematique des Enfant de la Rue : Etude de Base pour la Recherche Action dans Trois (3) Villes du Burkina Faso : Ouagadougou, Bobo-Dioulasso et Koupela. CERFODES. July 2007.

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ANNEX 1: SUMMARY OF FINDINGS

Summary of FindingsFramework, including Multisectoral Response and Linkages
The AWARE II assessment team examined 65 Burkinabe articles of law, codes, regulations, national strategic frameworks, strategic plans, guidelines and evaluations to assess whether policies, mechanisms, and coordinating bodies at the national level support linkage of HIV programs with Sexually Transmitted Infection (STI) and Reproductive Health (RH) programs and follow international best practices to address the needs of sex workers (SW), men who have sex with men (MSM), transgender individuals (TG) and detainees. These documents were reviewed to determine whether HIV sector policies align with nonhealth sectors, such as education and transportation.
Strengths HIV and STI service coordination with FP/RH services and with most relevant non-health sectors (particularly Education, Labor, Commerce, Transportation, and Military/Uniformed Services) mentioned in national policy, national strategic frameworks and strategic action plans Government and non-governmental organization roles and responsibilities are defined for HIV, STI, and FP/RH. Policies support involvement of and government collaboration with civil society and the private sector (The CSLS 20112015 emphasizes NGO and private sector involvement in service provision) HIV and STI programs identify services and government commitment to achieve coverage targets for SW and MSM, and clients of SW (HIV program only) Size estimation and evidence basis for funding decisions while not codified in policy, activities follow international standards for SW, clients of SW, and MSM UNGASS Indicators for most-at-risk populations are reported on (except indicator #14 percentage of most-at-risk populations who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission) Primary education reports sex-disaggregated quality and outcome indicators

Specific policy gaps Multisectoral Response o o o Non-health sector HIV policy documents do not include SW, MSM and detainees Operational guidelines or standards with detailed implementation mechanisms do not exist in non-health sectors addressing HIV and STIs as a rule Key committees and consultative bodies largely do not include Key populations Do not identify services, coverage targets, or outcomes for SW and TG Not coordinated with relevant non-health sectors in either general population programs or prison settings

FP/RH programs o o

STI Programs do not mention services, coverage targets, or outcomes for clients of SW, or MSM

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Prison settings o o o Do not mention HIV, STI, and FP/RH programs for SW, clients of SW, TG, or MSM Equitable levels of resources and services between community and prison programs are not promoted in policy documents No data collection requirements for incidence and context of sexual violence Services, coverage targets, or outcomes are not mentioned in HIV, STI, or FP/RH programs No size estimation policies or activities Scientific basis or international standards not referenced in HIV, STI, or FP/RH program design National Development or Poverty Reduction strategies do not identify needs and initiatives for SW, TG, or MSM Human rights of SW, TG, and MSM are not identified or addressed in HIV, STI, and FP/RH programs, either general population programs or prison settings

TG o o

Holistic programming and program rationale o o o

Other Barriers Gaps in implementation of HIV and STI service integration in FP/RH services Lack of current data on MSM, SW, TG and detainees Misinterpretation of penal code denies detainees access to FP/RH services, including condom and lubricant (C/L) distribution. Products must be bought on the black market at up to 10x cost

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Summary of FindingsCommunity Partnership

The AWARE II assessment team examined 15 Burkinabe decrees, codes, national strategic frameworks, strategic plans and guidelines to assess policies that facilitate participation of the private sector and civil society in the development and implementation of HIV/AIDS programs.
Strengths Establishment and support of non-governmental organizations serving SW and MSM in community settings is supported by HIV and STI policy Representation on CCM of SW, TG, or MSM is required. The CCM includes three organizations serving key populations.

Specific policy gaps Engagement of SW, TG, and MSM in decision-making processes o o Involvement of SW, TG, and MSM in decision-making, policy design and evaluation of policy implementation is not defined or required Representation of SW, TG, and MSM is not required in the National Coordination Unit for the Ministerial Committee for the Response to HIV, AIDS and STIs of the Ministry of Health (CMLS/Sant) Policy fails to support establishment of non-governmental organizations serving TG Policy fails to support establishment of non-governmental organizations serving SW, TG, and MSM in prison settings

Non-governmental organizations o

Other Barriers Unofficial denial of recognition of MSM-lead and comprised associations. Applications for official status/recognition receive no response, leaving them in indefinite limbo

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Summary of FindingsAuthorization
The AWARE II assessment team reviewed 22 policies, including Burkinabe articles of public health law, articles of HIV law, penal code, national public health strategies and national strategic frameworks and programs to identify the agency or agencies authorized to implement services for SW, TG and MSM in community and prison settings.
Strengths Broad authorization for provision of a comprehensive range of prevention and treatment services for HIV, STI, and FP/RH Public health agencies are given the authority to coordinate and deliver health and harm reduction programs in community settings

Specific policy gaps SW, TG and MSM are not mentioned in FP/RH policy. HIV and STI policy does not identify the range of services specifically for SW, TG and MSM Oversight of prison health services and medical protocols rests with prison authorities instead of health authorities and doctors Elective termination of pregnancy services only available under specific circumstances, including cases of rape and threat to the mothers health

Other Barriers Stockouts of medications and testing materials affect ability of public health officials to offer a complete range of HIV, STI and RH services

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Summary of FindingsConsent
The AWARE II assessment team examined 49 Burkinabe articles of HIV law, norms and protocols, national strategic framework, action plans and codes of professional conduct assess the extent to which Burkinabe policy regarding informed consent follows patients rights and international best practices.
Strengths Individual consent for medical testing and treatment for HIV, STI, and FP/RH o o Is required and follows international standards (exceptions below) Mandatory or compulsory medical testing and treatment are prohibited (exception below)

Access to information and counseling for HIV, STI, and FP/RH is guaranteed regardless of age and parental consent SW eligibility for services is not dependent on leaving sex work

Specific policy gaps Individual consent for medical testing and treatment for HIV, STI, and FP/RH not required in health-care initiated HIV testing as part of overall health screenings in ill patients, in data collection of seroprevalence among SW and in criminal court proceedings of rape or willful transmission. Currently no guidelines to determine conditions for HIV testing of ill patients Right to refuse or withdraw from medical test and treatment is not identified in policy Age appropriate information on sexual orientation and gender identity is not authorized for school curricula No clear guarantee of access to testing and medical services for HIV, STI, and FP/RH for adolescents without parental consent. Contradictions exist between age of consent laws, HCT guidelines and implementation of services Mandatory or compulsory medical or psychological procedures or confinement are not specifically prohibited for treatment of sexual orientation or gender identity

Policy is silent on regulations for obtaining consent of individual SW for all interventions for SW (e.g. 100% condom use and raid and rescue interventions)

Other Barriers Health care provider implementation of consent laws and regulations is variable, particularly in prenatal care settings

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Summary of FindingsConfidentiality of personal data

The AWARE II assessment team reviewed 38 policies, including Burkinabe articles of public health law, articles of HIV law, penal code, norms and protocols, national strategic frameworks and action plans to assess policy adherence to international best practices regarding confidentiality of personal data.
Strengths Individual-level personal medical data o o o Collection, use, disclosure and/or publication prohibited without individual consent in community and prison settings (exception below) Access to ability to request correction to personal medical records is provided Partner notification protocols seek to protect identity of individual with communicable disease

Breaches of confidentiality and sanctions for unauthorized release of confidential information are addressed by independent agency

Specific policy gaps Disclosure of personal data o o Disclosure of medical data of a minor to parents/guardians does not allow for prioritization of the best interest of the child Results of mandatory medical tests for SW are disclosed to authorities regardless of consent

Other barriers Breeches in provider confidentiality exist. Official complaints not filed

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Summary of FindingsRegistries
The AWARE II assessment team reviewed 13 policies, including Burkinabe articles of laws as well as norms and protocols to assess restrictions, directives and personal data protection regarding the use of medical registries. The assessment team was unable to access law enforcement policy documents to identify policy vis--vis the use of sex offender registries.
Strengths Medical registries o o o Follow strict rules of data protection and confidentiality Focus on ensuring quality of services Management by public health authorities

Potential policy gaps/other barriers Sex offender or other non-medical registries for SW, TG and MSM o o Lack of transparency in law enforcement use of registries Policy vis--vis law enforcement use of registries unavailable to public

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Summary of FindingsStigma and discrimination

The AWARE II assessment team reviewed 21 Burkinabe policies, including articles of the Constitution of Burkina Faso, articles of reproductive health law, articles of HIV law and the national strategic framework (CSLS 20112015) to identify measures that offer protection from stigma and discrimination to PLHIV and key population.
Strengths Stigma and discrimination are to be addressed in National HIV and STI Programs, according to new national HIV policy (PLHIV-specific . No mention of SW, TG ,MSM or detainees) National discrimination protections (Population-wide and PLHIV-specific . No mention of SW, TG, MSM or detainees) o o o Include education, housing, employment, and health services Include actual or perceived health conditions Include residency/citizenship

Protections for individuals who file discrimination complaints Information, education, or community mobilization campaigns are authorized to change customary laws and practices and attitudes associated with them (PLHIV -specific . No mention of SW, TG, MSM or detainees) It is unlawful to incite hatred toward someone on the basis of actual or perceived HIV infection

Specific policy gaps Stigma and discrimination are not addressed in National FP/RH Programs National discrimination protections o o o o Do not explicitly include SW, TG, MSM, prisoners or relatives or associates of prisoners Do not include source of income Do not include sexual orientation Do not include gender identity

Policy provides no legal remedies for customary laws, teaching or practices that effect the status or treatment of SW, TG, or MSM There are no clear prohibitions against incitement of hatred toward SW, TG, and MSM

Other barriers Religious and cultural beliefs and norms condemning sex work and same-sex sexual relations Endemic stigma and discrimination of SW and MSM, including verbal and physical aggression Violations of healthcare provider code of ethics in the form of verbal assaults against SW and MSM and refusal to deliver care to MSM, resulting in SW and MSM foregoing health care and/or selfmedicating

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Pressure for heterosexual relationships as a social cover Migration of SW and MSM as a result of stigma and discrimination Stigma and discrimination of SW and MSM in the media

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Summary of FindingsDefinitions
The AWARE II assessment team reviewed 9 Burkinabe policies, including codes, laws and the national strategic framework for HIV and STIs (CSLS 20112015) to evaluate the use of definitions that may impact the application of laws and policies.
Strengths Human trafficking is defined as acquisition of people by improper means

Specific policy gaps Definitions of disability do not include loss of function or ability to earn a living based on HIV infection Laws and HIV policy do not provide definitions for SW, TG and MSM to recognize their legal status. Definitions of acronyms are provided for SW (Sex Workers), TG (Transgender) and MSM (Men who have sex with men) in national HIV strategy. Sex work is defined in Burkinabe penal code as the act of a person of one sex or the other to habitually engage in sexual acts with others for remuneration, and is not explicitly legal or illegal.

Note Supportive legalization for SW, TG or MSM and the addition of supportive definitions in penal code could lead to backlash given the cultural context in Burkina Faso. Significant strides in addressing stigma and discrimination need to be made prior to affecting changes in this type of legislation.

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Summary of FindingsCriminal/administrative law

The AWARE II assessment team examined 43 Burkinabe articles of penal code, HIV law and public health law to identify criminal and administrative laws that affect access to HIV prevention, care and treatment for SW, TG, MSM and detainees, including criminalization of activities and behaviors in which these populations engage.
Strengths SW o o Silence* on the legality of selling or purchasing sex Escalating penalties for repeated convictions for SW are not identified Silence* on the legality and/or punishment for homosexuality and TG No restriction on the style of clothing Limited to activities that occur in public Serves to protect consent (or non-consent) to engage in behaviors Serves to protect individuals from harm or injustice Legal penalties imposed on anyone impeding IEC (information, education, communication) and prevention efforts for SW. Policy strongly supports IEC, prevention, care and treatment efforts

MSM/TG o o

Protection of public morality o o o

HIV prevention, care and treatment o

*Note: policy silence may be a strength or weakness depending on the broader political context

Specific policy gaps SW o o o o o o Soliciting SW is illegal Loitering laws specifically mention solicitation Operating places of prostitution is illegal Punished by imprisonment Alternatives to incarceration are not identified Lack of clear protection from prosecution for SW who have been trafficked or otherwise coerced into transactional sex

Medical or psychological treatment for the purpose of curing homosexuality is not clearly prohibited Extra-marital sexual conduct is regulated through criminal or financial sanctions

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Consensual sexual activity in prisons is penalized Criminalization of HIV transmission o o o Policy contains specific codes on HIV transmission instead of applying general criminal codes Policy criminalizes exposure with or without transmission Policy criminalizes non-disclosure of HIV status Policy does not explicitly mention protection of all types of HIV prevention information from censorship. The CSLS 2011-215 includes policy for mass media prevention campaigns but without specifications

Mass media protections o

Other barriers Law enforcement use of solicitation laws to harass and detain SW and MSM who are not soliciting Reports of police violence and extortion against SW and MSM Prison and law enforcement policy documents unobtainable, pointing to a lack of transparency o Unclear whether information provided in the process of reporting blackmail or filing a discrimination complaint can be used as evidence in criminal or administrative proceedings against SW, TG or MSM

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Summary of FindingsGender based violence

The AWARE II assessment team reviewed 22 Burkinabe policies, including articles of laws, penal code, programs, guidelines and the national strategic framework for HIV and STIs (CSLS 20112015) to assess the current legal and regulatory framework for attention and response to GBV.
Strengths Rape is broadly defined Access to complaint processes for sex workers who experience sexual abuse by their employers or clients (see other barriers) Access to medical treatment including post-exposure prophylaxis for sex workers and prisoners Domestic violence reporting regulations do not require universal reporting of incidents to law enforcement Access to domestic violence shelters is not restricted for MSM, TG, and SW (policy is silent) Female detainees are housed separately from male detainees Non-consensual sex is prohibited in prisons

Specific policy gaps Honor killings based on sexual orientation or sexual identity not clearly prohibited Legal fees for plaintiffs in sexual abuse cases Access to medical treatment not clearly provided for TG and MSM who experience sexual violence Counseling for survivors of sexual violence not clearly provided for in prison settings Housing of TG detainees with females not clearly directed Structures to punish and/or segregate sexual predators in prisons not provided

Other barriers SW do not pursue cases of sexual abuse o o o Unaware of rights Embarrassed or fearful of law enforcement Legal fees

SW and detainees limited access to post-exposure prophylaxis (PEP) due to unreported sexual abuse Single cell prison settings in small towns and rural areas unable to separate male and female detainees

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Summary of FindingsCruel, inhuman, or degrading treatment or punishment

The AWARE II assessment team examined 6 policies, including the Constitution of Burkina Faso and Burkinabe articles of penal code to identify protections for key populations against cruel, inhuman, or degrading treatment or punishment.
Strengths Cruel, inhuman or degrading treatment or punishment is prohibited with redress systems and sanctions identified in both community and prison settings Human rights violating social rehabilitation centers are prohibited

Specific policy gaps Sexual orientation and gender identity are not identified as protected from torture and illtreatment

Other barriers Acts of cruel, inhuman or degrading treatment go unreported due to stigma and discrimination o o Religious and cultural beliefs and norms leading to stigma and discrimination Cruel, inhuman or degrading treatment of MSM and SW within family and community

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Summary of FindingsHuman and legal rights

The AWARE II assessment team examined 32 policies, including the Constitution of Burkina Faso, Burkinabe codes and articles of law, and international treaties and conventions signed by Burkina Faso to examine the existence, monitoring and enforcement of human and legal rights.
Strengths International human rights o o o Broad ratification of international conventions and treaties Acknowledgement of supremacy of adopted international law over national legislation Recognition of international human rights bodies

Women provided full inheritance and equal distribution of assets in divorce Rights to education are delineated o o o Free education Compulsory education Continued schooling for pregnant or parenting girls

Independent anti-corruption bodies are authorized Bribery, coercion, and extortion by a public official are illegal Commensurate compensation of civil servants with public sector is identified as a goal Residency paper requirements are clear and process is accessible

Specific policy gaps Same-sex relationships not recognized in any way Sexual orientation or gender identity not recognized as justification for granting asylum Sex workers not provided legal protections or benefits of other occupations Financial and professional incentives for law enforcement officials not identified for enforcing crimes against SW, TG, or MSM or referring these individuals to services Rights to education for TG and MSM not guaranteed and bullying not prohibited on the basis of sexual orientation or gender identity No clear process for gender aligned residency papers for TG Anti-corruption bodies do not provide for civil society participation Anti-corruption public awareness campaigns are not identified Public servant codes of conduct are non-existent or non-transparent Education on legal rights is not provided by the state for SW, TG, MSM, or prisoners Funding to overcome basic legal costs not provided

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Other barriers Religious and customary laws may govern divorce and inheritance Women unaware of rights Financial barriers to school attendance include cost of uniform, books and transportation, and house and field work Legal cost to asserting rights through legal proceedings Police abuse of SW, MSM and detainees

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Summary of Findingsprocurement and supply management

The AWARE II assessment team examined 29 Burkinabe policies ministerial decrees, articles of law, regulations, strategic plans, guidelines and evaluations, and the national strategic framework to assess the governments Procurement and Supply Management (PSM) system for HIV drugs and commodities. The assessment focused on the status of the general supply chain, procurement, and forecasting systems in Burkina Faso and the PSM system for medications and supplies relevant to HIV prevention, care and treatment for key populations, including ARVs and laboratory tests to monitor ART.
Strengths PSM oversight bodies are identified Quality assurance standards are identified Essential medicines align with WHO and fall under controls of tariffs, distribution margins and pricing parameters Decentralized procurement and international tendering are allowed

Specific policy gaps PSM oversight bodies do not have representation from non-governmental organizations and do not make procurement records open to public Mechanisms do not exist for the participation of SW and MSM in selection of harm reduction commodities Commodity forecasting is not based on estimated or reported need Storage, distribution, and logistics are not budgeted for Redistribution of commodities between clinics to avoid stock outs and expiration is not allowed

Other barriers New national pharmacy policy has not been signed. Previous policy (1996) not widely disseminated or referenced Poor implementation of quality assurance standards Stockouts of ARVs, STI kits and lubricant common Reports of restrictive regulations regarding procurement and distribution of specific medications affecting Community Based Organizations (CBOs) serving key populations. Appears to be addressed in new, unsigned policy

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Summary of FindingsOverarching services design

The AWARE II assessment team examined 21 Burkinabe policies, including articles of HIV law, articles of RH law, penal code, strategic framework, norms and protocol, guidelines and evaluations to evaluate service design with a particular focus on integration of HIV and STI services in FP/RH, measures to address domestic and sexual violence, availability of services and HIV-related training.
Strengths Services directed to have protocols to assess FP/RH, STI and HIV need Referral mechanisms to other services identified Equal access for women and men guaranteed Guarantees access for females who are pregnant or have children Services available at times convenient to clients through rotating emergency pharmacies, hospitals and clinics (see other barriers)

Special policy gaps Domestic and sexual violence risk assessment protocols for SW, TG and MSM not identified Equal access for SW, TG and MSM not specifically guaranteed. RH law guarantees equal access for all citizens but does not specify these populations No mechanisms to ensure continuity of care between and within community and detention/prison/custodial settings Fails to prohibit mandatory use of family planning as a condition of receiving services No clear training requirements for law enforcement, judges, prison staff, teachers, or health care workers on o o o o o o o ethics and human rights stigma and discrimination domestic and sexual violence human sexuality specific needs of SW, TG, and MSM referral between law enforcement, medical, and harm reduction services hepatitis, TB, and HIV (except for professional curricula for health care workers)

Other barriers Financial barriers to accessing services Services for SW and MSM only in major urban centers. Services for SW generally unavailable in border towns and along trucking routes

55

Emergency pharmacies, clinics and hospitals may not be accessible to SW, TG and MSM due to stigma and discrimination MSM sub-populations fear being recognized at MSM-specific healthcare facilities. Refusal to disclose STI symptoms at healthcare facilities serving the general population ; fear of stigma and discrimination Healthcare providers refuse to treat SW and MSM citing religious and moral grounds Training for law enforcement, judges, prison staff, and teachers not implemented. Training for medical staff variable

56

Summary of FindingsHCT
The AWARE II assessment team reviewed 18 Burkinabe policies found in HIV law, national strategic frameworks, funding reports and reference manuals to assess quality of HIV Counseling and Testing (HCT) services and inclusion of specific components in Burkina Faso. The assessment team also evaluated access to HCT services for key populations.
Strengths Rapid testing algorithms available to diagnose HIV infection in community settings Confidential and anonymous testing available (see specific policy gaps) Government and non-government providers authorized International protocols adopted for counseling, consent, and referral (see specific policy gaps)

Specific policy gaps SW, TG, and MSM o o o not prioritized for free HCT not involved in development of protocols not involved in monitoring and evaluation of programs

Saliva-based rapid testing is not authorized Exceptions to informed consent, including unclear policy for minors regarding parental/guardian consent Prisoners not guaranteed access to voluntary confidential HIV testing and counseling (see other barriers)

Other barriers Cost (500 F CFA) - Free HCT only for PMTCT and in few Community Based Organizations (CBOs) Stigma and discrimination of SW, MSM, TG and PLHIV discourage them from accessing HCT services o o Double stigma for SW and MSM living with HIV SW fear loss of clients

HCT services unavailable in prison. Detainees must ask for HCT and be escorted to a testing site

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Summary of FindingsART
The AWARE II assessment team examined 9 Burkinabe policies in laws, strategic framework and guidelines to assess availability and accessibility of antiretroviral treatment (ART) for key populations and identify barriers to ART uptake.
Strengths Free ART authorized for all people living with HIV/PLHIV (see specific policy gaps and other barriers)

Specific policy gaps SW, TG and MSM not specifically identified as ART recipients; policy for all PLHIV Silence on detainee access to ART Silence on alcohol and drug-use restrictions to ART access Fees for related services

Other barriers Stockouts of HIV testing materials, CD4 and other laboratory testing materials, and ARVs Limited availability of second and third line ARVs Decentralization limited o Cost and time for travel to ART clinics Stigma and discrimination of PLHIV, SW, MSM and TG discourage them from accessing ART services

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Summary of FindingsSTI
The AWARE II assessment team reviewed 13 Burkinabe policies, including RH law, national strategic frameworks, norms and protocols and guidelines to assess quality, availability and accessibility of STI services for key populations.
Strengths State funding identified Syndromic management services authorized Periodic presumptive treatment authorized Expedited Partner Therapy authorized Most effective medicines available at all levels of the health care system (see other barriers)

Specific policy gaps SW, TG, MSM o o Not prioritized for free services No specialized clinics (limited number of CBOs in urban centers)

No HAV/HBV (hepatitis A/B) vaccination No provider liability protections for implementing syndromic, periodic presumptive or expedited partner protocols Oral, vaginal, and anal screening not included in protocols Pharmacists and other informal health care providers not authorized to provide syndromic management or periodic presumptive treatment Services unavailable in prison settings

Other barriers Frequent stockouts of government subsidized STI kits o Cost of treatment during stockouts Medications removed from STI kits and sold Stigma and discrimination of SW, MSM. TG and people with STIs discourage them from accessing STI services

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Summary of FindingsCondoms and lubrication

The AWARE II assessment team examined 5 Burkinabe policies found in strategic frameworks and guidelines to assess supply and access to condoms and lubrication (C/L). Condoms and lubrication are instrumental in preventing HIV among key populations.
Strengths State funding identified Eligibility not restricted based on criminalized status (see specific policy gaps) SW retain control over decision regarding condom use Public health authorities monitor uptake and effectiveness of programs Use with regular and casual and in addition to other birth control is emphasized WHO/UNFPA specifications referenced

Specific policy gaps SW, TG, MSM o Not prioritized for free services Lubrication not provided Detainee access limited due to interpretation of penal code

Other barriers Frequent stockouts of lubricant o o Unavailable outside of urban centers Large tubes available in pharmacy Difficult to transport Costly

Stigma and discrimination of SW and MSM discourage them from carrying C/L and accessing services offering C/L

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Summary of FindingsIEC
The AWARE II assessment team reviewed 6 Burkinabe policies in HIV law and the national strategic framework to identify policies that enable or pose challenges for information, education and communication (IEC) appropriate for key populations.
Strengths State funding identified Eligibility not restricted based on criminalized status SW, TG, MSM specific information not restricted General information on number of sexual partners, condom use, and HIV therapy included

Specific policy gaps SW, TG, MSM specific information not guaranteed Information on sero-sorting and sero-positioning not included

Other barriers MSM and TG specific IEC unavailable Stigma for SW, MSM and TG poses a barrier to the development and distribution of IEC

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Summary of FindingsOutreach
The AWARE II assessment team examined 8 Burkinabe policies found in strategic frameworks and guidelines to identify policies that enable or pose challenges to HIV prevention outreach. Outreach is instrumental in preventing HIV among key populations and providing information regarding available HIV services.
Strengths Broad and comprehensive outreach services authorized (see specific policy gaps) Strong government support of CBO outreach

Specific policy gaps Detainees not guaranteed access to services

Other barriers Stigma and discrimination of SW and MSM force these populations to remain hidden Criminalization of soliciting sex work on public streets Stockouts of lubricant Lack of MSM-specific IEC materials Heterogeneity of populations Safety concerns for night-duty outreach workers

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Summary of FindingsAlcohol harm reduction

The AWARE II assessment team was unable to find any harm reduction programs in Burkina Faso. The national framework for HIV and STIs (CSLS 20112015) recognizes alcohol as a mitigating factor in HIV transmission but does not include policy to address alcohol consumption aside from youth education campaigns.
Strengths Recognition of alcohol as a mitigating factor

Specific policy gaps Alcohol harm reduction services unavailable

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Summary of FindingsFP/RH
The AWARE II assessment team examined 6 Burkinabe articles of law and policies in strategic frameworks and guidelines to assess the availability and accessibility of FP/RH services that follow international best practices.
Strengths State funding identified Comprehensive services authorized (see specific policy gaps)

Specific policy gaps SW and TG not specifically identified to receive services; policy for all citizens Detainees lack access resulting from interpretation of penal code Abortion access limited o o o o Rape Incest Threat to health or life of mother Diagnosis of specific, serious condition in fetus

Other barriers Stigma and discrimination for SW and TG o Cost Healthcare providers refuse care citing religious and moral grounds

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ANNEX 2: LIST OF DOCUMENTS CONSULTED BY THE AWARE II ASSESSMENT TEAM

1. 2. 3. 4. 5. 6. 7. 10. Family Health International : Analyse situationnelle des soins et prise en charge du VIH SIDA et des IST (Burkina Faso, Cameroun, Cte dIvoire, Togo), Avril 2001 CNLS-IST : Estimation des flux de ressources et de dpenses nationales de lutte contre le VIH/SIDA et les IST, Burkina Faso, Octobre 2009 CNLS-IST/ONUSIDA : Rapport du suivi de la dclaration dengagement sur le VIH/SIDA Rapport UNGASS, 2010 CNLS-IST : Cadre Stratgique de lutte contre le VIH, le Sida et les IST, 2006 2010 CNLS-IST : Cadre stratgique de lutte contre le VIH, le Sida et les IST 20112015, juillet 2010 MS/CMLS : Etats Gnraux de la Sant/Lutte contre le VIH/Sida 2001-2010, fvrier 2010 Loi n 23/94/ADP portant Code de la Sant publique Dcret N 2010- 744 IPRES/PM/MS portant modalits d'application de la loi 30-2008/N du 20 mai 2008 portant lutte contre le VIH/Sida et protection des droits des personnes vivant avec le VIH/Sida. Dcret portant code de dontologie des mdecins au Burkina Faso Arrt N2001/0250/MS/CAB portant rglementation de la distribution des produits sous monopole pharmaceutique Arrt N2006/MS/CAB portant conditions dexploitation dune officine pharmaceutique prive Arrt N2006/MCPEA/MS portant fixation des prix de vente au Public Des Mdicaments Essentiels Gnriques (MEG) sous Dnomination Commune Internationale (DCI) au Burkina Faso Arrt N 2006/MS/CAB portant dfinition de la Liste des Mdicaments pouvant tre dtenus et dlivrs par les dpts privs de mdicaments Arrt N2006/MCPEA/MS portant fixation des prix de vente au public des Consommables Mdicaux dans les Formations Sanitaires Publiques et Prives but non lucratif, pratiquant le recouvrement des cots au Burkina Faso. Arrt N2006/MS/CAB portant Rglementation du Transfert dune officine pharmaceutique prive MASSN/CMLS : Plan National de Prise en Charge Psychosociale des personnes vivant avec le VIH 2010-2014 Dcret N 2005-398/PRES/PM/MS portant conditions dexercice priv des profession de sant

11. 12. 13. 14.

15. 16.

17. 18. 19.

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20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40.

MS/DEF : Profil pays, recherche en sant au Burkina Faso, novembre 2002 MS/DEF : Profil pays, recherche en sant au Burkina Faso, septembre 2005 CNLS/MS : Normes et Protocole de prise en charge des personnes vivant avec le VIH/Sida au Burkina Faso, novembre 2008 MS/DEF : Rseau de Mtrologie Sanitaire/Evaluation du Systme dInformation Sanitairerapport du Burkina Faso, dcembre 2008 MS : Guide du Systme Nationale de lInformation Sanitaire. 2006. MS/DEF : Plan dAcclration de Rduction de la Mortalit Maternelle et Nonatale au Burkina Faso, octobre 2006 MS : Protocole de sant de la reproduction/composantes communes, mai 2010 MS : Protocole de sant de la reproduction/Sant du nourrisson, de lenfant, de ladolescent et du jeune, mai 2010 MS : Protocole de sant de la reproduction/Sant de la femme-Prise en charge gyncologique, mai 2010 MS : Protocole de sant de la reproduction MS : Document de Politique Sanitaire Nationale, septembre 2000 MS: Programme national dassurance qualit en sant, mai 2003 MS: Programme national de prvention de la transmission mre enfant du VIH 2006-2010, octobre 2006 MS: Rapport dtude sur les shmas de finnacement communautaire de la sant au Burkina faso, aot 2005 UNFPA: Evaluation de la qualit des donnes de la sant de la reproduction au Burkina Faso, juillet 2008 MS/DEF : Programme dactions prioritaires de mise en uvre du CSLP : Rapport de mise en uvre pour lanne 2008, avril 2009 MS/DEF/PADS : Rapport sur le Systme de Sant au Burkina Faso dans une optique de construction des Comptes Nationaux de la Sant, septembre 2005 MS : Plan national de dveloppement sanitaire 2001-2010, septembre 2005 MS/DEF : Rapport relatif lidentification des donnes existantes dans le Systme National dInformation Sanitaire, dcembre 2005 MS : Document de lanalyse de la situation sanitaire nationale, juin 2010 MS : Plan national de dveloppement sanitaire 2011-2020, juin 2011

66

41. 42. 43. 44.

Politique Nationale DEnseignement et de Formation Techniques et Professionnels, juillet 2008. Ministere des Engeignements Secondaire Suprieur et de la Recherche Scientifique. BASP96 : Enqute de surveillance comportementale auprs des groupes haut risque : Travailleuses du sexe et leurs clients au Burkina Faso, Mars 2011 A. Moreau, C.Compaor : Analyse situationnelle sur la problmatique des minorits sexuelles en rapport avec le VIH au Burkina Faso, octobre 2010 CMLS : Modes de transmission du VIH en Afrique de lOuest : Analyse de la distribution des nouvelles infections par le VIH au Burkina Faso et recommandations pour la prvention, mars 2009 MS/DGPLM : Cartographie des systmes dapprovisionnement des mdicaments et autres produits de sant au Burkina Faso, Dcembre 2010 CNLS: Guide lintention des intervenants dans le milieu de la prostitution dans, cadre de la lutte contre le Sida et les IST au Burkina Faso , mars 2006 MS/DGPLM : Guide national des approvisionnements pharmaceutiques du secteur sanitaire public, novembre 2007 MS : Politique pharmaceutique national, 2me d, 2011 MS : Liste des mdicaments essentiels sous dnomination commune internationale, 2011 MS : Plan stratgique pharmaceutique, 20112015 Constitution du Burkina Faso Loi 43-96 ADP du portant code pnal, modifi par la LOI 6-2004 AN du - Avril 2004 Loi 010-2004/AN du 20 Avril 2004 portant protection des donnes caractre personnel Loi n 017/99/AN du 29 Avril 1999 portant code de drogues au Burkina Faso ; Code civil de 1804 applicable au Burkina Faso Loi n 99-022/an du 18 mai 1999 portant code de procdure civile au Burkina Faso Zatu AN VII 13 du 16 Novembre 1989 portant institution du Code des Personnes et de la Famille au Burkina Faso Ordonnance 68-7 PRES du 21 Fvrier 1968 portant institution dun Code de Procdure Pnal Loi organique n 032-2006/AN du 21 dcembre 2006 portant modification de la loi organique n 036-2001/AN du 13 dcembre 2001 portant statut du corps de la magistrature. Loi N030-2008/AN du 20 Mai 2008 portant lutte contre le VIH/SIDA et protection des droits des personnes vivant avec le VIH/Sida. Loi n 049-2005/an du 22 dcembre 2005 portant sante de la reproduction au Burkina Faso

45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61.

67

62. 63. 64. 65. 67. 68. 69.

Loi n022-2005/AN du 24 mai 2005 portant code de lhygine publique au Burkina Faso Loi n028 -2008/an du 13 Mai 2008 portant code du travail au Burkina Faso Loi n 034/98 AN du 18 Mai 1998 portant Loi hospitalire du Burkina Faso Code de dontologie des pharmaciens du Burkina Faso Loi n 013/98/AN du 28 avril 1998 rgime juridique applicable aux emplois et aux agents de la Fonction Publique du Burkina Faso, Loi N 10/92/ADP Du 15 dcembre 1992 portant Libert dassociation au Burkina Faso Dcret N 2010- 744 IPRES/PM/MS portant modalits d'application de la loi n30-2008/AN du 20 mai 2008 portant lutte contre le VIH/Sida et protection des droits des personnes vivant avec le VIH/Sida. Dcret N2009-558/PRES/PM/MJ/MEF/MATD du 22 juillet 2009 portant organisation de lassistance judiciaire au Burkina Faso. JO N 33 du 13 Aout 2009, Arrt N 2007-240/MS/CAB Portant Charte de lUtilisateur des services de Sant Arrt n2004-077/SECU/CAB du 27 dcembre 2004 instituant un Code de bonne conduite des personnels de la police nationale Dcret N 2010-744/PRES/PM/MS portant modalits dapplication de la loi N30-2008/AN du moi 2008 portant lutte contre le VIH/Sida et protection des droits des personnes vivant avec le VIH/Sida. Dclaration Nationale tripartite de lutte contre le VIH/SIDA et les IST en milieu du travail du 03 Juillet 2007 portant prvention et lutte contre et la stigmatisation et la discrimination en milieu de travail Dcret N2010-001/MTSS/CAB portant cration attributions et fonctionnement du Cadre Tripartite de Lutte contre le Virus Immuno Dficience Humaine (VIH/Sida), les Infections Sexuellement Transmissibles et la Tuberculose en Milieu de Travail (CTLS/MT) Arrte N2010-004/MTSS/CAS portant nomination des membres du Cadres Tripartite de Lutte contre le VIH/SIDA, les Infections Sexuellement Transmissibles et la Tuberculose en Milieu de Travail (CTLS/MT) Arrte N2011-1355/MFPTSS/CAB portant modification de lArrt N2010-004/MTSS/CAB du 02 avril 2010 portant nomination des membres du Cadre Tripartite de Lutte contre le VIH/SIDA, les Infection Sexuellement Transmissibles et la Tuberculose en Milieu de Travail (CTLS/MT) Plan Oprationnel de la Stratgie Sectorielle de Lutte contre le VIH, les IST et la Tuberculose en milieu du travail La Politique National Genre

70. 71. 72. 73.

74.

75.

76.

77.

78. 81.

68

82. 83. 84. 85. 86. 87. 88. 89. 90. 91. 94. 95. 96.

Stratgie Sectoriel de Lutte contre le VIH, les IST et la Tuberculose en milieu du travail, Ministre du Travail Orientation Stratgiques du Secteur de lEducation en Matire de Lutte contre les IST, le VIH/SIDA, dautre Problmes de Sant et de Nutrition 2010 2015 Plan dAction National dEducation pour Tous, septembre 2002. Ministre de lEnseignement de Base et de lAlphabtisation. Rapport Premire Phase de lActualisation de la Stratgie de Dveloppement du Secteur du Transport au Burkina Plan dAction 2012 du Ministre des Transports Plan dActions 2012 de Lutte contre le VIH, le SIDA et les IST du Ministre des Transports, des Postes et de lEconomie. 2011. Stratgie de Croissance Acclr et de Dveloppement Durable (SCADD) 20112015 Plan Cadre de Nations Unies pour lAide au Dveloppement (UNDAF) 20112015 MS : La Politique et Normes en Matire de la Sant de la Reproduction. 2010. MS : Annuaire Statistique Sant Burkinab 2008 Loi N 012-2007/AN du 31 mai 2007 portant organisation et rglementation des activits statistiques La Proposition du Burkina Faso au Round 10 du Fond Mondial Le Dcret N2007-078 PRES/PM/MS/MASSN portant modification du dcret 2001-510 PRES/PM/MS Du 1er Octobre 2001 portant cration, attribution, organisation et fonctionnement du conseil national de Lutte contre le SIDA et les IST au Burkina Faso Etude sur le Contexte Juridique de Protection des Jeunes en Difficult au Burkina Faso. ABBEF/IPPF. 2008. Etat de la Prise en Charge Mdicale des Patients Infects par le VIH au Burkina Faso au 31 Dcembre 2011. CMLS. Burkina Faso. 2012. Atelier de Restitution des Donnes de lInfection VIH en 2011. CMLS. Burkina Faso. Fvrier 2012. Manuel de rfrence en conseil dpistage VIH en milieu de soins lusage du personnel de sant, 2me d. Novembre 2008. SP/CNLS Algorithmes de prise en charge des infections sexuellement transmissibles de la version rvise, fvrier 2008. SP/CNLS Loi no 015-2006 du 11 mai 2006 portant rgime de la scurit sociale applicable aux travailleurs salaris et assimils au Burkina Faso

97. 98. 99. 100. 101. 102.

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ANNEX 3: SW AND MSM POLICY ASSESSMENT INVENTORY

CONTENTS
Framework (National, Regional, Local, etc)........................................................................................... Community Partnership .......................................................................................................................... Legal Environment Authorization ....................................................................................................... Legal Environment Consent.................................................................................................................. Legal Environment Privacy and confidentiality ................................................................................... Legal Environment Registries ............................................................................................................... Legal Environment Stigma and discrimination.................................................................................... Legal Environment Definitions ............................................................................................................. Legal Environment Criminalization..................................................................................................... Legal Environment Gender-based violence ......................................................................................... Legal Environment Cruel, inhuman, or degrading treatment or punishment....................................... Legal Environment Monitoring and enforcement of human and legal rights ...................................... Intervention design, access, and implementation Procurement and supply management .................... Intervention design, access, and implementation Overarching services design................................... Intervention design, access, and implementation HCT ........................................................................ Intervention design, access, and implementation ART ........................................................................ Intervention design, access, and implementation Sexually Transmitted Infection Services (STI) ...... Intervention design, access, and implementation Condoms and Lubrication ...................................... Intervention design, access, and implementation Information, Education, Communication (IEC) ..... Intervention design, access, and implementation Outreach ................................................................. Intervention design, access, and implementation Alcohol Harm Reduction ....................................... Intervention design, access, and implementation Reproductive Health/Family Planning (FP/RH) .... Works Cited...................................................................................................................................................

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Framework (National, Regional, Local, etc) International guidelines identify the importance of a coordinated, participatory, transparent, and accountable approach that integrates program responsibilities across all branches of government, aligns with international standards, supports international initiatives, and shares knowledge and information. (UNAIDS, 2006, p. 63) A framework identifies the value of multisectoral coordination, roles and responsibilities, coordination between related health programs, the importance of services within the prison system in achieving national goals and the central role of evidence-based decision making about program priorities, budgets and approaches for services for SW and MSM. Programs or strategies often Lack a clearly defined budget,

Do not contain explicit provisions for allocating the funds necessary to implement the programs and actions contemplated Fail to ensure compliance of priorities and targets with available scientific evidence Fail to provide specific coverage or scale-up targets for SW and MSM services

Omit specific provisions ensuring access of SW, MSM and prison populations , to HIV prevention, care and treatment interventions or state them in a vague, declarative manner not binding executive bodies for specific actions Fail to get full commitment from all designated authorities across various sectors Fail to identify clear implementation mechanisms (UNODC, CHALN, 2010)

Programs are often declarative in nature, amounting to statements of the governments policy intentions or desired outcomes, but with no real force. For example, a program may recognize SW, MSM and inmates as priority groups, but not guarantee specific access to evidence-based interventions. The Program may call for ensuring access of most-at-risk populations to comprehensive package of services; however it lacks clear definition who most-at-risk populations are, of the package of services to be delivered, and makes no direct reference to UNODC/WHO/UNAIDS core interventions. Legal silence on scientifically-based HIV prevention, care and treatment services is probably one of the major reasons why, from the policy formulation point of view, the HIV strategies and programs are unspecific, non-binding and neglect scientific evidence. Since access to specific services for SW and MSM is not required by the law, policy-makers are reluctant to indicate specific actions and indicators in the lower level policies and resort to very broad or unclear statements. As a result, executive bodies do not bear any responsibility for not ensuring availability and quality of services, while advocates cannot refer to the national strategies and programs to demand access to core interventions.

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Inventory and analysis of country documents Country: ____________________________________ Date completed: _________________________

Name of data collector __________________________________________________________________

Position: _____________________________________________________________________________

Contact information for data collector: Email address:_________________________________________________________________________

Telephone/fax: ________________________________________________________________________

Instructions to data collector: Please fill out this page and indicate the best way to contact you (email, telephone, fax, etc.) should we need further information from you.

Refer to the instructions page for directions on how to fill out the inventory. Please provide information only on those areas that you are familiar with or have been assigned to research and leave the others blank. Within the areas that you are working on, please be sure to answer yes or no to each item. All data collectors should address the open-ended question at the end of the areas they are working on.

If you come across a policy document that addresses areas that you are not working on, send the document or citation to the team leader. They will share this information with the individual who has primary responsibility for that section.

When you have completed the inventory, please send all the pages and all the documents you have referenced to [team leader should fill this in before distributing to team members].

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Framework (National, Regional, Local, etc) An effective framework for the response to HIV ensures a coordinated, participatory, transparent, and accountable approach, integrating HIV policy and program responsibilities across all branches of government (ABAROLI, 2011, p. 25) 1. Framework Coordination of HIV, STI, and FP/RH with education, labor, commerce, transportation, immigration, prison, and military programs a. Collect all policy documents that describe gender, education, labor, commerce, transportation, immigration, and military programs
Immigration/Migr ation Military/Uniformed Services 8) Transportation

Education

Commerce

Gender

Program mentions environments or circumstances where sex work may take place (Y) Program fails to mention environments or circumstances where sex work may take place (N) Program mentions environments or circumstances where male to male sexual activity may take place (Y) Program fails to mention environments or circumstances where male-to male sexual activity may take place (N)

1) 9)

2) 10)

3) 4) 5)

6)

11) 12) 13) 14)

For each affirmative citation (Y), make an additional assessment (#) on the level of coordination and alignment. Report on a scale of 1-5. One representing limited coordination, contradictory program goals and approaches, etc; five representing complete alignment of program goals and approaches. Program mentions HIV prevention, care, and treatment services or identifies coordination mechanisms with HIV Programs (Y, #) Program fails to mentions HIV prevention, care, and treatment services or identifies coordination mechanisms with HIV Programs (N) Program mentions STI diagnosis and treatment services or identifies coordination mechanisms with STI Programs (Y, #) Program fails to mentions STI diagnosis and treatment services or identifies coordination mechanisms with STI Programs (N) Program mentions reproductive health and family planning services or identifies coordination mechanisms with FP/RH Programs (Y, #) Program fails to mention reproductive health and family planning services or identifies coordination mechanisms with FP/RH Programs (N)
17) 18) 19) 20) 21) 22) 23) 24)

25)

26)

27) 28) 29) 30)

33)

34)

35) 36) 37) 38)

73

Prisons 7)

Labor

15) 16)

31) 32)

39) 40)

b. Collect all policy documents that describe general development plans (UNAIDS, 2009b, p. 95)

The National Development Plan specifically identifies initiatives that address specific needs of population (Y) The National Development Plan fails to specifically identify initiatives that address the needs of population(N) The Common Country Assessment/UN Development Assistance Framework specifically identifies initiatives that address specific needs of population (Y) The Common Country Assessment/UN Development Assistance Framework fails to specifically identify initiatives that address the needs of population(N) The Poverty Reduction Strategy specifically identifies initiatives that address specific needs of population (Y) The Poverty Reduction Strategy fails to specifically identify initiatives that address the needs of population(N) List other development plans that address needs of population

1)

2)

3)

4)

5)

6)

7)

8)

9)

10)

11)

12)

c. Collect all policy documents that describe HIV, STI, and FP/RH programs in community settings
FP/RH HIV 2) 4) 6) 8) 11) 14) 9) 12) 15) STI 1) 3) 5) 7) 10) 13) For each affirmative citation (Y), make an additional assessment (#) on the level of coordination and alignment. Report on a scale of 1-5. One representing limited coordination, contradictory program goals and approaches, etc; five representing complete alignment of program goals and approaches.

Program guiding documents mention coordination with FP/RH Program (Y, #) Program fails to mention coordination with FP/RH Program (N) Program guiding documents mention coordination with STI Program (Y, #) Program fails to mention coordination with STI Program (N) Program guiding documents mention coordination with HIV Program (Y, #) Program fails to mention coordination with HIV Program (N) Program guiding documents mention coordination with education programs (Y, #) Program fails to mention coordination with education programs (N) Program guiding documents mention coordination with labor programs (Y, #) Program fails to mention coordination with labor programs (N) Program guiding documents mention coordination with commerce programs (Y, #) Program fails to mention coordination with commerce programs (N)

74

MSM

SW

TG

Program guiding documents mention coordination with transportation programs (Y, #) Program fails to mention coordination with transportation programs (N) Program guiding documents mention coordination with immigration/migration programs (Y, #) Program fails to mention coordination with immigration/migration programs (N) Program guiding documents mention coordination with prison programs (Y, #) Program fails to mention coordination with prison programs (N) Program guiding documents mention coordination with military programs (Y, #) Program fails to mention coordination with military programs (N) Program guiding documents address the human rights of SW (Y) Program fails to address the human rights of SW (N) Program guiding documents address the human rights of TG (Y) Program fails to address the human rights of TG (N) Program guiding documents address the human rights of MSM (Y) Program fails to address the human rights of MSM (N)

16)

17)

18)

19)

20)

21)

22) 25) 28) 31)

23) 26) 29) 32) 34)

24) 27) 30) 33) 35)

d. Intentionally blank to align with PWID DM e. Collect all policy documents that describe HIV, STI, and FP/RH programs in prison settings
FP/RH HIV 2) 4) 6) 8) 11) 14) 17) 9) 12) 15) 18) 21) 24) 27) 30) 33) 35) STI 1) 3) 5) 7) 10) 13) 16) 20) 23) 26) 29) 32) 34) For each affirmative citation (Y), make an additional assessment (#) on the level of coordination and alignment. Report on a scale of 1-5. One representing limited coordination, contradictory program goals and approaches, etc; five representing complete alignment of program goals and approaches.

Program guiding documents mention coordination with FP/RH Program (Y, #) Program fails to mention coordination with FP/RH Program (N) Program guiding documents mention coordination with STI Program (Y, #) Program fails to mention coordination with STI Program (N) Program guiding documents mention coordination with HIV Program (Y, #) Program fails to mention coordination with HIV Program (N) Program guiding documents mention coordination with education programs (Y, #) Program fails to mention coordination with education programs (N) Program guiding documents mention coordination with labor programs (Y, #) Program fails to mention coordination with labor programs (N) Program guiding documents mention coordination with commerce programs (Y, #) Program fails to mention coordination with commerce programs (N) Program guiding documents mention coordination with transportation programs (Y, #) Program fails to mention coordination with transportation programs (N) Program guiding documents mention coordination with immigration/migration programs (Y, #) Program fails to mention coordination with immigration/migration programs (N) Program guiding documents mention coordination with prison programs (Y, #) Program fails to mention coordination with prison programs (N) Program guiding documents mention coordination with military programs (Y, #) Program fails to mention coordination with military programs (N) Program guiding documents address the human rights of SW (Y) Program fails to address the human rights of SW (N) Program guiding documents address the human rights of TG (Y) Program fails to address the human rights of TG (N) Program guiding documents address the human rights of MSM (Y) Program fails to address the human rights of MSM (N)

19)

22) 25) 28) 31)

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f.

Intentionally blank to align with PWID DM

g. Collect all policy documents that describe HIV, STI, and FP/RH programs in community or prison settings (WHO, 1993, pp. 1-8), (UNODC, 2006, pp. 17, 22-26), (WHO, 2007a, pp. 6, 11), (UNAIDS, 1999a, p. 61) , (UNODC, 2008b, p.
18), (UNODC, 2009, pp. 42, 43), (UNODC, 2010, pp. 39, 41)

FP/RH

Policy defines or promotes equitable levels of access and resources between community and prison settings (Y) Policy is silent on equitability or describes different or conflicting levels of access and resources for community and prison settings (N)

1)

2)

3)

h. Collect all policy documents that describe HIV, STI, and FP/RH programs in community or prison settings

Policy defines roles and responsibilities between government agencies and nongovernment organizations for administration and provision of services (Y) Policy makes no mention of roles and responsibilities between government agencies and non-government organizations (N)

(Y/N) Communit y Prison

HIV Program STI Program FP/RH Program

1) 3) 5)

2) 4) 6)

Please include any additional remarks or observations about related policy areas not included in the items listed above. If analysis is being done at different levels of government, be sure to identify if national, regional, and/or local policies differ or contradict each other.

76

HIV

STI

2. Framework Data use and decision making a. Collect all policy documents that describe FP/RH, STI, and HIV programs in community and prison settings (CESCR, 2000, p. 13), (UNAIDS, 2006, p. 23), (CESCR, 2000, p. 7), (WHO, 1993, p. 8), (UNODC, 2006, p. 28), (CHALN, 2006e, p. 34)
FP/RH STI Community 3) 9) HIV Prison Community 4) 10) 5) 11) Prison 6) 12)

Policy:

Community

Prison 2) 8)

Identifies services for SW (Y) Fails to identify services for SW (N) Requires international recognized scientific basis for determining services for SW(Y) Fails to state that services will be determined by scientific evidence, identifies another evidence base, or identifies services that do not fall within internationally recognized standards (N) Identifies coverage targets for SW (Y) Fails to mention coverage targets for SW (N) Coverage targets for SW reference international coverage recommendations (Y) Coverage targets are made without reference or comparison to international coverage recommendations (N) Requires evidence basis for funding decisions for SW (Y) Policy for making funding decisions for SW services is not clear or not based on scientific and epidemiological data (N) Identifies achievement of coverage targets for SW as a goal for funding allocations (Y) Fails to tie funding decisions to achievement of coverage targets (N) Identifies government commitment to scale up services for SW (Y) Fails to identify government commitment to scaling up services for SW (N) Identifies data reporting requirements that disaggregate SW from other participants (Y) Fails to identify data reporting requirements specific to SW (N) Policy describes mechanisms for identifying, monitoring and evaluation of program outcomes for SW (Y) Policy makes no mention of SW-specific outcomes (N) Identifies services for TG (Y) Fails to identify services for TG (N)

1) 7)

13) 19)

14) 20)

15) 21)

16) 22)

17) 23)

18) 24)

25)

26)

27)

28)

29)

30)

31)

32)

33)

34)

35)

36)

37) 43)

38) 44)

39) 45)

40) 46)

41) 47)

42) 48)

49)

50)

51)

52)

53)

54)

55)

56)

57)

58)

59)

60)

77

61) 62) Requires international recognized scientific basis for determining services for TG(Y) Fails to state that services will be determined by scientific evidence, identifies another evidence base, or identifies services that do not fall within internationally recognized standards (N) 67) 68) Identifies coverage targets for TG (Y) Fails to mention coverage targets for TG (N) 73) 74) Coverage targets for TG reference international coverage recommendations (Y) Coverage targets are made without reference or comparison to international coverage recommendations (N) 79) 80) Requires evidence basis for funding decisions for TG (Y) Policy for making funding decisions for TG services is not clear or not based on scientific and epidemiological data (N) 86) Identifies achievement of coverage targets for TG as a goal for funding allocations (Y) 85) Fails to tie funding decisions to achievement of coverage targets (N) 91) 92) Identifies government commitment to scale up services for TG (Y) Fails to identify government commitment to scaling up services for TG (N) 97) 98) Identifies data reporting requirements that disaggregate TG from other participants (Y) Fails to identify data reporting requirements specific to TG (N) 103) 104) Policy describes mechanisms for identifying, monitoring and evaluation of program outcomes for TG (Y) Policy makes no mention of TG-specific outcomes (N) Identifies services for clients of SW (Y) Fails to identify services for clients of SW (N) Requires international recognized scientific basis for determining services for clients of SW(Y) Fails to state that services will be determined by scientific evidence, identifies another evidence base, or identifies services that do not fall within internationally recognized standards (N) Identifies coverage targets for clients of SW (Y) Fails to mention coverage targets for clients of SW (N) Coverage targets for clients of SW reference international coverage recommendations (Y) Coverage targets are made without reference or comparison to international coverage recommendations (N) Requires evidence basis for funding decisions for clients of SW (Y) Policy for making funding decisions for clients of SW services is not clear or not based on scientific and epidemiological data (N) Identifies achievement of coverage targets for clients of SW as a goal for funding allocations (Y) Fails to tie funding decisions to achievement of coverage targets (N)

63)

64)

65)

66)

69) 75)

70) 76)

71) 77)

72) 78)

81)

82)

83)

84)

87) 93) 99)

88) 94) 100)

89) 95) 101)

90) 96) 102)

105)

106)

107)

108)

109) 113)

110) 114)

111) 115)

112) 116)

117) 121) 125)

118) 122) 126)

119) 123) 127)

120) 124) 128)

129)

130)

131)

132)

78

Identifies government commitment to scale up services for clients of SW (Y) Fails to identify government commitment to scaling up services for clients of SW (N) Identifies data reporting requirements that disaggregate clients of SW from other participants (Y) Fails to identify data reporting requirements specific to clients of SW (N) Policy describes mechanisms for identifying, monitoring and evaluation of program outcomes for clients of SW (Y) Policy makes no mention of clients of SW-specific outcomes (N) Identifies services for MSM (Y) Fails to identify services for MSM (N) Identifies coverage targets for MSM (Y) Fails to mention coverage targets for MSM (N) Coverage targets for MSM reference international coverage recommendations (Y) Coverage targets are made without reference or comparison to international coverage recommendations (N) Requires evidence basis for funding decisions for MSM (Y) Policy for making funding decisions for MSM services is not clear or not based on scientific and epidemiological data (N) Identifies achievement of coverage targets for MSM as a goal for funding allocations (Y) Fails to tie funding decisions to achievement of coverage targets (N) Identifies government commitment to scale up services for MSM (Y) Fails to identify government commitment to scaling up services for MSM (N) Identifies data reporting requirements that disaggregate MSM from other participants (Y) Fails to identify data reporting requirements specific to MSM (N) Policy describes mechanisms for identifying, monitoring and evaluation of program outcomes for MSM (Y) Policy makes no mention of MSM-specific outcomes (N) Collect any available reports for these programs and analyze actual reporting against reporting requirements

133) 137) 141)

134) 138) 142)

135) 139) 143)

136) 140) 144)

145) 149) 153) 157)

146) 150) 154) 158)

147) 151) 155) 159)

148) 152) 156) 160)

161) 165) 169) 173)

162) 166) 170) 174)

163) 167) 171) 175)

164) 168) 172) 176)

79

b. Collect all policy documents that describe regular populations size estimation requirements for SW, TG, clients of SW, and MSM (UNAIDS/WHO, 2003, pp. 29-37)
Census/ca pturerecapture Policy identifies data and methodologies for SW population size estimation (Y) Policy fails to mention data and methodologies for SW population size estimation (N) Policy identifies data and methodologies for SW client population size estimation (Y) Policy fails to mention data and methodologies for SW client population size estimation (N) Policy identifies data and methodologies for TG population size estimation (Y) Policy fails to mention data and methodologies for TG population size estimation (N) Policy identifies data and methodologies for MSM population size estimation (Y) Policy fails to mention data and methodologies for MSM population size estimation (N) Multiplier Population Behavioral Surveys

1)

2)

3)

4)

5)

6)

7)

8)

9)

10)

11)

12)

Please note if policy requires other size estimation methodologies for any of these populations. Collect the most recent size estimation reports, if available

c. Collect the most recent UNGASS Indicator Report (UNAIDS, 2009b)

Country reports on Indicator #8 (percentage of most-at-risk populations that have received an HIV test in the last 12 months and who know the results) (Y) Country data is no more than 2 years old (Y) Country does not report on Indicator #8 or uses data that is more than 2 years old (N) Country reports on Indicator #9 (percentage of most-at-risk populations reached with HIV prevention programs) (Y) Country data is no more than 2 years old (Y) Country does not report on Indicator #9 or uses data that is more than 2 years old (N) Country reports on Indicator #12 (current school attendance among orphans and non-orphans aged 10-14) (Y) Country data is no more than 5 years old (Y) Country does not report on Indicator #12 or uses data that is more than 5 years old (N) Country reports on Indicator #14 (percentage of most-at-risk populations who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission) (Y) Country data is no more than 2 years old (Y) Country does not report on Indicator #14 or uses data that is more than 2 years old (N) Country reports on Indicator #18 (percentage of female and male sex workers reporting the use of a condom with their most recent client) (Y) Country data is no more than 2 years old (Y) Country does not report on Indicator #18 or uses data that is more than 2 years old (N) 1)

2)

3)

4)

5)

80

Country reports on Indicator #19 (percentage of men reporting the use of a condom the last time they had anal sex with a male partner) (Y) Country data is no more than 2 years old (Y) Country does not report on Indicator #19 or uses data that is more than 2 years old (N) Country reports on Indicator #23 (percentage of most-at-risk populations who are HIV infected) (Y) Country data is no more than 1 year old (Y) Country does not report on Indicator #23 or uses data that is more than 1 year old (N)

6)

7)

d. Collect all policy documents that describe regular data collection requirements for sexual violence in prison
Policy identifies data collection requirements of the incidence and context of sexual violence in prison (Y) Policy fails to identify data collection requirements or does not include data specific to sexual violence in prison (N) 1)

If policy requires collection of data on sexual violence, obtain a copy of the last report with this information and analyze actual reporting against reporting requirements

e. Collect all policy documents that describe regular data collection requirements for primary education (UNICEF, 2011, p. 27)
Policy identifies sex-disaggregated data collection requirements for primary education quality and outcome indicators (Y) Policy fails to identify data collection requirements for primary education indicators or does not require sex-disaggregated reporting (N) 1)

If policy requires collection of data on education indicators, obtain a copy of the last report with this information and analyze actual reporting against reporting requirements

Please include any additional remarks or observations about related policy areas not included in the items listed above. If analysis is being done at different levels of government, be sure to identify if national, regional, and/or local policies differ or contradict each other.

81

Community Partnership The value of including target populations in the design, implementation, and evaluation of programs and policies is well documented in both human rights and intervention specific guidelines. Research has shown the positive impact on health outcomes when communities are engaged in efforts to improve their own health (Manandhar et al. 2004. Green et al 2006). More specifically, WHO HIV program guidelines (2011) call on governments to include MSM and transgender people in development of health plans as supported by medical ethics and human rights models. The crucial role of SW and their organizations in HIV prevention, care and treatment efforts has also been reported (UNAIDS Advisory Group 2011). This component identifies policy factors that impact partnerships of government and community organizations in the design, implementation and monitoring of policy and services. Programs or policies that are developed without the involvement and support of the people they are attempting to assist or serve are less likely to succeed (WHO, 2005a, p. 47) States should ensure, through political and financial support, that community consultation occurs in all phases of HIV/AIDS policy design, program implementation and evaluation and that community organizations are enabled to carry out their activities, including in the fields of ethics, law and human rights, effectively. Community representation should comprise [people living with HIV, communitybased organizations, AIDS-service organizations], human rights NGOs and representatives of vulnerable groups. Formal and regular mechanisms should be established to facilitate ongoing dialogue with and input from such community representatives into HIV-related government policies and programs. (UNAIDS, 1999a, pp. 199-120)

83

Inventory and analysis of country documents

Country: ____________________________________

Date completed: _________________________

Name of data collector __________________________________________________________________

Position: _____________________________________________________________________________

Contact information for data collector: Email address:_________________________________________________________________________

Telephone/fax: ________________________________________________________________________

Instructions to data collector: Please fill out this page and indicate the best way to contact you (email, telephone, fax, etc.) should we need further information from you.

Refer to the instructions page for directions on how to fill out the inventory. Please provide information only on those areas that you are familiar with or have been assigned to research and leave the others blank. Within the areas that you are working on, please be sure to answer yes or no to each item. All data collectors should address the open-ended question at the end of the areas they are working on.

If you come across a policy document that addresses areas that you are not working on, send the document or citation to the team leader. They will share this information with the individual who has primary responsibility for that section.

When you have completed the inventory, please send all the pages and all the documents you have referenced to [team leader should fill this in before distributing to team members].

84

3. Government/community partnerships and engagement of key populations in decision making for hepatitis, TB, HIV, drug use, and/or drug treatment programs a. Collect all policy documents that identify decision making processes for government policies and programs for FP/RH, STI, and HIV programs (UNAIDS, 1999a, pp. 119-120), (UNAIDS, 2006, pp. 24-26), (UNDP, 2009b,
pp. 10, 11)

FP/RH

STI 2)

HIV 3)

1) Policy identifies formal and regular mechanisms for active participation in decision making or policy design from individual and organizational representatives of SW (Y) Policy fails to provide specific mechanisms ensuring active participation or explicitly excludes participation by SW (N) 4) Policy identifies formal and regular mechanisms for active participation in evaluation of policy implementation from individual and organizational representatives of SW (Y) Policy fails to provide specific mechanisms ensuring active participation or explicitly excludes participation by SW (N) 7) Policy identifies formal and regular mechanisms for active participation in decision making or policy design from individual and organizational representatives of TG (Y) Policy fails to provide specific mechanisms ensuring active participation or explicitly excludes participation by TG (N) 10) Policy identifies formal and regular mechanisms for active participation in evaluation of policy implementation from individual and organizational representatives of TG (Y) Policy fails to provide specific mechanisms ensuring active participation or explicitly excludes participation by TG (N) Policy identifies formal and regular mechanisms for active participation in decision making or policy design from individual and organizational representatives of MSM (Y) Policy fails to provide specific mechanisms ensuring active participation or explicitly excludes participation by MSM (N) Policy identifies formal and regular mechanisms for active participation in evaluation of policy implementation from individual and organizational representatives of MSM (Y) Policy fails to provide specific mechanisms ensuring active participation or explicitly excludes participation by MSM (N)

5)

6)

8)

9)

11)

12)

13)

14)

15)

16)

b. Collect all policy documents that describe the CCM

Documents require membership of SW or organizations serving SW (Y) Documents fail to require membership of SW or organizations serving SW (N) Documents require membership of TG or organizations serving TG (Y) Documents fail to require membership of TG or organizations serving TG (N) Documents require membership of MSM or organizations serving MSM (Y) Documents fail to require membership of MSM or organizations serving MSM (N) 1) 2) 3)

c. Collect all policy documents that describe identify national multisectoral HIV/AIDS coordination bodies (National AIDS Council or equivalent)

85

Documents require membership of SW or organizations serving SW (Y) Documents fail to require membership of SW or organizations serving SW (N) Documents require membership of TG or organizations serving TG (Y) Documents fail to require membership of TG or organizations serving TG (N) Documents require membership of MSM or organizations serving MSM (Y) Documents fail to require membership of MSM or organizations serving MSM (N)

4) 5) 6)

Collect membership list of CCM and compare to representation requirements

d. Collect all policy documents that identify role of non-governmental organizations for service delivery of FP/RH, STI, and HIV programs (UNAIDS, 1999a, p. 130) (UNAIDS-e, 2008, pp. 215-217), (UNDP, 2009b, pp. 10, 11)

FP/RH

STI Community 3)

HIV Prison Community 4) 5) Prison 6)

Policy:

Community

Prison

1) 2) Policy supports the establishment and sustainability of non-governmental organizations (formal or informal) inclusive of but not limited to those comprised of SW for peer education, empowerment, positive behavior change, and social support (Y) Policy fails to mention non-governmental organizations or explicitly restricts funding to or service delivery by non-governmental organizations for SW (N) 7) 8) Policy supports the establishment and sustainability of non-governmental organizations (formal or informal) inclusive of but not limited to those comprised of TG for peer education, empowerment, positive behavior change, and social support (Y) Policy fails to mention non-governmental organizations or explicitly restricts funding to or service delivery by non-governmental organizations for TG(N) Policy supports the establishment and sustainability of nongovernmental organizations (formal or informal) inclusive of but not limited to those comprised of MSM for peer education, empowerment, positive behavior change, and social support (Y) Policy fails to mention non-governmental organizations or explicitly restricts funding to or service delivery by nongovernmental organizations for MSM (N)

9)

10)

11)

12)

13)

14)

15)

16)

Please include any additional remarks or observations about related policy areas not included in the items listed above. If analysis is being done at different levels of government, be sure to identify if national, regional, and/or local policies differ or contradict each other.

86

Legal Environment Authorization It is of significant importance to identify the agency authorized to implement services for SW and MSM. Policies can authorize oversight and coordination of programs, laws and/or services by public health agencies, law enforcement and/or judicial agencies, which can in turn have a profound impact on implementation. For example, law enforcement involvement in safer sex programming, as with some 100% condom programs implemented among SW in South Asia, can have serious ramifications on program success (UNAIDS Advisory Group 2011). Similarly, public health legislation that gave police the authority to monitor the sexual health of sex workers in Madagascar created serious obstacles and was detrimental to both sex workers and project success. In prison settings, authority to make health care decisions is often placed under law enforcement, prison, or detention authorities rather than health care providers with deleterious consequences.

87

Inventory and analysis of country documents

Country: ____________________________________

Date completed: _________________________

Name of data collector __________________________________________________________________

Position: _____________________________________________________________________________

Contact information for data collector: Email address:_________________________________________________________________________

Telephone/fax: ________________________________________________________________________

Instructions to data collector: Please fill out this page and indicate the best way to contact you (email, telephone, fax, etc.) should we need further information from you.

Refer to the instructions page for directions on how to fill out the inventory. Please provide information only on those areas that you are familiar with or have been assigned to research and leave the others blank. Within the areas that you are working on, please be sure to answer yes or no to each item. All data collectors should address the open-ended question at the end of the areas they are working on.

If you come across a policy document that addresses areas that you are not working on, send the document or citation to the team leader. They will share this information with the individual who has primary responsibility for that section.

When you have completed the inventory, please send all the pages and all the documents you have referenced to [team leader should fill this in before distributing to team members].

88

4. Authorization of FP/RH, STI, and HIV programs a. Collect all policy documents that describe authority to provide FP/RH, STI, and HIV services Policy empowers public health authorities to provide a comprehensive range of prevention and treatment services for the following programs (Y) Policy fails to authorize or limits authority or services provided for the following programs (N) (UNAIDS, 2006, pp. 26, 27)
1) FP/RH (contraception, disease screening, vaccinations, sexual functioning, fertility evaluation, etc) If No what service(s) are missing? 1)

2) STI (screening, diagnosis, syndromic management, contact tracing, etc) If No what service(s) are missing?

2)

3) HIV (testing, treatment, etc) If No what service(s) are missing?

3)

b. Collect all policy documents that identify the government sector with the authority to coordinate health and harm reduction programs
Policy authorizes public health agencies with oversight and coordination authority for SW services (Y) Policy authorizes law enforcement and/or judicial agencies with oversight and coordination authority for SW services(N) Note: if both statements are true indicate (Y/N) and comment 1)

Policy authorizes public health agencies with oversight and coordination authority for TG services (Y) Policy authorizes law enforcement and/or judicial agencies with oversight and coordination authority for TG services(N) Note: if both statements are true indicate (Y/N) and comment

2)

Policy authorizes public health agencies with oversight and coordination authority for MSM services (Y) Policy authorizes law enforcement and/or judicial agencies with oversight and coordination authority for MSM services(N)

3)

89

Note: if both statements are true indicate (Y/N) and comment

c. Collect all policy documents that mentions responsibility for the management and provision of pre-trial detention, prison, and minor-custody health services (UNODC,
2006, pp. 18, 22)

Policy assigns responsibility for prison health services to the same ministries, departments, and agencies providing health services to the general population (Y) Policy does not explicitly mention responsibility for health services or assigns prison health to law enforcement, prison, or detention authorities (N)

1)

Note: if both statements are true indicate (Y/N) and comment Policy provides for independent health provider decisions in prison settings (Y) Policy places health provider treatment decisions under authority of law enforcement, prison, or detention authorities (N) 2)

Please include any additional remarks or observations about related policy areas not included in the items listed above. If analysis is being done at different levels of government, be sure to identify if national, regional, and/or local policies differ or contradict each other.

90

Legal Environment Consent Informed consent is one of the three Cs of HIV testing, along with confidentiality of test results and counseling (WHO 2007). Declaration on the promotion of patients rights in Europe, adopted by the European Meeting on Patient Rights, Amsterdam (WHO, 1994, p. 11) states that the informed consent of the patients is a prerequisite of any medical intervention, including the right to refuse or to halt a medical intervention. Mandatory testing also drives people in need away from needed services thus reducing access to prevention and treatment. However abuses of this right have been reported for many countries in the world. The right for informed consent may be abused if policies do not set requirements or specify components and procedures for the informed consent (e.g. the nature of testing or treatment, risks and benefits, the right to refuse intervention at any stage without punishment etc). For instance, laws may state that citizens and their legal representatives have the right to refuse testing and treatment at any stage, and refusal should be provided in written form. However if the law lacks provisions requiring health care providers to obtain informed consent from the patients it may be interpreted to mean that the absence of written refusal of the patient counts as informed consent. Similarly, HIV legislation and policies stating the voluntary nature of testing for HIV often fail to specify the procedures for informed consent (for details see the section on HIV testing and counseling).

Legal silence on the right for informed consent and related procedures may lead to vague policies lacking details on service providers responsibilities. For example, policies may indicate that voluntary testing for HIV is done with the persons informed consent; however no specifics on how this consent should be obtained (oral or written) or what kind of information should be provided to the client are given. In this case service providers may assume that consent is obtained if no objections are made by the patient, effectively violating the requirement for informed consent (UNODC, CHALN, 2010) Age restrictions States parties need to introduce legislation or regulations to ensure that children have access to confidential medical counseling and advice without parental consent, irrespective of the childs age, where this is needed for the childs safety or well-being. Children may need such access, for example, where they are experiencing violence or abuse at home, or in need of reproductive health education or services, or in case of conflicts between parents and the child over access to health services. The right to counseling and advice is distinct from the right to give medical consent and should not be subject to any age limit (UN, 2009, p. 23) States must ensure that adolescents have access to appropriate health information and services regardless of parental consent, particularly those concerning sexual and reproductive health. Given sufficient maturity, adolescents may request confidential health services and information (UNGA, 2009, p. 14) Young people in many countries are reported to have limited access to core health services due to age limitations posed by policy or health care providers. Requiring parental consent to access health information and services is a major obstacle to STI and HIV prevention, care and treatment efforts. Research in West Africa has shown that FSW clients include students and other youth. Stigma and violence against MSM in Burkina Faso often originate from within the family (Niang, et al. 2004) which underscores the need for access to confidential health services for these youth.

91

Mandatory/compulsory testing and treatment UNAIDS/WHO supports mandatory screening for HIV and other blood borne viruses of all blood that is destined for transfusion or for manufacture of blood products. Mandatory screening of donors is required prior to all procedures involving transfer of bodily fluids or body parts, such as artificial insemination, corneal grafts and organ transplant. UNAIDS/WHO do not support mandatory testing of individuals on public health grounds (WHO, 2005b, p. 8) Mandatory or compulsory testing continues being a reality, particularly for members of most-at-risk and vulnerable populations. Sometimes it is done without the knowledge of the person being tested. The purpose of such testing is not to provide access to HIV prevention, treatment, care and support, but most often to exclude people with HIV from access to certain services, or otherwise impose restrictions on them. Such mandatory or compulsory forms of testing violate ethical principles and basic rights of consent, privacy and bodily integrity; they cannot be justified on public health grounds (WHO, 2010c, p. 12) The vague and unelaborated language of laws and ministerial instructions regulating HIV testing and especially those related to testing of vulnerable groups opens the door for discrimination and other human rights violations (UNODC, CHALN, 2010) Despite WHO and UNODC recommendations, legislation in some countries requires mandatory HIV testing for reasons other than transplantation or blood transfusion procedures. Legislation may provide for mandatory HIV testing for the broad categories of people including drug users, pregnant women, persons diagnosed with STIs, and persons suspected by public health or law enforcement agencies to be HIVpositive, which results in police raids targeting drug users and sex workers and involving compulsory HIV testing (EHRN, 2011c). In other countries the problem lies in legislation failing to explicitly prohibit broad application of mandatory HIV testing or requiring obtaining informed consent. In such cases ministerial orders and guidelines tend to expand categories of people who should be tested based on epidemiological indications.

92

Inventory and analysis of country documents

Country: ____________________________________

Date completed: _________________________

Name of data collector __________________________________________________________________

Position: _____________________________________________________________________________

Contact information for data collector: Email address:_________________________________________________________________________

Telephone/fax: ________________________________________________________________________

Instructions to data collector: Please fill out this page and indicate the best way to contact you (email, telephone, fax, etc.) should we need further information from you.

Refer to the instructions page for directions on how to fill out the inventory. Please provide information only on those areas that you are familiar with or have been assigned to research and leave the others blank. Within the areas that you are working on, please be sure to answer yes or no to each item. All data collectors should address the open-ended question at the end of the areas they are working on.

If you come across a policy document that addresses areas that you are not working on, send the document or citation to the team leader. They will share this information with the individual who has primary responsibility for that section.

When you have completed the inventory, please send all the pages and all the documents you have referenced to [team leader should fill this in before distributing to team members].

93

5. Consent a. Collect all policy documents that mentions consent for medical testing and treatment for FP/RH, STI, and HIV in prison and community settings- (WHO, 2007e, pp. 36, 37), (UNGA, 2009), (UNODC, 2006, p. 25), (WHO, 2007a, p. 7),
(WHO, 2007c, p. 6), (UNODC, 2009, p. 39), (WHO, 1993, p. 7),

FP/RH Community Prison 2)

STI Community 3) Prison 4)

HIV Community 5) Prison 6)

Policy requires consent for medical testing and treatment (Y) Policy does not explicitly mention consent requirements or describes limitations on consent protections for medical testing and treatment (N) Policy identifies the right to refuse or withdraw from medical testing and treatment at any time (Y) Policy does not explicitly mention the right to refuse or withdraw from medical testing and treatment (N) Policy identifies the following elements required for consent to medical and drug testing and treatment (Y)
o o o o o o the consent must relate specifically to the treatment administered; the consent must be fully informed; the consent must be given voluntarily; the consent is given individually, in private, in the presence of a health-care provider the consent may be verbal or written; and the consent must not be obtained through misrepresentation, coercion, or fraud

1)

7)

8)

9)

10)

11)

12)

13)

14)

15)

16)

17)

18)

Policy does not explicitly identify consent components listed above (N)

b. Collect all policy documents mentioning access by children, in and out of state custody, to confidential medical counseling and advice about FP/RH, STI, and HIV (UNGA, 2009, pp. 5, 14), (HRC, 2011, p. 19)
FP/RH STI 2) HIV 3)

Policy guarantees access to information and counseling regardless of parental/caregiver consent, irrespective of the childs age (Y) Policy does not explicitly guarantee access to information or describes parental consent requirements or age restrictions (N) Policy specifically authorizes age-appropriate school curricula that is inclusive of all sexual orientations and gender identities (Y) Policy fails to authorize or prohibits school curricula that is inclusive of all sexual orientations and gender identities (N)

1)

4)

5)

6)

c. Collect all policy documents mentioning access by adolescents, in and out of state custody, to information and medical services for FP/RH, STI and HIV(UNGA, 2009, pp. 5, 14)
FP/RH STI 2) HIV 3)

Policy guarantees access to information and medical services regardless of parental consent (Y) Policy does not explicitly guarantee access or describes parental consent requirements or age restrictions higher than adolescence (N)

1)

94

d. Policy that mentions mandatory or compulsory testing or treatment (WHO, 1993, p. 5), (UNODC, 2006, p. 18), (WHO, 2007a, p. 7), (UNODC, 2009, p. 35), (UNODC, 2010, p. 38), (UNAIDS, 1999a, pp. 124, 128), (UNAIDS, 2006, p. 37), (UNGA, 2009, pp. 8, 23, 24), (WHO, 2002, p. 9) , (Inter-Parliamentary Unit [IPU], 2007, p. 79), (YP,
2007, p. 23)

FP/RH

STI

HIV

Policy: Prohibits mandatory or compulsory medical testing except for screening of donated blood prior to transfusion, occupational exposure, and before all procedures involving transfer of bodily fluids or body parts, such as artificial insemination, corneal grafts and organ transplant (Y) Fails to prohibit or allows mandatory or compulsory testing of SW, TG, MSM or prisoners (exception above notwithstanding) (N) Prohibits mandatory or compulsory medical treatment (Y) Fails to prohibit or allows mandatory medical treatment of SW, TG, MSM or prisoners (N)

Community Prison 1) 2)

Community Prison Community Prison 3) 4) 5) 6)

7)

8)

9)

10)

11)

12)

Y/N 13) Prohibits mandatory or compulsory medical or psychological treatment, procedure, testing or confinement to a medical facility based on sexual orientation (Y) Fails to prohibit or allows mandatory or compulsory medical or psychological treatment, procedure, testing or confinement to a medical facility based on sexual orientation (N) 14) Prohibits mandatory or compulsory medical or psychological treatment, procedure, testing or confinement to a medical facility based on gender identity (Y) Fails to prohibit or allows mandatory or compulsory medical or psychological treatment, procedure, testing or confinement to a medical facility based on gender identity (N) Please include any additional remarks or observations about related policy areas not included in the items listed above. If analysis is being done at different levels of government, be sure to identify if national, regional, and/or local policies differ or contradict each other.

95

e. Collect all policy documents mentioning services or interventions for SW (CHALN, 2007, p. 8) Policy requires that services for SW be provided only with informed consent of participants including 100% condom use and raid and rescue interventions(Y) Policy fails to require informed consent for services for SW (N) Policy requires that eligibility for services is not dependent on leaving sex work (Y) Policy requires that eligibility for services is dependent on leaving sex work (N)

1)

2)

96

Legal Environment Privacy and confidentiality Public health legislation should ensure that HIV and AIDS cases reported to public health authorities for epidemiological purposes are subject to strict rules of data protection and confidentiality. Public health legislation should ensure that information related to the HIV status of an individual is protected from unauthorized collection, use or disclosure in the health care and other settings, and that the use of HIV-related information requires informed consent (UNAIDS, 1999a, p. 122) The presence of mandatory disclosure policies or a process of designating those tested and their results by name may reduce uptake of HCT. This may be due to a fear of stigma and discrimination subsequent to involuntary disclosure, effect on occupation or personal relations, or any other desires for privacy. Laws and regulations can require an individual to disclose his or her status or define situations under which a health worker should or should not disclose HIV status to the clients sexual or other partner (duty to warn), or to a parent (in the case of minors). Ndjamena-type model laws found in 11 countries in the AWARE II region generally impose an obligation for disclosure to partners. The Ndjamena model law template includes Article 26 that requires the person with diagnosed HIV infection to disclose as soon as possible and by six weeks at the most. At least 3 countries in the region allow health care providers to disclose to a partner or parent. Laws and regulations can also authorize or require a level of confidentiality. Even though many countries have acted to limit potential loss of confidentiality during HIV testing and counseling, there are still gaps. Moreover, public health legislation regarding confidentiality is not always implemented in health care settings. For FSW and MSM who are already stigmatized, fear of HIV-status disclosure can prevent them from participating in HCT and getting subsequent care and treatment.

97

Inventory and analysis of country documents

Country: ____________________________________

Date completed: _________________________

Name of data collector __________________________________________________________________

Position: _____________________________________________________________________________

Contact information for data collector: Email address:_________________________________________________________________________

Telephone/fax: ________________________________________________________________________

Instructions to data collector: Please fill out this page and indicate the best way to contact you (email, telephone, fax, etc.) should we need further information from you.

Refer to the instructions page for directions on how to fill out the inventory. Please provide information only on those areas that you are familiar with or have been assigned to research and leave the others blank. Within the areas that you are working on, please be sure to answer yes or no to each item. All data collectors should address the open-ended question at the end of the areas they are working on.

If you come across a policy document that addresses areas that you are not working on, send the document or citation to the team leader. They will share this information with the individual who has primary responsibility for that section.

When you have completed the inventory, please send all the pages and all the documents you have referenced to [team leader should fill this in before distributing to team members].

98

6. Privacy and confidentiality of personal medical and drug treatment/services utilization data a. Collect all policy documents mentioning personalized individual-level data on FP/RH, STI, and HIV.
(UNAIDS, 1999a, pp. 122, 124, 125), (UNAIDS, 2006, p. 28), (ABAROLI, 2011, p. 64), (CHALN, 2006e, pp. 19, 20)

FP/RH Community Prison 2)

STI Community 3)

HIV Prison Community 4) 5) Prison 6)

Policy explicitly includes individual-level data on within definitions of personal/medical data subject to protection which prohibits its collection, use, disclosure, and/or publication without the individuals consent (Y) Policy fails to explicitly describe protections of individual-level data or identifies mechanisms for its collection, use, disclosure, and/or publication without the individuals consent (N)

1)

b. Collect all policy documents mentioning disclosure of individual-level data on medical and psychological service utilization, , (WHO, 1993, p. 7), (UNODC, 2006, p. 18)
FP/RH Community Prison 2) STI Community 3) HIV Prison Community 4) 5) Prison 6)

Policy explicitly prohibits routine disclosure of individual-level data on medical service utilization, without the individuals consent (for example to administrative and security personnel and law enforcement authorities) (Y) Policy fails to explicitly prohibit disclosure of individual-level data on medical service utilization beyond direct service providers or identifies mechanisms for its routine disclosure without the individuals consent (for example to administrative and security personnel and law enforcement authorities) (N) Policy explicitly prohibits routine disclosure of individual-level data on psychological service utilization, without the individuals consent (for example to administrative and security personnel and law enforcement authorities) (Y) Policy fails to explicitly prohibit disclosure of individual-level data on psychological service utilization beyond direct service providers or identifies mechanisms for its routine disclosure without the individuals consent (for example to administrative and security personnel and law enforcement authorities) (N)

1)

7)

8)

9)

10)

11)

12)

99

Collect all policy documents defining parental/guardian notification requirements (WHO, 1993,
p. 8)

FP/RH

STI 2)

HIV 3)

Policy requiring notifying parents or guardians of their childrens medical status requires due regard for the principle that the best interests of the child or adolescent are paramount (Y) Policy requiring notification of parents of a childs medical stats has no leeway or exceptions for the best interests of the child or adolescent (N)

1)

c. Collect all policy documents mentioning individual access to their personal medical records (ABAROLI, 2011, p. 64)
FP/RH STI 2) HIV 3)

Policy gives individuals access to their own personal medical records and the ability to request amendments to ensure that information is accurate, relevant, complete, and up-to-date (Y) Policy fails to explicitly allow individuals access to their own personal medical records and the ability to request amendments to ensure that information is accurate, relevant, complete, and up-to-date or restricts such access (N)

1)

d. Collect all policy documents that identifies recourse for release of confidential information
(UNAIDS, 2006, p. 33), (Inter-Parliamentary Unit [IPU], 2007, p. 94), (ABAROLI, 2011, p. 64), (UNODC, 2006, p. 18), (UNODC, 2009, p. 35)

Policy establishes an independent agency to address breaches of condentiality and related sanctions for the unauthorized release of confidential information (Y) Policy fails to identify mechanisms for recourse for release of confidential information (N)

1)

e. Collect all policy documents mentioning mandatory medical testing for SW

FP/RH STI 2) HIV 3)

If mandatory testing exists for SW, policy states that confirmation of testing is provided to the relevant authorities, but that the test results are not disclosed without the consent of the individual. (Y) If mandatory testing exists for SW, policy allows for disclosure of test results to relevant authorities (N)

1)

f. Intentionally blank to align with PWID DM g. Collect all policy documents mentioning partner notification for cases of exposure to communicable disease
STI HIV 2)

Policy specifically mentions protocols to protect the identification of the individual with the communicable disease (Y) Policy makes no mention of protections or specifically authorizes the disclosure of the identification of the individual with a communicable disease (N)

1)

Please include any additional remarks or observations about related policy areas not included in the items listed above. If analysis is being done at different levels of government, be sure to identify if national, regional, and/or local policies differ or contradict each other.

100

Legal Environment Registries Registries are used in public health for epidemiological purposes and at the health clinic or provider level to record patient information, including sensitive health records. In cases where data are linked to personal identifiers, such as name or address, data protection and confidentiality should be maintained. Policies can prohibit use of certain types of registries or inclusion of certain information, explicitly lay out regulations for data protection (such as use of unique identification codes and encryption of databases) and confidentiality, or remain vague with few or no guidelines to protect patients. Sex offender registries Government sex offender registries exist in many countries and are used to keep records of individuals involved in and/or accused of sexual activities prohibited under current laws. In countries where sex work and same-sex sexual relations are illegal, these registries can include SW and MSM. Governments can enact policy that forbids discriminatory acts against SW and MSM, or in extreme cases, these registries can be accessed and information can be used to take away custody of children and deny access to state services such as housing, education and employment.

101

Inventory and analysis of country documents

Country: ____________________________________

Date completed: _________________________

Name of data collector __________________________________________________________________

Position: _____________________________________________________________________________

Contact information for data collector: Email address:_________________________________________________________________________

Telephone/fax: ________________________________________________________________________

Instructions to data collector: Please fill out this page and indicate the best way to contact you (email, telephone, fax, etc.) should we need further information from you.

Refer to the instructions page for directions on how to fill out the inventory. Please provide information only on those areas that you are familiar with or have been assigned to research and leave the others blank. Within the areas that you are working on, please be sure to answer yes or no to each item. All data collectors should address the open-ended question at the end of the areas they are working on.

If you come across a policy document that addresses areas that you are not working on, send the document or citation to the team leader. They will share this information with the individual who has primary responsibility for that section.

When you have completed the inventory, please send all the pages and all the documents you have referenced to [team leader should fill this in before distributing to team members].

102

7. Registries a. Collect all policy documents that authorize reporting individual-level data to public health authorities for epidemiological purposes (UNAIDS, 2006, p. 27), (ABAROLI, 2011, p. 65)
FP/RH STI 2) HIV 3)

Policy subjects individual-level data to strict rules of data protection and condentiality (Y) Policy fails to mention confidentiality protections or provides for regular disclosure of this data to non-health agencies (N)

1)

b. Collect all policy documents that authorize registries of providers and clients for FP/RH, STI, and HIV services (WHO, 2004b, p. 28), (CHALN, 2006b, p. 32)
If Registries are authorized assess the following. If Registries are NOT authorized, respond with a N/R in the appropriate box
FP/RH STI HIV

Policy focuses implementation of registry on ensuring the quality of services (Y) Policy provides no mention of mechanisms for quality assurance (N) Policy guarantees patient and provider confidentiality (Y) Policy makes no mention of patient or provider confidentiality or provides for regular disclosure of data (N) Policy authorizes management of the monitoring system solely by public health authorities (Y) Policy authorizes management of the monitoring system by non-health authorities (e.g. law enforcement) (N)

1) 4)

2) 5)

3) 6)

7)

8)

9)

c. Collect all policy documents that mentioning non-medical registries (i.e. sexual offender registries)
Policy does not register SW in non-medical registries (Y) skip to questions on TG below Policy requires SW registration on non-medical registries (N) continue analysis If policy registers SW on non-medical registries Policy prohibits discriminatory actions such as o loss of child custody, o denial of state services such as education, housing, and financial assistance, or o denied eligibility for employment or drivers license solely on the basis of being registered as a sex offender (Y) Policy fails to prohibit discrimination or authorizes actions such as any of those listed above solely on the basis of being registered as a sex offender (N). If No, describe discriminatory action 1) 2)

If policy authorizes registration of SW on non-medical registries Policy identifies clear and easy processes and timeline for removal of a persons name from the registry (Y) Policy provide no clear mechanism or timeline for removal of a persons name from the registry (N) If policy authorizes registration of SW on non-medical registries Policy requires individual consent or court authorization to disclose individual information (Y) Policy grants access to health records to prosecutors, police, and other agencies without court authorization (N)

3)

4)

103

 Policy does not register TG in non-medical registries (Y) skip to questions on MSM below Policy requires TG registration on non-medical registries (N) continue analysis If policy registers TG on non-medical registries Policy prohibits discriminatory actions such as o loss of child custody, o denial of state services such as education, housing, and financial assistance, or o denied eligibility for employment or drivers license solely on the basis of being registered as a sex offender (Y) Policy fails to prohibit discrimination or authorizes actions such as any of those listed above solely on the basis of being registered as a sex offender (N). If No, describe discriminatory action

5) 6)

If policy authorizes registration of TG on non-medical registries Policy identifies clear and easy processes and timeline for removal of a persons name from the registry (Y) Policy provide no clear mechanism or timeline for removal of a persons name from the registry (N) If policy authorizes registration of TG on non-medical registries Policy requires individual consent or court authorization to disclose individual information (Y) Policy grants access to health records to prosecutors, police, and other agencies without court authorization (N) Policy does not register MSM in non-medical registries (Y) skip the rest of the assessment on non-medical registries Policy requires MSM registration on non-medical registries (N) continue analysis If policy registers MSM on non-medical registries Policy prohibits discriminatory actions such as o loss of child custody, o denial of state services such as education, housing, and financial assistance, or o denied eligibility for employment or drivers license solely on the basis of being registered as a sex offender (Y) Policy fails to prohibit discrimination or authorizes actions such as any of those listed above solely on the basis of being registered as a sex offender (N). If No, describe discriminatory action

7)

8)

9)

10)

If policy authorizes registration of MSM on non-medical registries Policy identifies clear and easy processes and timeline for removal of a persons name from the registry (Y) Policy provide no clear mechanism or timeline for removal of a persons name from the registry
104

11)

(N) If policy authorizes registration of MSM on non-medical registries Policy requires individual consent or court authorization to disclose individual information (Y) Policy grants access to health records to prosecutors, police, and other agencies without court authorization (N)

12)

Please include any additional remarks or observations about related policy areas not included in the items listed above. If analysis is being done at different levels of government, be sure to identify if national, regional, and/or local policies differ or contradict each other.

105

Legal Environment Stigma and discrimination . States should enact or strengthen anti-discrimination and other protective laws that protect vulnerable groups, people living with HIV and people with disabilities from discrimination in both the public and private sectors (UNAIDS, 2006, pp. 17-18) Stigma and discrimination on the grounds of sex work and sexual orientation In 2006, heads of State and government representatives committed to enact legislation, regulations and other measures to eliminate all forms of discrimination against, and to ensure the full enjoyment of all human rights and fundamental freedoms, by people living with HIV and members of vulnerable groups (Political Declaration on HIV/AIDS 2006). In 2012, stigma and discrimination on the grounds of sex work and sexual orientation are still common throughout West Africa and in many other parts of the world. SW are stigmatized for their occupation and because they are perceived as high risk for HIV. Even in Senegal where SW can register with the government, they report stigmatization, rape, abuse from health care clinic staff, police corruption that includes extortion and bribery, and discrimination by potential landlords and schools for their children (OSI 2006). For SW living with HIV there is a double stigma leading to poor treatment by health officials and pressure to stop working. Stigma and discrimination lead SW to avoid HIV testing and treatment, to self-medicate or to hide their occupation from health care providers, often resulting in inadequate diagnosis and treatment (NSWP 2010). Research in Burkina Faso revealed that MSM experience stigma, discrimination and violence, including being beaten and publicly humiliated by family members (Niang, et al. 2004). Stigma and discrimination cause many MSM to hide their behavior, making them afraid to access HIV treatment and making it difficult for prevention, care and treatment efforts to reach them. Stigma and discrimination also result in heterosexual marriage as a social cover among MSM in the region (World Bank/NACA 2008), which can in turn further increase the spread of HIV among the general population. Stigmatization is even greater for MSM living with HIV who are stigmatized for their behavior, sexual identity and Detailed Technical Guidance HIV status. Policies related to national-level FP/RH, STI, and HIV programs can identify the causes of stigma and discrimination among key populations and ways to measure them. Approaches to reducing stigma and discrimination of key populations can also be addressed, including programming to sensitize health care workers and using sympathetic health mediators to accompany SW, MSM and TG to health care facilities. Laws, regulations and policies of non-discrimination in access to health care are also important for SW, MSM, TG and prisoners. Antidiscrimination policies can be general or can specifically lay out non-discrimination based on sexual orientation, sexual identity, sources of income and prisoner status. Discrimination based on nationality and place of residence In many countries around the world, policies discriminating

UNAIDS Stigma and Discrimination Resource Page http://www.unaids.org/en/targetsa ndcommitments/eliminatingstigm aanddiscrimination/

Stigma Action Network http://www.stigmaactionnetwork. org/web/guest/home

107

against foreign nationals pose barriers for SW to key health care and harm reduction services. Migrants, and particularly migrant sex workers and PWID, often lack health insurance in the host country and thus can only attend private clinics and personally pay for services received placing medical service out of financial reach for these individuals (UNODC, CHALN, 2010). Some countries still have legal provisions requiring deportation of foreigners living with HIV, TB, and STIs. Foreign citizens face mandatory testing for conditions such as HIV, TB, syphilis, and drug dependency and face imminent cancelation of residency permits and deportation (UNODC, CHALN, 2010). The threat of deportation may cause migrants, including SW, to avoid testing and treatment for HIV, TB and STIs in the host country (International Organization on Migration [IOM], 2010). The removal of passports as a result of imprisonment and the absence of a registered residency address upon release mean that ex-prisoners face difficulties to register for and continue TB or HIV treatment or any other medical services (WHO, 2010a, p. 5) Denial of services based on nationality or residence registration, which is an example of restrictive policies, is unjustified in terms of public health, as it limits access to services to those who are most in need of them.

108

Inventory and analysis of country documents

Country: ____________________________________

Date completed: _________________________

Name of data collector __________________________________________________________________

Position: _____________________________________________________________________________

Contact information for data collector: Email address:_________________________________________________________________________

Telephone/fax: ________________________________________________________________________

Instructions to data collector: Please fill out this page and indicate the best way to contact you (email, telephone, fax, etc.) should we need further information from you.

Refer to the instructions page for directions on how to fill out the inventory. Please provide information only on those areas that you are familiar with or have been assigned to research and leave the others blank. Within the areas that you are working on, please be sure to answer yes or no to each item. All data collectors should address the open-ended question at the end of the areas they are working on.

If you come across a policy document that addresses areas that you are not working on, send the document or citation to the team leader. They will share this information with the individual who has primary responsibility for that section.

When you have completed the inventory, please send all the pages and all the documents you have referenced to [team leader should fill this in before distributing to team members].

109

8. Stigma and discrimination a. Collect all policy documents describing national-level FP/RH, STI, and HIV programs (ABAROLI, 2011, p. 47), (UNAIDS-d, 2007, pp. 11-16), (Inter-Parliamentary Unit [IPU], 2007, p. 92), (UNDP, 2009b, pp. 10, 11), (Mahon, 2009, p. 244),
(WHO, 2011, p. 30)

Policy:

FP/RH

STI 2) 5)

HIV 3) 6)

Identifies the root causes of stigma and discrimination against SW (Y) 1) Fails to identify root causes of stigma and discrimination against SW (N) 4) Identifies mechanisms to measure stigma and discrimination against SW (Y) Fails to measure stigma and discrimination against SW (N) 7) Implements and monitors a multifaceted national approach to reduce stigma and discrimination against SW (Y) Fails to implement and monitor activities to address stigma and discrimination against SW (N) Identifies the root causes of stigma and discrimination against TG (Y) 10) Fails to identify root causes of stigma and discrimination against TG (N) 13) Identifies mechanisms to measure stigma and discrimination against TG (Y) Fails to measure stigma and discrimination against TG (N) 16) Implements and monitors a multifaceted national approach to reduce stigma and discrimination against TG (Y) Fails to implement and monitor activities to address stigma and discrimination against TG (N) Identifies the root causes of stigma and discrimination against MSM (Y) Fails to identify root causes of stigma and discrimination against MSM (N) Identifies mechanisms to measure stigma and discrimination against MSM (Y) Fails to measure stigma and discrimination against MSM (N) Implements and monitors a multifaceted national approach to reduce stigma and discrimination against MSM (Y) Fails to implement and monitor activities to address stigma and discrimination against MSM (N)

8)

9)

11) 14)

12) 15)

17)

18)

19) 21) 23)

20) 22) 24)

b. Collect all policy documents that describe the general country-wide antidiscrimination policy (e.g. prohibiting discrimination based on individual characteristics such as gender, race, etc) (UNAIDS, 2006, p. 31), , , (UNAIDS, 1999a, p. 127), (Inter-Parliamentary Unit [IPU], 2007, p. 93), (WHO, 2011, p. 12), (WHO, 2011, p. 30)
Policy mentions prisoners as individuals protected from discrimination (Y) Policy fails to mention prisoners (N) Policy mentions relatives or associates of prisoners as individuals protected from discrimination (Y) Policy fails to mention relatives or associates of prisoners (N) Policy mentions individuals with actual or perceived health conditions (including hepatitis, TB, or HIV) as individuals protected from discrimination (Y) Policy fails to mention actual or perceived health conditions (N) Policy mentions actual or perceived source of income as a characteristic protected from discrimination (Y) Policy fails to mention actual or perceived source of income (N) Policy mentions actual or perceived sexual orientation as a characteristic protected from 1) 2)

3)

4)

5)

110

discrimination (Y) Policy fails to mention actual or perceived sexual orientation(N) Policy mentions actual or perceived gender identity as a characteristic protected from discrimination (Y) Policy fails to mention actual or perceived gender identity(N) Policy identifies protections against harassment and victimization for individuals who file a discrimination complaint (Y) Policy fails to provide protections against harassment and victimization (N) If traditional and customary laws, teachings, or practices affect the status and treatment of SW, TG or MSM (UNAIDS, 2006, p. 32), (WHO, 2011, p. 30) Policy provides for legal remedies if such laws or practices are used against SW, TG, or MSM (Y) Policy fails to provide for legal remedies (N) Policy authorizes and supports information, education, or community mobilization campaigns to change these customary laws and the attitudes associated with them (Y) Policy fails to support activities to change laws and attitudes (N)

6)

7)

8)

9)

If legal remedies are provided, please describe

c. Collect all policy documents that describe anti-discrimination policy for the following services.
(WHO, 2006, p. 6), , (UNAIDS-e, 2008, p. 187)

Employment

Education

Housing

FP/RH

Policy prohibits discrimination based on source of income (Y) Policy fails to prohibit discrimination based on source of income (N) Policy prohibits discrimination based on gender identity (Y) Policy fails to prohibit discrimination based on gender identity (N) Policy prohibits discrimination based on sexual orientation (Y) Policy fails to prohibit discrimination based on sexual orientation (N) Policy prohibits discrimination based on HIV status (Y) Policy fails to prohibit discrimination based on HIV status (N) Policy prohibits discrimination based on residency/citizenship (Y) Policy fails to prohibit discrimination based on residency/citizenship (N)
pp. 15, 16), (UNAIDS, 2006, p. 36), (UNAIDS, 2009)

1)

2)

3)

4)

5)

6)

7)

8)

9)

10)

11)

12)

13)

14)

15)

16)

17)

18)

19) 25)

20) 26)

21) 27)

22) 28)

23) 29)

24) 30)

d. Collect all policy documents that mention incitement of hatred, contempt, or ridicule (CHALN, 2006g,
SW TG MSM HIV

111

HIV

STI

Policy states that it is unlawful to incite hatred towards, serious contempt for, or severe ridicule of a person or group of persons on the ground that they are, or are perceived to be, (1) Sex Workers, (2) TG, (3) MSM, (4) HIV infected (Y) Policy does not mention incitement of hatred, contempt, or ridicule of people or promotes such actions (N)

1)

2)

3)

4)

Please include any additional remarks or observations about related policy areas not included in the items listed above. If analysis is being done at different levels of government, be sure to identify if national, regional, and/or local policies differ or contradict each other.

112

Legal Environment Definitions The application of laws and policies can be impacted by the way populations, behaviors and health status are defined in those laws and policies. For example, efforts to stop human trafficking often lead to displacement of SWs who must avoid police raids (UNAIDS Advisory Group 2011). This impedes affective HIV outreach and can have a direct impact on HIV risk (UNAIDS 2009d). Lack of a clear distinction between trafficking and consensual sex work in policy takes agency away from CSW and can lead to practices that impact HIV prevention, care and treatment efforts.

Although the way populations and behaviors are defined in policies is often a reflection of cultural attitudes, it can also spread stigma and discrimination. When specific behaviors, sexual orientation or gender identity are criminalized or defined as deviant or socially unacceptable, stigma, discrimination and violence, including police brutality, may be more acceptable, making HIV outreach and access to services more difficult.

113

Inventory and analysis of country documents

Country: ____________________________________

Date completed: _________________________

Name of data collector __________________________________________________________________

Position: _____________________________________________________________________________

Contact information for data collector: Email address:_________________________________________________________________________

Telephone/fax: ________________________________________________________________________

Instructions to data collector: Please fill out this page and indicate the best way to contact you (email, telephone, fax, etc.) should we need further information from you.

Refer to the instructions page for directions on how to fill out the inventory. Please provide information only on those areas that you are familiar with or have been assigned to research and leave the others blank. Within the areas that you are working on, please be sure to answer yes or no to each item. All data collectors should address the open-ended question at the end of the areas they are working on.

If you come across a policy document that addresses areas that you are not working on, send the document or citation to the team leader. They will share this information with the individual who has primary responsibility for that section.

When you have completed the inventory, please send all the pages and all the documents you have referenced to [team leader should fill this in before distributing to team members].

114

9. Definitions a. Intentionally left blank to align with PWID DM b. Collect all policy documents that describe or define disability (UNAIDS, 2006, p. 31), (CHALN, 2006g, p. 12),
(CHALN, 2006g, p. 14)

Disability policy includes the loss of physical or mental function/ability to earn a living based on HIV infection (Y) Disability policy does not include HIV infection as a condition in the definition of disability (N)

1)

c. Collect all policy documents that describe or define sex work, solicitation, prostitution, or crimes against nature (UNODC)
Sex work is identified as a legitimate, legal occupation (Y) Sex work is identified as criminal or otherwise socially unacceptable (N) 1)

d. Collect all policy documents that describe or define human trafficking

Policy defines human trafficking as the acquisition of people by improper means such as force, fraud or deception, with the aim of exploiting them (Y) Policy makes no distinction between trafficking and consensual sex work (N) 1)

e. Collect all policy documents that mention homosexuality, sodomy, or buggery (UNAIDS,
2006, p. 36), (HRC, 2010, p. 6)

Same-sex sexual behavior is recognized as a naturally occurring, normal expression of sexual behavior (Y) Sam-sex sexual behavior is defined as deviant, criminal, an illness, or otherwise socially unacceptable (N)

1)

f.

Collect all policy documents that mention gender conformity or identity (HRC, 2010, p. 6)
Gender identity refers to each persons deeply felt internal and individual experience of gender, which may or may not correspond with the sex assigned at birth, including the personal sense of the body and other expressions of gender (Y) Gender non-conformity is defined as deviant, criminal, an illness, or otherwise socially unacceptable (N) 1)

Please include any additional remarks or observations about related policy areas not included in the items listed above. If analysis is being done at different levels of government, be sure to identify if national, regional, and/or local policies differ or contradict each other.

115

Legal Environment Criminalization Criminal law establishes definitions and parameters of behavior that reflect a criminal justice perspective and identify options for enforcement and remedy. In this section the Decision Model identifies criminal laws that impact access to services. Special attention is paid to criminal laws that increase HIV risk or exposure to high-risk environments such as prisons. Criminalization of sex work Criminalization of voluntary sex work, including laws prohibiting commercial sex work, soliciting, pimping, brothel-keeping and trafficking can adversely affect SW access to HIV prevention, treatment and care. In some places, condoms are used as evidence against FSW and their clients. In addition to criminalization of sex work, other laws or articles, such as those that criminalize loitering or public indecency, are often used to stop, harass and regulate SW in public settings. Sex workers are often displaced from commercial development areas, which further interferes with access to services. Consensual sex workers are also harassed through programs and policies aimed to target human trafficking (UNAIDS Advisory Group 2011). Criminalization and police harassment can deter SW from carrying condoms, prevent them from reporting abuse, discourage them from accessing HIV services and put them in unsafe and exploitive working conditions that make condom negotiation more difficult. Moreover, they legitimize generalized social stigma and discrimination of FSW. Criminalization of homosexuality Criminalization of same-sex behavior, male-male or female-female, is found in some countries in the AWARE II region. These laws often have significant penalties, including imprisonment, institutionalize stigma and create an enabling environment for police brutality and violence against MSM. Moreover, they legitimize generalized social stigma and discrimination of MSM forcing them to hide. Such legal sanctions have a profound effect on MSM, who may become hidden and hence less accessible for prevention, treatment, and care interventions in their area. A recent review suggested that HIV prevalence among MSM is higher in settings with criminalization of same-sex behavior than those where it is legal (MSMGF 2010). Also, the very existence of some of these laws is considered suspect from a human rights standpoint. Criminalization of transmission of communicable diseases (including HIV) Laws that criminalize negligent or willful exposure seek to deter individuals whose actions lead to exposure of others to HIV and potential transmission (Gable, Gamharter et al. 2007). In this context, intent and actual occurrence of transmission may be relevant legally, though difficult to prove. Article 36 of the Ndjamena-type model law found in the AWARE II region refers to willful transmission, defined as transmission of HIV through any means by a person with full knowledge of his/her HIV/AIDS status to another person (Pearshouse 2007). This leaves the law open to interpretation with the potential to include cases where condoms were used but failed, even in instances where water-based lubricants (WBL) were not available. Many countries in the AWARE II region that adopted Ndjamena-type model laws have acted to criminalize transmission of HIV but may not have appropriately defined the conditions under which this is considered willful or negligent. The criminalization of willful transmission is prevalent in the eleven countries that have adopted the model laws. However, some countries are revising portions of the law with the assistance from AWARE II. These laws are problematic in the context of SW, who may not have sufficient agency to negotiate safe sex even if they are aware of their HIV status and wish to do so, and for MSM who may not have access to WBL. A WHO guidance on this matter determined that criminalization of HIV transmission should be

117

a last resort, seen as a failure of prevention efforts, and only undertaken in a manner consistent with human rights (WHO 2006). The guidance also raised the issue of such criminalization being potentially linked to greater stigma and discrimination for PLHIV. Key populations may avoid HIV testing or public health settings if such prosecutions are likely in the context of unsafe sex or injecting drug use. Referral to services rather than prosecution Prosecution of SW, MSM or PLHIV can be a major barrier to prevention efforts, adoption of safer sex behaviors and access to support and care services. These populations may avoid HIV testing and services for fear of prosecution. SW and MSM are often forced to hide making it harder for them to access services and for outreach efforts to find them. Service referral in lieu of prosecution can ensure key populations get the services they need. Aiding and abetting legislation Educational material which may necessarily involve detailed information about transmission risks and may target groups engaged in illegal behavior, such as injecting drug use and sexual activity between the same sexes, where applicable, should not be wrongfully subject to censorship or obscenity laws or laws making those imparting the information liable for aiding and abetting criminal offences (UNAIDS, 2006, p. 97)

118

Inventory and analysis of country documents

Country: ____________________________________

Date completed: _________________________

Name of data collector __________________________________________________________________

Position: _____________________________________________________________________________

Contact information for data collector: Email address:_________________________________________________________________________

Telephone/fax: ________________________________________________________________________

Instructions to data collector: Please fill out this page and indicate the best way to contact you (email, telephone, fax, etc.) should we need further information from you.

Refer to the instructions page for directions on how to fill out the inventory. Please provide information only on those areas that you are familiar with or have been assigned to research and leave the others blank. Within the areas that you are working on, please be sure to answer yes or no to each item. All data collectors should address the open-ended question at the end of the areas they are working on.

If you come across a policy document that addresses areas that you are not working on, send the document or citation to the team leader. They will share this information with the individual who has primary responsibility for that section.

When you have completed the inventory, please send all the pages and all the documents you have referenced to [team leader should fill this in before distributing to team members].

119

10. Criminal/Administrative law criminalization and punishment

a. b. c. d. Intentionally left blank to align with PWID DM Intentionally left blank to align with PWID DM Intentionally left blank to align with PWID DM Collect all policy documents that mention sex work, prostitution or solicitation (UNAIDS, 2006) Policy states that selling sexual services is legal (Y) Policy states that selling sexual services is illegal (N) Policy states that purchasing sexual services is legal (Y) Policy states that purchasing sexual services is illegal (N) Policy states that solicitation for sex work is legal (Y) Policy states that solicitation for sex work is illegal (N) Policy states that operating places of prostitution is legal (Y) Policy states that operating places of prostitution is illegal (N) Policy states that sex work, prostitution or solicitation is not punished by imprisonment (Y) Sex work, prostitution or solicitation is punished by imprisonment (N) Policy identifies alternatives to prison and non-custodial diversions for people convicted of offences related to sex work, prostitution or solicitation (Y) Policy does not identify alternatives to prison or requires prison sentences for offences related to sex work, prostitution or solicitation (N) Policy does not identify escalating penalties for repeated convictions for sex work, prostitution or solicitation (Y) Policy identifies escalating penalties for repeated convictions for sex work, prostitution or solicitation (N) Policy states that individuals who have been trafficked or otherwise coerced into transactional sex are not prosecuted for participating in the sex industry (Y) Policy fails to protect individuals who have been trafficked or coerced into transactional sex from prosecution (N) Collect all policy documents that mention homosexuality or sexual orientation (YP, 2007, pp. 1112, 23), (HRC, 2011, p. 7) Policy does not mention homosexual identity or identifies them as legal (Y) Policy classifies homosexual identity as illegal (N) Policy does not punish homosexual identity by death (Y) Policy punishes homosexual identity by death (N) Policy does not punish homosexual identity by imprisonment (Y) Policy punishes homosexual identity by imprisonment (N) Regulations ensure that medical or psychological treatment or counseling does not, explicitly or implicitly treat sexual orientation as a medical conditions to be treated, cured, or suppressed (Y) Regulations allow for curative therapies for sexual orientation (N) Collect all policy documents that mention gender identity or gender nonconformity (YP, 2007, pp. 11-12) Policy does not mention transgender identity or gender nonconformity or identifies it as legal (Y) Policy classifies transgender identity or gender nonconformity as illegal (N) Policy does not punish transgender identity or gender nonconformity by death (Y) Policy punishes transgender identity or gender nonconformity by death (N) Policy does not punish transgender identity or gender nonconformity by imprisonment (Y) Policy punishes transgender identity or gender nonconformity by imprisonment (N) Regulations ensure that medical or psychological treatment or counseling does not, explicitly

1) 2) 3) 4) 5) 6)

7)

8)

e.

1) 2) 3) 4)

f.

1) 2) 3) 4)

120

g.

h.

or implicitly treat gender identity as a medical conditions to be treated, cured, or suppressed Regulations allow for curative therapies for gender identity Collect all policy documents that mention consensual same-sex sexual activity, sodomy, debauchery, indecency or buggery (YP, 2007, pp. 11-12), (UNAIDS, 1999a, p. 127), (HRC, 2010, p. 5), (UNODC, 2006, p. 19), (UNAIDS, 2009), (HRC, 2011, p. 15) Consensual same-sex sexual activity among persons who are over the age of consent is legal (Y) Consensual same-sex sexual activity among persons who are over the age of consent is illegal (N) Policy defines the age of consent to sex as consistent for heterosexual and homosexual relationships (Y) Policy does not define the age of consent for homosexual relationships or identifies an age that is different for heterosexual and homosexual relationships (N) Policy does not regulate extra-marital sexual conduct through criminal or financial sanctions (Y) Policy regulates extra-marital sexual conduct through criminal or financial sanctions (N) Policy recognizes that consensual sexual activity occurs in prisons, and ensures that consensual sexual activity is not penalized (Y) Policy penalizes consensual sexual activity in prisons (N) Consensual same-sex sexual activity among persons who are over the age of consent is not punishable by death (Y) Consensual same-sex sexual activity among persons who are over the age of consent is punishable by death (N) Consensual same-sex sexual activity among persons who are over the age of consent is not punishable by imprisonment (Y) Consensual same-sex sexual activity among persons who are over the age of consent is punishable by imprisonment (N) Policy identifies alternatives to prison and non-custodial diversions for people convicted of offences related to consensual same-sex sexual activity among persons who are over the age of consent (Y) Policy does not identify alternatives to prison or requires prison sentences for offences related to consensual same-sex sexual activity among persons who are over the age of consent (N) Policy does not identify escalating penalties for repeated convictions of consensual same-sex sexual activity among persons who are over the age of consent (Y) Policy identifies escalating penalties for repeated convictions of consensual same-sex sexual activity among persons who are over the age of consent (N) Collect all policy documents that mention transmission of communicable diseases (including HIV) (UNAIDS, 1999a, p. 123), (UNAIDS, 2006, p. 29), (UNDP, 2008, p. 1), (ABAROLI, 2011, pp. 91, 92), (HRC, 2010, p. 17) Criminal and/or public health legislation does not include specific offences against the deliberate and intentional transmission of HIV (Y) Policy contains specific HIV transmission criminalization codes (N) Policy applies general criminal offences in the instance of deliberate, intentional, malicious transmission of HIV (Y) Policy contains specific HIV transmission criminalization codes (N) Criminal liability does not exist for HIV exposure without transmission (Y) Criminal liability exists for HIV exposure (N) Criminal liability does not exist for non-disclosure of HIV status (Y) Criminal liability exists for non-disclosure of HIV status (N) Criminal law is not be applied where there is no significant risk of transmission or where the person: (Y) o Did not know that he/she was HIV-positive o Did not understand how HIV is transmitted o Disclosed his/her HIV-positive status to the person at risk (or honestly believed the

1)

2)

3)

4)

5)

6)

7)

2)

1)

2)

3) 4) 5)

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other person was aware of his/her status through some other means) Did not disclose his/her HIV-positive status because of fear of violence or other serious negative consequences o Took reasonable measures to reduce risk of transmission, such as practicing safer sex through using a condom or other precautions to avoid higher risk acts o Previously agreed on a level of mutually acceptable risk with the other person Criminal law is applied in any of these circumstances (N) i. Collect all policy documents that describe restrictions on loitering, movement and association (includes hooligan, rouge, vagabond, etc) (UNAIDS, 2006) Policy provides for no restrictions on movement, association, and assembly (Y) Policy provides for restrictions on movement, association, and assembly (N) If loitering policies exist, they do not specifically mention prostitution or solicitation (Y) Loitering policies specifically mention prostitution or solicitation (N) j. Collect all policy documents that mention protection of public morality and public scandal (Bradley), (UNAIDS, 2009) Policy relates to: o Activities in public (Y) Policy fails to limit protection of public morality to public activities or authorizes authority over private activities (N) Protection of consent to engage in behaviors (Y) Policy fails to limit protection of public morality to the protection of consent or authorizes authority that undermines individual consent (N) Protection from injustice (Y) Policy fails to limit protection of public morality to the protection of injustice or authorizes authority that undermines justice (N)

1) 2) 3)

1)

2)

3)

k.

l.

Collect all policy documents that mention cross dressing Policy provides no restriction of the style of clothing worn (Y) Policy restricts the style of clothing to that of an individuals physiological sex at birth (N) Collect all policy documents that define admissible evidence of criminalized behaviors for the purposes of determining criminal or administrative offense (CHALN, 2006e, p. 25) , (UNAIDS, 2009) Community Policy states that the presence of disease or the mode of transmission is not admissible as evidence of criminalized behavior (Y) Policy fails to protect information regarding the presence of disease or the mode of transmission from admissibility in criminal or administrative proceedings (N) SW TG MSM Policy states that condoms and other safer sex materials are not admissible as evidence of criminalized behavior for the purposes of determining any criminal or administrative offence (Y) Policy fails to protect condoms and other safer sex materials from admissibility to criminal or administrative proceedings (N) SW TG MSM Policy states that information provided in the process of reporting violence is not admissible for the purposes of any criminal or administrative offence (Y)

1)

Prison

1) 3) 5)

2) 4) 6)

7) 9) 11)

8) 10) 12)

122

Policy fails to disallow information from the report of violence or allows this information to serve as evidence in criminal or administrative proceedings (N) 13) 14) SW 15) 16) TG 17) 18) MSM Policy states that information provided in the process of reporting blackmail is not admissible for the purposes of any criminal or administrative (Y) Policy fails to disallow information from the report of blackmail or allows this information to serve as evidence in criminal or administrative proceedings (N) 19) 20) SW 21) 22) TG 23) 24) MSM Policy states that information provided in the process of filing a discrimination complaint is not admissible for the purposes of any criminal or administrative offence related to criminalized identity or behavior (Y) Policy fails to disallow information from the a discrimination complaint or allows this information to serve as evidence in criminal or administrative proceedings (N) 25) 26) SW 27) 28) TG 29) 30) MSM m. Collect all policy documents that mention promotion, facilitation, or aiding and abetting of criminal offences, (UNAIDS, 2006, p. 97), (UNAIDS-e, 2008, p. 203) 1) Policy states that educational materials which include detailed information about disease transmission risks, drug treatment, and harm reduction information and may target groups engaged in illegal behavior, such as sex work or same sex sexual behavior are not subject to laws making those imparting the information liable for aiding and abetting criminal offences (Y) Policy fails to mention protection from criminal liability for HIV prevention and harm reduction information (N) 2) Policy states that beneficiaries of HIV prevention, drug treatment, and harm reduction activities are provided immunity from aiding and abetting prosecution (Y) Policy fails to mention protection from criminal liability for beneficiaries of HIV prevention and harm reduction information and activities (N) 3) Policy states that health care providers of HIV prevention, drug treatment, harm reduction and general medical care activities are provided immunity from aiding and abetting prosecution (Y) Policy fails to mention protection from criminal liability for health care providers for HIV prevention, drug treatment, harm reduction and general medical care (N) 4) Policy states that non-medical service providers of HIV prevention, drug treatment, harm reduction and general medical care activities are provided immunity from aiding and abetting prosecution (Y) Policy fails to mention protection from criminal liability for non-medical service providers for HIV prevention, drug treatment, harm reduction and general medical care (N) n. Collect all policy documents that mention delivery of drug use-related information about hepatitis and HIV through mass media, (UNAIDS, 1999a, p. 128) 1) Policy enables widespread provision of information on how HIV is spread and assures that this information is not inappropriately subject to censorship or other broadcasting standards (Y) Policy does not explicitly mention protection of HIV information from censorship or identifies inappropriate censorship barriers to its delivery (N) Please include any additional remarks or observations about related policy areas not included in the items listed above. If analysis is being done at different levels of government, be sure to identify if national, regional, and/or local policies differ or contradict each other.

123

Legal Environment Gender-based violence Definition of rape Reporting and prosecution of rape is affected by how rape is defined under the law and in policies that affect rape victims and their perpetrators. Although laws in many countries are being broadened to cover any gender of victim and attacker, laws typically consider victims as female and perpetrators as male. In countries where physical resistance is required, instances in which the victim is incapable of giving consent due to the influence of drugs, alcohol or because of age may not be covered by the law. Insertion and penetration may be limited to specific body parts (e.g. penis and vagina) or recognize other forms of rape. Experience of SW with sexual violence Sexual violence against sex workers is common and comes from many sources, including clients, pimps, members of the community and police. In a study in Burkina Faso, 68% of FSW interviewed reported being victims of recurrent theft and rape (Drabo, et al. 2010). Sexual violence against SW reduces their ability to negotiate condom use and access adequate health care and increases risk of HIV transmission. In places like Burkina Faso where sex work is illegal, SW are unlikely to report cases of sexual violence or press charges out of fear of being prosecuted themselves. As a group, populations with criminalized status, occupations, and behaviors such as TG, SW and MSM have more experience with the legal system and detention and prison settings. A key concern with any harm reduction program for SW and MSM will be to address sexual violence in detention and prison settings as this violence provides another mechanism for both human rights violations and disease transmission.

125

Inventory and analysis of country documents

Country: ____________________________________

Date completed: _________________________

Name of data collector __________________________________________________________________

Position: _____________________________________________________________________________

Contact information for data collector: Email address:_________________________________________________________________________

Telephone/fax: ________________________________________________________________________

Instructions to data collector: Please fill out this page and indicate the best way to contact you (email, telephone, fax, etc.) should we need further information from you.

Refer to the instructions page for directions on how to fill out the inventory. Please provide information only on those areas that you are familiar with or have been assigned to research and leave the others blank. Within the areas that you are working on, please be sure to answer yes or no to each item. All data collectors should address the open-ended question at the end of the areas they are working on.

If you come across a policy document that addresses areas that you are not working on, send the document or citation to the team leader. They will share this information with the individual who has primary responsibility for that section.

When you have completed the inventory, please send all the pages and all the documents you have referenced to [team leader should fill this in before distributing to team members].

126

11. Domestic, sexual, and gender-based violence

Y/N

a. Collect all policy documents that describe or define rape (UNHCHR & McDougal, 1998),
The definition of rape Identifies any penetration without consent or under conditions of force, coercion, or duress (Y) Requires higher proof than non-consent such as physical resistance (N) Includes insertion of any body part or object (Y) Is limited to the insertion of a penis (N) Includes penetration of the mouth, anus, and vagina (Y) Penetration in rape is limited to the vagina (N) identifies non-gender specific descriptions of the victim and perpetrator (Y) Victims are limited to females and/or perpetrators are limited to males (N)
1) 2) 3) 4)

Y/N

b. Collect all policy documents that mention honor killings

(UNAIDS, 2009, p. 15)

Policy identifies full prosecution and punishment for honor killings of individuals based on sexual orientation or sexual identity. (Y) Policy identifies sexual orientation or gender identity as mitigating factors in the prosecution and punishment for honor killings (N)

1)

c. Collect all policy documents that mention sexual violence or abuse (Pivot Legal Society, 2006, pp.
145-148, 190)

Policy states that sex workers have full access to complaint process in cases where they are subject to sexual harassment or abuse by their employers and clients (Y) Policy excludes sex workers from resolution processes for sexual harassment or abuse(N) Policy states that despite any terms of a contract (formal or informal) for the provision of commercial sexual services, a person may, at any time, refuse to provide, or to continue to provide, a commercial sexual service to any other person. (Y) Policy fails to protect individual consent for sexual services or identifies a contract as carte blanche consent (N)

1)

2)

d. Collect all policy documents that mention services for individuals who experience sexual violence or abuse (UNDP, 2009b, pp. 10, 11)
SW TG 2) MSM 3) Prisoners 4)

Policy provides for access to medical assistance for people who experience sexual abuse (Y) Policy fails to provide for access to medical assistance (N) Policy authorizes Post-Exposure Prophylaxis (PEP) for individuals who experience sexual abuse (Y) Policy fails to authorize PEP for individuals who experience sexual abuse (N) Policy stipulates that criminalized status, occupation, or behavior does NOT preclude an individual from legal recourse for sexual abuse (Y) Policy precludes individuals or circumstances that involve criminalized status, occupation, or behavior from legal recourse for sexual abuse(N)

1)

5)

6)

7)

8)

9)

10)

11)

12)

127

Y/N

e. Collect all policy documents that mention domestic violence reporting requirements
Policy does not require universal reporting of domestic violence incidents to police as this may discourage SW, TG, or MSM from seeking medical attention (Y) Policy provides no leeway or judgment in domestic violence reporting requirements (N) 1)

Y/N

f.

Collect all policy documents that mention access eligibility for domestic violence shelters
Policy does not restrict access of SW to domestic violence shelters (Y) Policy restricts access of SW to domestic violence shelters (N) Policy does not restrict access of TG to domestic violence shelters (Y) Policy restricts access of TG to domestic violence shelters (N) Policy does not restrict access of MSM to domestic violence shelters (Y) Policy restricts access of SW to domestic violence shelters (N) 1) 2) 3)

Y/N

g. Collect all policy documents that mention housing of detainees (WHO, 2009c, p. 11)
Policy directs that female detainees are housed separately from male detainees (Y) Policy does not provide for separate housing for female and male detainees (N) Policy directs that all transgender detainees are housed with female detainees (Y) Policy does not house transgender detainees with female detainees (N) 1) 2)

h. Collect all policy documents that mention non-consensual sex in prison (WHO, 1993, pp. 5, 6) ,
(UNODC, 2006, p. 19), (UNODC, 2010, p. 38), (UNAIDS, 1999a, p. 124), (UNAIDS, 2006, pp. 30, 31), (CHALN, 2006e, p. 34)

Y/N
1) 2) 3)

Policy prohibits non-consensual sex, coerced sex, bullying, and rape (Y) Policy fails to mention or prohibit non-consensual sex (N) Policy outlines structures and processes to punish and/or segregate sexual predators (Y) Policy fails to identify structures and processes to punish sexual predators (N) Policy provides for comprehensive and compassionate care and counseling for survivors of sexual violence (Y) Policy fails to provide for care and counseling for survivors of sexual violence (N)

Please include any additional remarks or observations about related policy areas not included in the items listed above. If analysis is being done at different levels of government, be sure to identify if national, regional, and/or local policies differ or contradict each other.

128

Legal Environment Cruel, inhuman, or degrading treatment or punishment Policies to protect SW, MSM, TG and prisoners are necessary given high levels of stigma and discrimination found in the AWARE II region. MSM and FSW in Burkina Faso have reported incidences of stigma, discrimination and violence that point to the need for protective policies (Niang, et al 2004. Drabo et al. 2010). Policies can also endorse or prohibit detention centers for social rehabilitation of SW, TG or MSM.

129

Inventory and analysis of country documents

Country: ____________________________________

Date completed: _________________________

Name of data collector __________________________________________________________________

Position: _____________________________________________________________________________

Contact information for data collector: Email address:_________________________________________________________________________

Telephone/fax: ________________________________________________________________________

Instructions to data collector: Please fill out this page and indicate the best way to contact you (email, telephone, fax, etc.) should we need further information from you. Refer to the instructions page for directions on how to fill out the inventory. Please provide information only on those areas that you are familiar with or have been assigned to research and leave the others blank. Within the areas that you are working on, please be sure to answer yes or no to each item. All data collectors should address the open-ended question at the end of the areas they are working on. If you come across a policy document that addresses areas that you are not working on, send the document or citation to the team leader. They will share this information with the individual who has primary responsibility for that section. When you have completed the inventory, please send all the pages and all the documents you have referenced to [team leader should fill this in before distributing to team members].

130

12. Cruel, inhuman, or degrading treatment or punishment a. Collect all policy documents that mention torture or cruel, inhuman, or degrading treatment or punishment (HRC, 2011, p. 6)
Community Prison Settings Settings Policy defines torture or cruel, inhuman or degrading treatment or punishment as illegal and liable for imprisonment (Y) Policy fails to mention or endorses torture or cruel, inhuman, or degrading treatment (N) Policy guarantees freedom from torture and other cruel, inhuman or degrading treatment or punishment (Y) Policy fails to protect from torture and other cruel, inhuman or degrading treatment (N) Policy specifically mentions sexual orientation and gender identity as protected from torture and ill-treatment Policy fails to mention sexual orientation and gender identity as protected from torture and ill-treatment Policy specifically identifies protections from torture and ill-treatment in contexts of State custody or control Policy fails to mention protections from torture and ill-treatment in contexts of State custody or control Policy identifies redress for victims of torture and ill-treatment Policy fails to identify redress for victims of torture and ill-treatment 1) 2)

3)

4)

5)

6)

7)

8)

9)

10)

b. Collect all policy documents that mention isolation, detention, or quarantine (ABAROLI,
2011, p. 108)

Y/N 1)

Policy prohibits detention centers for social rehabilitation which impose arbitrary confinement and other human rights abuses (e.g., forced labor) on SW, TG, or MSM (Y) Policy endorses detention centers which impose arbitrary confinement (N)

Please include any additional remarks or observations about related policy areas not included in the items listed above. If analysis is being done at different levels of government, be sure to identify if national, regional, and/or local policies differ or contradict each other.

131

Legal Environment Monitoring and enforcement of human and legal rights

States should ensure monitoring and enforcement mechanisms to guarantee the protection of HIV-related human rights, including those of people living with HIV, their families and communities. (UNAIDS, 2006, p. 19) Bribery, coercion, and extortion In the AWARE II region, police violence, illegal detention and arrests, and police bribes in sex or fines are common among SW (NSWP 2010). Even in Senegal where FSW can register with the government, FSW report police corruption that includes extortion and bribery (OSI 2006). MSM in Burkina Faso report frequent police raids (Niang et al 2004). Police arrest quotas can also lead to police abuse and driving SW and MSM underground. This type of police abuse legitimizes generalized social stigma and may make it difficult for SW and MSM to form networks that could assist with HIV prevention efforts.

Detailed Technical Guidance

The Global Programme against Corruption

http://www.unodc.org/unodc/e n/corruption/index.html

However it should be noted that repressive policing policies are not the only cause of police abuse of SW and MSM; in many developing countries the problem is exacerbated by the broader structural factors like weak judicial system; corruption and lack of accountability of law enforcement; stigma and intolerance among general population. So if the broader issues are not addressed, police may continue to harass SW and MSM and prevent them from accessing the services even when sex work or homosexuality is decriminalized. The above examples demonstrate that stigma and discrimination and widespread abuse at the hands of the police may seriously hamper access to or undermine the quality of services for SW and MSM. Absence of legislation setting effective mechanisms of monitoring and enforcement of legal and human rights of SW, MSM, and persons living with HIV hamper elimination of stigma and discrimination. In contrast, policies that ensure protection of human rights and that put an end to police abuse, enlist police support to protect key populations from abuse and violence and provide legal aid to abused SW, TG and MSM can help ensure HIV prevention, care and treatment efforts are able to reach these key populations. One example is using performance indicators that provide incentives to respond to reports of violence against SW, TG and MSM

132

Inventory and analysis of country documents

Country: ____________________________________

Date completed: _________________________

Name of data collector __________________________________________________________________

Position: _____________________________________________________________________________

Contact information for data collector: Email address:_________________________________________________________________________

Telephone/fax: ________________________________________________________________________

Instructions to data collector: Please fill out this page and indicate the best way to contact you (email, telephone, fax, etc.) should we need further information from you. Refer to the instructions page for directions on how to fill out the inventory. Please provide information only on those areas that you are familiar with or have been assigned to research and leave the others blank. Within the areas that you are working on, please be sure to answer yes or no to each item. All data collectors should address the open-ended question at the end of the areas they are working on. If you come across a policy document that addresses areas that you are not working on, send the document or citation to the team leader. They will share this information with the individual who has primary responsibility for that section. When you have completed the inventory, please send all the pages and all the documents you have referenced to [team leader should fill this in before distributing to team members].

133

13. Monitoring and enforcement of human and legal rights

Y/N

a. Collect all policy documents that mention individual rights

(HRC, 2011, p. 17)

Policy describes the right of all individuals to the highest attainable standard of physical and mental health (Y) Policy fails to mention or guarantee the right of all individuals to the highest attainable standard of physical and mental health (N)

1)

b. Collect all policy documents that mention same-sex relationships (UNAIDS, 2006, p. 36), (HRC,
2010, p. 6), (HRC, 2011, p. 22)

Y/N 1)

Policy provide legal recognition of same-sex relationships and governs such relationships with (Y) Policy fails to provide legal recognition of same-sex relationships (N) Policy governs same-sex relationships with the same property, divorce and inheritance provisions as heterosexual relationships (Y) Policy fails to provide equal provisions for property, divorce, and inheritance (N)

2)

Y/N

c. Collect all policy documents that mention property, divorce and inheritance
Policy provides legal mechanisms for full inheritance of property for women (Y) Policy fails to provide legal mechanisms or restricts inheritance for women (N) Policy provides legal mechanisms for equal distribution of assets for women in divorce (Y) Policy fails to provide legal mechanisms or restricts distribution of assets for women in divorce (N) 1) 2)

d. Collect all policy documents that mention legality of sex work (Pivot Legal Society, 2006, pp. 145148, 157, 180)

Y/N 1) 2) 3) 4) 5)

Policy is silent or identifies sex work as a legal occupation(Y) Policy criminalizes sex work (N) Policy is silent or identifies the exchange of money for sex as legal (Y) Policy criminalizes exchange of money for sex (N) Policy is silent or identifies solicitation as legal (Y) Policy criminalizes solicitation (N) Policy is silent or identifies proceeds from sex work as legal income (Y) Policy criminalizes living off the earnings of sex work (N) Policy states that a persons entitlement to social assistance may not be cancelled or affected in any other way by his or her work as a sex worker (Y) Work as a sex worker disqualifies an individual from social assistance (N) Where sex work is legal, sex work qualifies individuals for 6) 7) 8) 9) 10) 11) 12) Social security/pension/retirement (Y/N) Welfare/unemployment/employment insurance (Y/N) Healthcare/workers compensation (Y/N) Employment discrimination protections (Y/N) Occupational safety standards and resources (Y/N) Unionization (Y/N) Work place Sexual harassment/coercion/extortion protections (Y/N)

6) 7) 8) 9) 10) 11) 12)

Where sex work is legal Policy does not place any legislative restrictions on the way that prostitution businesses are structured (e.g. sole proprietorships, partnerships, corporations, and cooperatives (Y) Policy place restrictions on the structure of businesses (N)

13)

134

Policy stipulates that refusal to provide a commercial sexual service to any person does not constitute just cause for the termination of an employee (Y) Policy is fails to protect individual consent for sexual services (N)

14)

Y/N

e. Collect all policy documents that mention asylum Policy identifies persecution on the basis of sexual orientation as a justification for granting
asylum (Y) Policy makes no mention of persecution on the basis of sexual orientation as a justification for granting asylum (N) Policy identifies persecution on the basis of gender identity as a justification for granting asylum (Y) Policy makes no mention of persecution on the basis of gender identity as a justification for granting asylum (N)

1)

2)

Y/N

f.

Collect all policy documents that mention corruption (UNODC, 2006c, p. 19) Policy authorizes an independent anti-corruption body or bodies in charge of preventive
measures and policies (Y) Policy fails to mention or authorize an independent anti-corruption body (N) Policy directs the participation of civil society, non-governmental organizations and community-based organizations in anti-corruption activities (Y) Policy fails to mention or restricts nongovernmental and public participation in anti-corruption activities (N) Policy identifies activities to increase public awareness of the threats, causes and consequences of corruption (Y) Policy does not explicitly mention anti-corruption measures (N)

1)

2)

3)

g. Collect all policy documents that mention or define public servant codes of conduct
(UNODC, 2004b, p. 123), (UNODC, 2006c, p. 80), (UNODC, 2004b, p. 15)

Y/N 1)

Policy states that bribery, coercion, and extortion by a public official is illegal (Y) Policy does not mention bribery, coercion, and extortion by public officials or endorses such behavior (N) Policy identifies mechanisms to identify and manage conflict of interest that create barriers in access to services (Y) Policy fails to mention or encourages conflicts of interest (N) Policy identifies mechanisms to limit ability of companies to incentivize particular diagnostic and treatment decisions (Y) Policy is silent on corporate incentives or encourages their use (N)
Available to public Monitored

2)

3)

Enforced

Policy identifies a code of conduct for public servants that is (4) available to the public, (5) monitored through a public complaints system and (6) enforced through disciplinary boards (Y) Policy fails to identify a code of conduct for public servants that is available to the public, monitored through a public complaints system and enforced through disciplinary boards (N)

4)

5)

6)

135

h. Collect all policy documents that guide compensation of civil servants and political leaders (UNODC, 2004b, p. 125)
Policy identifies the goal of commensurate compensation between civil servants and political leaders with those in positions in the private sector of similar responsibility (Y) Policy makes no mention of commensurate compensation levels between private and public sectors (N)

Y/N 1)

i.

Collect all policy documents that identify performance indicators for law enforcement officials. (EHRN, 2011)
Policy provides financial and professional incentives for law enforcement to respond to violence (Y) Policy provides no incentive or allows law enforcement to charge those who report violence with a crime (N) SW TG MSM Policy provides financial and professional incentives for law enforcement to refer individuals to health and harm reduction resources (Y) Policy provides no incentive for referral (N) SW TG MSM Policy identifies compulsory education requirements for all children especially girls (Y) Policy fails to identify compulsory education requirements (N) Policy allows for continued schooling for pregnant girls or re-admission to schools after pregnancy (Y) Policy restricts access to schools for girls who become pregnant (N) Policy identifies free access to primary education (Y) Policy establishes schools fees or other expenses for primary education (N) Policy prohibits discrimination in accessing education on the basis of sexual orientation or gender identity (Y) Policy fails to prohibit or specifically endorses discrimination in education on the basis of sexual orientation or gender identity (N) Policy prohibits bullying and other forms of discrimination and violence on the basis of sexual orientation and gender identity(Y) Policy fails to prohibit or endorses bullying or other forms of discrimination and violence on the basis of sexual orientation and gender identity (N)

Y/N

1) 2) 3)

j.

Collect all policy documents that describe rights to education (UNICEF, 2011, pp. 12, 27), (HRC,
2011, p. 19)

4) 5) 6) Y/N 1) 2)

3) 4)

5)

k. Collect all policy documents that identify processes to obtain identity papers and other official documentation. (UNDP-b, 2009, p. 10), (UNICEF, 2011, p. 12), (UNAIDS, 2009, p. 15), (HRC, 2011, p. 22)
Policy identifies clear and accessible process to obtain residency papers required for accessing services (Y) Policy is unclear or creates unreasonable barriers to obtaining residency papers (N) Policy guarantees the ability of transgender to obtain gender-aligned identity papers and other official documentation that they need in order to access services (Y) Policy restricts or fails to address changing gender on official identity papers or requires divorce, sterilization, genital surgery and/or psychiatric diagnosis of sexual or gender dysphoria(N)

Y/N 1)

2)

136

l.

Collect all policy documents that mention access to legal advice and representation (UNAIDS, 2006, p. 48), (ABAROLI, 2011, p. 128), (Pivot Legal Society, 2006, p. 220)
SW TG MSM Prisoners

Policy identifies state funding to educate about legal rights (Y) Policy fails to provide funding for education on legal rights (N) Policy provides funding to overcome basic costs associated with the legal system and access to free legal aid/consultation (Y) Policy fails to provide access to free legal aid/consultation (N)

1)

2)

3)

4)

5)

6)

7)

8)

Y/N m. Collect all policy documents that mention international law (ABAROLI, 2011, p. 124), (HRC, 2011)
Country has ratified the following international conventions/treaties (Y)/(N) Universal Declaration of Human Rights International Covenant on Civil and Political Rights Optional Protocol to the International Covenant on Civil and Political Rights Second Optional Protocol to the International Covenant on Civil and Political Rights, aiming at the abolition of the death penalty 5) The International Covenant on Economic, Social and Cultural Rights (ICESCR) 6) The Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (CAT) 7) The Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), 8) Convention Relating to the Status of Refugees 9) Convention on Rights of the Child (CRC) Identify regional conventions/treaties that impact SW or MSM and indicate whether or not there is country ratification (Y)/(N) 10) 11) 12) 13) Policy recognizes the supremacy of adopted international law vis-a-vis national legislation (Y) Policy fails to mention supremacy of adopted international law (N) Policy recognizes the competence of international human rights bodies to receive complaints or communications from individual who claim that their rights have been violated (Y) Policy fails to mention international human rights bodies or explicitly denies their jurisdiction (N) 1) 2) 3) 4) 1) 2) 3) 4) 5) 6) 7) 8) 9)

10) 11) 12) 13) 14) 15)

Please include any additional remarks or observations about related policy areas not included in the items listed above. If analysis is being done at different levels of government, be sure to identify if national, regional, and/or local policies differ or contradict each other.

137

Intervention design, access, and implementation Procurement and supply management

Procurement and supply management A key element to the success of any of the services identified in this Decision Model is a functioning system for the procurement and supply management (PSM) of medicines and medical commodities. Central to PSM is the concept of Approved Drugs and Essential Drugs. There are several documents a national government may use to control or specify which drugs and other medical commodities may be used in the country. The Inventory includes two of these: the Approved Drug List, and the Essential Drug (or Medicine) List. In addition, the government may specify which drugs are approved for local manufacture and which are approved for importation. Alternatively, the government may explicitly indicate by law or regulation the use of controlled medications.
Detailed Technical Guidance

Operational Principles for Good Pharmaceutical Procurement http://apps.who.int/medicinedocs/ en/d/Jwhozip49e/7.html

USAID/Deliver

http://deliver.jsi.com/dhome/

Approved Drug List: The Approved Drug List is the largest, most extensive listing of medical pharmaceuticals that are permitted for use in the country. It typically is maintained by the equivalent of the U.S. Food and Drug Administration (FDA, part of HHS). The Approved Drug list usually includes generic formulations as well as brand name drugs; it also covers both drugs that can be sold or distributed over-the-counter (i.e., without a physicians prescription) and those that require a physicians prescription. The Approved Drug List typically does not include drugs still being tested for safety and efficacy or those permitted only for research purposes. Essential Drug List: Many countries also maintain an Essential Drug List. Most are adapted from the World Health Organization (WHO) Model Lists of Essential Medicines, which are updated every two years. The WHO model list includes a core list of minimum medicines for a basic healthcare system to address public health concerns and a complementary list of essential medicines for priority diseases, for which specialized diagnostic or monitoring facilities, specialist medical care, and/or specialist training are needed. The Essential Drug List is usually smaller than the Approved Drug Listin other words, all of the drugs on the Essential Drug List should also be found on the Approved Drug List, but the reverse is not the casenot all drugs on the Approved Drug List will be found on the Essential Drug List. Countries may use their Essential Drug List in different ways. Some countries may require that government health programs purchase only drugs listed in the Essential Drug List; on the other hand, private sector organizations may purchase any drugs that are on the Approved Drug List, whether or not they are on the Essential List. Other countries may require that government programs stock all of the drugs on the Essential Drug List. And some countries may not specify their own Essential Drug List, but instead direct their government health programs to use the WHO Model Lists as reference. More than 150 countries have published an official essential drugs or medicines list.

139

Local manufacture and importation: The drugs distributed and used in a country may include some products that are manufactured locally (in-country) and others that are imported from another country. The decision to manufacture locally vs. import is based on many considerations, including costs and type of laboratory installations required to manufacture the product. Government approvals to manufacture a drug locally (sometimes with imported raw materials) and/or to import the finished product may be found in different policy documents. In some cases, the approvals are indicated in the Approved Drug List and/or Essential Drug List. In other cases, approvals may be issued by special documents. Registration and procurement of ART medications Complicated, lengthy, costly and non-transparent process of drug registration undermines competition on ART market, resulting in high cost and limited range of available ART medications. Many countries also lack smooth and coherent management information system of forecasting, procurement and stock management of ART medications. Often all data collection and decisions are made by one specialist, which makes the system susceptible to errors (Leonchuk, De Lussini, & Schonning, 2009). Problems with procurement and supply of ART medications may result in stock-outs depriving patients of this life-saving treatment. In some countries, the cost of ART drugs was unreasonably high because Governments either failed to register the generic versions of ART drugs (HRW, 2007a), to exempt them from taxes (Belyaeva & Aftandilyants, 2010) or to establish effective monitoring of procurement process. Procurement mechanisms GFATM performance measurements rely heavily on quantitative indicators such as coverage and the number of commodities distributed while overlooking quality issues and clients satisfaction with services. Only recently have some programs adopted the system of collecting clients feedback on the commodities quality and assortment to inform procurement-related decisions. (OSI, 2009d)

140

Inventory and analysis of country documents

Country: ____________________________________

Date completed: _________________________

Name of data collector __________________________________________________________________

Position: _____________________________________________________________________________

Contact information for data collector: Email address:_________________________________________________________________________

Telephone/fax: ________________________________________________________________________

Instructions to data collector: Please fill out this page and indicate the best way to contact you (email, telephone, fax, etc.) should we need further information from you. Refer to the instructions page for directions on how to fill out the inventory. Please provide information only on those areas that you are familiar with or have been assigned to research and leave the others blank. Within the areas that you are working on, please be sure to answer yes or no to each item. All data collectors should address the open-ended question at the end of the areas they are working on. If you come across a policy document that addresses areas that you are not working on, send the document or citation to the team leader. They will share this information with the individual who has primary responsibility for that section. When you have completed the inventory, please send all the pages and all the documents you have referenced to [team leader should fill this in before distributing to team members].

141

14. Procurement and supply management of medicine and medical commodities a. Collect all policy documents that identify bodies with PSM oversight responsibility (JSI/Deliver, 2005a, p.
29)

Oversee, coordinate, and track resources

Identify gaps in funding

Identify technical assistance needs

Oversee Tendering

b.

1) 2) 3) Policy states that oversight bodies have responsibility to; 1) oversee, coordinate, and track resources that have been promised and allocated, 2) identify gaps in funding, medicines and medical commodity inventories, 3) identify technical assistance needs, and 4) oversee tendering (Y) No mention of PSM oversight body or responsibilities (N) Policy identifies representation of non-governmental organizations on oversight bodies (Y) Policy fails to identify or restricts representation of non-governmental organizational organizations (N) Policy guarantees that procurement records are open to the public (Y) Policy restricts access to procurement records (N) Procurement policy prioritizes utilization of WHO Prequalified Drugs List (Y) Policy fails to mention use of WHO Prequalified Drugs List (N) Policy identifies quality assurance standards for medicine and medical commodities (Y) Policy fails to mention quality assurance standards (N) Policy identifies post-procurement quality control medicine and medical commodities (Y) Policy fails to mention post-procurement quality assurance standards (N)
(UNAIDS-e,

4)

5)

6)

Collect all policy documents that mention quality standards for medicines and medical commodities
1) 2) 3) Y/N 1)

c. Collect all policy documents that mention the Country essential medicines list
2008, p. 200), (WHO, 2003, p. 4)

The country essential medicines list includes all medications identified in the WHO Model List of Essential Medicines for STI and HIV (Y) The essential medicines list excludes some of the medications identified by WHO (N) Drugs that can procured through government funding include medications for STI and HIV Government funding is restricted for any medications for STI and HIV Policy explicitly allows importation or local manufacture for clinical use of all medications identified in the WHO Model List of Essential Medicines for STI and HIV (Y) Policy fails to explicitly allow importation or local manufacture of WHO medicines for clinical use (N) Policy removes or reduces taxes and tariffs on essential medicines, controls distribution margins, and sets pricing parameters (Y) Policy fails to mention reduction in taxes or tariffs, distribution margins or pricing parameters (N)

2) 3)

4)

d. Collect all policy documents that mention the process for selection of harm reduction commodities (WHO, 2010f, p. 85)
Policy identifies mechanisms for SW to be involved in the product selection of harm reduction commodities (Y) Policy fails to mention or excludes SW from product selection process (N) Policy identifies mechanisms for TG to be involved in the product selection of harm 1)

Y/N

2)

142

reduction commodities (Y) Policy fails to mention or excludes TG from product selection process (N) Policy identifies mechanisms for MSM to be involved in the product selection of harm reduction commodities (Y) Policy fails to mention or excludes MSM from product selection process (N)

3)

e. Collect all policy documents that identify the process for quantification and forecasting of medicine and commodity need (WHO, 1999, pp. 12, 13), (JSI/Deliver, 2003, pp. 2, 8)
Reliable estimate of need Review and update every six months Monthly reporting cycle

1) Policy identifies mechanisms to calculate order quantities 1) 2) based on reliable estimate of need including all those who are eligible for prevention, diagnostics, and treatment based on internationally accepted guidelines(Y) 2) Policy requires review and updating of forecasting and quantification of medicines and medical commodities at least every six months (Y) 3) Policy requires implementation of a monthly reporting cycle (Y) Policy fails to mention mechanisms for calculation or uses mechanisms that fail to consider current forecasts of need (N) Policy allows for participation of individuals or non-governmental organizations serving SW in forecasting (Y) Policy fails to support or restricts involvement of individuals or non-governmental organizations (N) Policy allows for participation of individuals or non-governmental organizations serving TG in forecasting (Y) Policy fails to support or restricts involvement of individuals or non-governmental organizations (N) Policy allows for participation of individuals or non-governmental organizations serving MSM in forecasting (Y) Policy fails to support or restricts involvement of individuals or non-governmental organizations (N) Policy identifies guidelines that include cost effectiveness measures for forecasting and procurement of appropriate quantities of initial and advanced categories of medicines and commodities (Y) Policy makes no mention of cost effectiveness or encourages procurement of advanced categories of medicines and commodities (N)

3)

4)

5)

6)

7)

f.

Collect all policy documents that establish budgets for medicines and medical commodities (JSI/Deliver,
2005a, p. 26), (WHO, 2007b, pp. 50-57)

Budget for storage

Budget for distribution

Budget for logistics

1) Budgets for medicines and medical commodities include a specific mechanism to finance: 1) storage, 2) distribution, and 3) logistics (Y) Budgets fail to fund storage, distribution, and logistics (N) Policy allows for flexibility for decentralized procurement (Y) Policy prohibits decentralized procurement (N) Policy allows for international tendering (Y) Policy prohibits international tendering (N)

2)

3)

4) 5)

143

g. Collect all policy documents that mention medicine and medical commodity distribution (JSI/Deliver, 2005b, p. 9)
Policy identifies systems to redistribute medicines and medical commodities to prevent, stock outs, overstock, and expiration (Y) Policy fails to identify systems or prohibits redistribution (N) 1)

Y/N

Please include any additional remarks or observations about related policy areas not included in the items listed above. If analysis is being done at different levels of government, be sure to identify if national, regional, and/or local policies differ or contradict each other.

144

Intervention design, access, and implementation Overarching services design Obstacles to access to interventions and services for key populations can be mitigated using best practices in intervention design and by ensuring human rights. Integrating STI and HIV services in FP/RH and other health services can increase access to services, including STI and HIV screening. A lack of such service integration and referral mechanisms can lead to lost opportunities for reaching SW and MSM and can discourage these populations from seeking services. Moreover, if services are not convenient and accessible to clients, or if clients fear gaps in confidentiality or stigma and discrimination from health care providers and law enforcement, key populations will not be reached. Perceived lack of confidentiality, stigma and discrimination from health care providers and law enforcement can be major impediments to key populations access to services. Research in Senegal (Larmarange 2010) and Botswana (Fay, Baral et al. 2010) indicate that MSM delay or neglect medical treatment, including STI symptoms due to fear of stigma, abuse or lack of confidentiality. Evidence that their fears are warranted can be found in Senegal where 13 % of MSM reported being raped by a police officer in the previous year and in Burkina Faso where there is anectodal evidence of breaches of medical confidentiality and reports of illegal arrests and stigma among MSM and CSW (Drabo, et al 2010). UNAIDS and WHO recommendations include training for prison, law enforcement and health care providers in ethics and human rights areas such as informed consent, confidentiality and avoiding stigma and discrimination. With proper policies and training, police can be enlisted to protect CSW, MSM and TG from abuse and violence and to ensure safe venues for their networks to gather. Policies and programming to sensitize health care workers can be a first step in reducing stigma and discrimination and can support integrated services in reaching more CSW, MSM and TG.

145

Inventory and analysis of country documents

Country: ____________________________________

Date completed: _________________________

Name of data collector __________________________________________________________________

Position: _____________________________________________________________________________

Contact information for data collector: Email address:_________________________________________________________________________

Telephone/fax: ________________________________________________________________________

Instructions to data collector: Please fill out this page and indicate the best way to contact you (email, telephone, fax, etc.) should we need further information from you. Refer to the instructions page for directions on how to fill out the inventory. Please provide information only on those areas that you are familiar with or have been assigned to research and leave the others blank. Within the areas that you are working on, please be sure to answer yes or no to each item. All data collectors should address the open-ended question at the end of the areas they are working on. If you come across a policy document that addresses areas that you are not working on, send the document or citation to the team leader. They will share this information with the individual who has primary responsibility for that section. When you have completed the inventory, please send all the pages and all the documents you have referenced to [team leader should fill this in before distributing to team members].

146

15. Overall FP/RH, STI, and HIV services design a. Collect all policy documents that guide implementation of FP/RH, STI, and HIV services (UNODC, 2009, p. 43), (WHO, 1993, pp. 6, 8), (UNODC, 2010, pp.
39, 41), (WHO, 2007c, p. 6), (UNODC, 2006, pp. 23, 26), (CHALN, 2006e, pp. 30, 31), (UNAIDS, 1999a, p. 123), (UNAIDS, 2008, p. 187), (UNDP, 2009b, pp. 10-11), (UNAIDS, 2009b, pp. 122, 123), (UNAIDS, 2006, pp. 29, 30)

FP/RH

STI Prison Community 1)

HIV Prison Community 2) 3) 7) Prison 4) 8)

Policy:

Community

Policy directs all services to have protocols to assess need for FP/RH (Y) Policy fails to identify FP/RH need assessment protocols (N) Policy directs all services to have protocols to assess risk for STI (Y) Policy fails to identify STI risk assessment protocols (N) Policy directs all services to have protocols to assess risk for HIV (Y) Policy fails to identify HIV risk assessment protocols (N) Policy directs all services dealing with drug users to have protocols to assess risk for sexual and domestic violence(Y) Policy fails to identify domestic and sexual violence risk assessment protocols (N) Identifies mechanisms of referral to other services (Y) Fails to identify mechanisms of referral (N) Policy ensures equal access for women and men Policy fails to ensure equal access for women and men Policy ensures equal access for SW Policy fails to ensure equal access for SW Policy ensures equal access for TG Policy fails to ensure equal access for TG Policy ensures equal access for MSM Policy fails to ensure equal access for MSM Policy states that criminal laws prohibiting sexual acts between consenting adults in private does not impede provision of services (Y) Policy fails to guarantee services regardless of legality of private behavior (N) Identifies mechanisms to ensure continuity of care between and within community and detention/prison/custodial settings (Y) Fails to mention continuity of care between and within detention/prison/custodial settings and community services (N) Prohibits mandatory use of family planning as a condition for receiving services (Y) Fails to prohibit or requires use of family planning to receive services (N)

5) 9) 13)

6) 10) 14) 11) 15) 12) 16)

17)

18)

19) 25) 31) 37)

20) 26) 32) 38)

21) 27) 33) 39) 43)

22) 28) 34) 40) 44) 50)

23) 29) 35) 41) 45) 51)

24) 30) 36) 42) 46) 52)

47)

48)

49)

53)

54)

55)

56)

57)

58)

59)

60)

61)

62)

63)

64)

147

Guarantees access for females who are pregnant or have children (Y) Policy fails to mention or denies access to females who are pregnant or have children (N) Directs that services be available at times convenient to clients (e.g. before/after working hours/weekends) (Y) Identifies restricted service hours (N)

65)

66)

67)

68)

69)

70)

71)

72)

73)

74)

75)

76)

148

b. Collect all policy documents that define training requirements for prison, law enforcement and health care providers (UNAIDS, 1999a, p. 122), (UNAIDS, 2006, p. 29), (UNODC, 2009, pp. 33, 34, 41), (WHO, 2011, p. 31), (UNAIDS,
2009b, p. 124)

Policy require the following staff to undergo regular training (Y) Policy fails to mention training requirement (N): Law enforcement staff

Ethics and human rights including consent and confidentiality

Avoiding stigma and discrimination

Domestic and sexual violence

Human Specifi sexuality c needs of SW, TG, and MSM

Referral between law enforcement, medical, and harm reduction services 6)

Training on hepatitis, TB, and HIV

1)

2)

3)

4)

5)

7)

Judges/court staff

8)

9)

10)

11)

12)

13)

14)

Detention/prison workers

15)

16)

17)

18)

19)

20)

21)

Teachers

22)

23)

24)

25)

26)

27)

28)

Health care workers

29)

30)

31)

32)

33)

34)

35)

Please include any additional remarks or observations about related policy areas not included in the items listed above. If analysis is being done at different levels of government, be sure to identify if national, regional, and/or local policies differ or contradict each other.

149

Intervention design, access, and implementation HCT

HIV testing must always be done with informed consent, adequate pre-test information or counseling, post-test counseling, protection of confidentiality and referral to services (WHO, 2010c, p. 10) Government policies can authorize, prohibit or fail to address specific regulations and components of HCT services (WHO, 2010a, p. 10), (UNAIDS, 2006, pp. 26, 27), (WHO, 2004d), (WHO, 2011, p. 39). Uptake of and access to HIV services can be affected by cost, whether or not HCT is integrated with other health services, location and type of agency providing HCT and length of time before receiving test results. For example, in many countries HIV testing is provided for free, however in some cases fees may be imposed that may discourage vulnerable groups from testing. There are instances when HIV testing may be provided for free, however if a client needs to obtain an official test certificate, a fee is charged (UNODC, CHALN, 2010), (Saidov, 2010). Authorization for integrating services, offering free HCT, NGO provision of HCT and rapid testing can be crucial in enabling delivery of HCT that is accessible to key populations. Given stigma and discrimination of CSW, MSM, TG and PLHIV, policies that guarantee anonymity and confidentiality of test results are vital. Required elements of HCT can include best practices and respect for human rights such as pretest counseling, use of informed consent, voluntary testing and counseling with the opt-in approach to provider initiated HCT and post-testing referral for HIV services (UNAIDS, 2006, p. 27), (CHALN, 2006e, p. 18), (UNODC, 2006, pp. 18, 25), (WHO-b, 2009, p. 10), (UNODC, 2010, p. 38), (WHO, 2007a, p. 7), (WHO, 2007c, p. 6), (UNODC, 2009, p. 43), (OSI, UNAIDS & WHO, 2010b, pp. 9, 16, 17), (WHO, 2007e, p. 25), (WHO, 2011, p. 39). Involvement of SW, TG and MSM in development of HIV testing and counseling protocols can ensure that HCT is conducted in ways that meet the needs of these key populations and encourage HCT uptake. Centralized HIV testing In many countries testing of blood for HIV and post-test counseling are mostly performed in AIDS centers. Even if pre-test counseling and blood specimen drawing are done outside of AIDS centers, clients with positive or uncertain results are often referred to AIDS centers for confirmatory tests. In countries with a limited laboratory infrastructure the use of HIV rapid testing algorithms has been more feasible and as effective as ELISA/Western Blot algorithms (WHO, 2004d, p. 13) HIV testing is commonly done in two stages if the first test demonstrates positive or uncertain result, another, confirmatory test is administered. In these cases, local HIV/AIDS authorities in some countries send blood samples to central province or national laboratories for immunoassay analysis, so receiving final results may take up to one month, while the clients are in suspense and endure significant psychological stress; some clients may also fail to come and receive the confirmatory test results (Bobrova, Sarang, Stuikyte, & Lezhentsev, 2007), (Ibragimov, Latypov, Jamolov, & Khasanova, 2011). This issue can be addressed, at least in some countries, by using rapid HIV tests for confirmation as recommended by WHO for resource limited settings (WHO, 2004d).

151

Inventory and analysis of country documents

Country: ____________________________________

Date completed: _________________________

Name of data collector __________________________________________________________________

Position: _____________________________________________________________________________

Contact information for data collector: Email address:_________________________________________________________________________

Telephone/fax: ________________________________________________________________________

Instructions to data collector: Please fill out this page and indicate the best way to contact you (email, telephone, fax, etc.) should we need further information from you. Refer to the instructions page for directions on how to fill out the inventory. Please provide information only on those areas that you are familiar with or have been assigned to research and leave the others blank. Within the areas that you are working on, please be sure to answer yes or no to each item. All data collectors should address the open-ended question at the end of the areas they are working on. If you come across a policy document that addresses areas that you are not working on, send the document or citation to the team leader. They will share this information with the individual who has primary responsibility for that section. When you have completed the inventory, please send all the pages and all the documents you have referenced to [team leader should fill this in before distributing to team members].

152

16. HIV counseling and testing (HCT) a. Collect all policy documents that authorizing HCT services (WHO, 2010a, p. 10), (UNAIDS, 2006, pp.
26, 27), (WHO, 2004d), (WHO, 2011, p. 39)

Policy:

Community Settings 1) Policy guarantees state funding for HCT services (Y) Policy fails to mention access or funding for HCT (N) 3) Policy guarantees access to free HCT for SW(Y) Policy fails to identify free services for SW or identifies fees for HCT testing or HIV-status certification (N) 5) Policy guarantees access to free HCT for TG(Y) Policy fails to identify free services for TG or identifies fees for HCT testing or HIV-status certification (N) 7) Policy guarantees access to free HCT for MSM(Y) Policy fails to identify free services for MSM or identifies fees for HCT testing or HIV-status certification (N) 9) Policy authorizes an integrated service model (Y) Policy identifies HCT as an isolated service (N) 11) Policy allows use of saliva-based rapid testing (Y) Policy fails to authorize or prohibits saliva-based rapid testing (N) 13) Policy allows use of rapid testing algorithms to diagnose HIV infection (Y) Policy fails to identify or prohibits diagnosis by rapid testing technologies (N) Policy guarantees that HCT services including receipt of test results, are available on 15) an confidential basis (Y) Policy allows for the release of HCT results without the consent of the individual (N) Policy guarantees that HCT services including receipt of test results, are available on 17) an anonymous basis (Y) Policy requires that names be provided for provision of HCT (N) Policy authorizes either government or nongovernment providers to deliver HCT and provide HIV test results (Y) Policy restricts either delivery of HCT or provision of test results to government bodies (N) Policy does not put any restrictions on the frequency of free HIV testing (Y) Policy restricts the frequency of free HIV testing (N)

Prison Settings 2) 4)

6)

8)

10) 12) 14) 16)

18)

19)

20)

b. Collect all policy documents defining protocols for HCT (UNAIDS, 2006, p. 27), (CHALN, 2006e, p. 18), (InterParliamentary Unit [IPU], 2007, p. 82), (UNODC, 2006, pp. 18, 25), (WHO-b, 2009, p. 10), (UNODC, 2010, p. 38), (WHO, 2007a, p. 7), (WHO, 2007c, p. 6), (UNODC, 2009, p. 43), (OSI, UNAIDS & WHO, 2010b, pp. 9, 16, 17), (WHO, 2007e, p. 25), (WHO, 2011, p. 39)

Policy: Requires pre-test counseling, for all HIV testing (Y) Fails to require pre-test counseling, for all HIV testing (N) Requires informed consent, for all HIV testing (Y) Fails to require informed consent, for all HIV testing (N) Requires that HCT be voluntary Fails to assure voluntary HCT or makes HCT a requirement for SW licensing Requires post-test counseling, for all HIV testing (Y) Fails to require post-test counseling, for all HIV testing (N) Requires referral to medical and prevention services in for all HIV testing (Y) Fails to require referral to medical and prevention services in for all HIV testing (N) Identifies mechanisms for SW to be involved in the development of HIV testing

Community Settings

Prison Settings

1) 3) 5) 7) 9) 11)

2) 4) 6) 8) 10) 12)

153

and counseling protocols (Y) Fails to mention SW involvement in program design (N) Identifies mechanisms for TG to be involved in the development of HIV testing and counseling protocols (Y) Fails to mention TG involvement in program design (N) Identifies mechanisms for MSM to be involved in the development of HIV testing and counseling protocols (Y) Fails to mention MSM involvement in program design (N) Policy identifies mechanisms to monitor HCT program outcomes for SW (Y) Policy fails to mention monitoring and evaluation of HCT programs for SW-specific outcomes (N) Policy identifies mechanisms to monitor HCT program outcomes for TG (Y) Policy fails to mention monitoring and evaluation of HCT programs for TG-specific outcomes (N) Policy identifies mechanisms to monitor HCT program for MSM (Y) Policy fails to mention monitoring and evaluation of HCT programs for MSMspecific outcomes (N) Policy identifies mechanisms for SW to be involved in the monitoring and evaluation of HIV testing and counseling programs (Y) Policy fails to mention SW involvement in program monitoring (N) Policy identifies mechanisms for TG to be involved in the monitoring and evaluation of HIV testing and counseling programs (Y) Policy fails to mention TG involvement in program monitoring (N) Policy identifies mechanisms for MSM to be involved in the monitoring and evaluation of HIV testing and counseling programs (Y) Policy fails to mention MSM involvement in program monitoring (N)

13)

14)

15)

16)

17)

18)

19)

20)

21)

22)

23)

24)

25)

26)

27)

28)

c. Collect all policy documents mentioning access to HCT for prisoners (WHO, 1993, p. 5), (UNODC,
2006, p. 25) (WHO, 2007a), (WHO, 2007c, p. 6), (UNODC, 2009, pp. 36, 37, 39), (UNODC, 2010, p. 38), (WHO, 2006, p. 10), (CHALN, 2006e, p. 18)

Policy requires that prisoners are made aware of and offered or recommended voluntary, confidential HIV testing with counseling upon entry and during imprisonment - especially if a prisoner has signs, symptoms or medical conditions that could indicate HIV infection (Y) Policy fails to mention HCT access for prisoners (N)

1)

d. Collect all policy documents mentioning provision of HCT in the health care setting (WHO,
2007e, p. 5), (UNGA, 2009, p. 10)

Policy identifies an opt-in approach to provider initiated HCT for SW (Y) Policy identifies an opt-out approach to provider initiated HCT for SW (N) Policy identifies an opt-in approach to provider initiated HCT for TG (Y) Policy identifies an opt-out approach to provider initiated HCT for MSM (N) Policy identifies an opt-in approach to provider initiated HCT for MSM (Y) Policy identifies an opt-out approach to provider initiated HCT for MSM (N) Policy requires that accessing HCT services be voluntary for SW (Y) Fails to assure voluntary nature of HCT access or makes HCT a requirement for SW licensing (N) Policy focuses on prevention, diagnosis and treatment of HCT among SW (Y) Policy takes a punitive approach to HCT among SW (e.g. removal of work license or deportation if diagnosed with HIV) (N)

1) 2) 3)

e. Collect all policy documents that mention HCT services

1) 2)

Please include any additional remarks or observations about related policy areas not included in the items listed above. If analysis is being done at different levels of government, be sure to identify if national, regional, and/or local policies differ or contradict each other.

154

Intervention design, access, and implementation ART Although Burkina Faso has made a commitment to universal access of ART, as of 2009 only 47.03% of PLHIV at an advance stage were receiving ARVs (UNGASS 2010). Limited funding is a major impediment to universal coverage in Burkina. However, policies regarding ART eligibility and cost of services may impact access to ART medications. Though in many developing countries ART medications are provided for free sponsored by international donors, collateral fees for laboratory monitoring may pose a significant barrier for patients (WHO, 2010b), (Wolfe, Carrieri, & Shepard, 2010), (Belyaeva & Aftandilyants, 2010). Eligibility criteria, documentation and testing requirements The absence of the following desirable and optimal tests cannot be a barrier to starting ART: CD4 lymphocyte count to determine the severity of immunodeficiency (if available) Viral load testing (if available) to monitor the response to ART (WHO, 2008b, p. 14)

Detailed Technical Guidance

WHO HIV Guidelines http://www.who.int/hiv/pub/guid elines/en/

Eligibility criteria can require specific testing that may be unavailable to segments of the population thus impacting access to ART. Access can also be affected by policies that do not ensure the application of national guidelines in detention or prison settings. Requiring documentation for HIV treatment can preclude access by CSW who are often immigrants, as is common in West Africa (Ghys et al. 2002. AduOppong et al. 2007. Kahn et al. 2008), or who have their documentation confiscated by pimps or brothelowners, as reported in Burkina Faso (Drabo et al. 2010).

155

Inventory and analysis of country documents

Country: ____________________________________

Date completed: _________________________

Name of data collector __________________________________________________________________

Position: _____________________________________________________________________________

Contact information for data collector: Email address:_________________________________________________________________________

Telephone/fax: ________________________________________________________________________

Instructions to data collector: Please fill out this page and indicate the best way to contact you (email, telephone, fax, etc.) should we need further information from you. Refer to the instructions page for directions on how to fill out the inventory. Please provide information only on those areas that you are familiar with or have been assigned to research and leave the others blank. Within the areas that you are working on, please be sure to answer yes or no to each item. All data collectors should address the open-ended question at the end of the areas they are working on. If you come across a policy document that addresses areas that you are not working on, send the document or citation to the team leader. They will share this information with the individual who has primary responsibility for that section. When you have completed the inventory, please send all the pages and all the documents you have referenced to [team leader should fill this in before distributing to team members].

156

17. Antiretroviral Therapy (ART) a. Collect all policy documents that authorizing ART services
Policy:
Community Settings Prison Settings 2)

Policy guarantees state funding for ART services (Y) Policy fails to mention access or funding for ART (N) States that any related or required services are provided free of charge (Y) Fails to expressly prohibit fees or identifies fees for related services (N) Policy guarantees access to free ART for SW(Y) Policy fails to identify free services for SW or identifies fees for ART or related or required services (N) Policy guarantees access to free ART for TG(Y) Policy fails to identify free services for TG or identifies fees for ART or related or required services (N) Policy guarantees access to free ART for MSM(Y) Policy fails to identify free services for MSM or identifies fees for ART or related or required services (N)

1)

3)
5)

4)
6)

7)

8)

9)

10)

b. Collect all policy documents defining ART eligibility (WHO, 2006, p. 20), (WHO, 2009a, pp. 20, 21), (WHO, 2008a, p. 7), (WHO, 2010e, p. 20), (WHO, 2010e, p. 64), (WHO, 2010e, p. 21), (WHO, 2010e, p. 67), (WHO, 2008a, p. 7), (UNODC, 2010, p. 39)
Policy: Explicitly states that eligibility for ART includes those with past or present drug use and does not require detoxification as a prerequisite to access and initiate HIV treatment and care (Y) Fails to mention eligibility for ART for individuals with past or present drug use, or places detoxification or stability requirements as a prerequisite to initiate HIV treatment and care (N) Explicitly states that alcohol dependence and mental health problems are not reasons to withhold treatment (Y) Policy fails to mention alcohol dependent or those with mental health problems as eligible for ART, or places detoxification or stability requirements as a prerequisite to initiate HIV treatment and care (N)
Community Settings Prison Settings

1)

2)

3)

4)

c. Collect all policy documents defining protocols for ART 1) Policy specifically states that national guidelines on care and treatment of HIV apply detention/prison/residential settings (Y) Policy is silent on inmate/resident eligibility for ART or identifies more restrictive eligibility guidelines for detention/prisons/residential settings (N) Please include any additional remarks or observations about related policy areas not included in the items listed above. If analysis is being done at different levels of government, be sure to identify if national, regional, and/or local policies differ or contradict each other.

157

Intervention design, access, and implementation Sexually Transmitted Infection Services (STI)

At the policy and decision-making levels, the following factors operate. Policy-makers and planners give low priority to control of sexually transmitted infections. This situation is potentially aggravated by the stigmatization and prejudice associated with the infections and ignorance of the importance of their impact on health and economic development. Donors are increasingly using sector-wide approaches to allocate aid to the whole health sector rather than to specic projects, such as sexually transmitted infection control. Although this allows health ministries to determine national priorities, it also means that countries that have traditionally accorded little importance to these infections in their health budgets because of stigmatization can continue to do so. There is a failure to provide suitable education and services to populations identied as being particularly vulnerable to sexually transmitted infections, such as young people and adolescents, sex workers (both male and female) and their clients, men who have sex with men, transgendered people, substance users, prisoners, mobile populations (for work or recreation), children and young people on the street, and people affected by conict and civil unrest. (WHO, 2007f, p. 13)

However, even where sex work is legal and licensed, the diagnosis of an STI may cause a sex worker to lose their license and with it the means of supporting themselves. As a result sex workers may avoid health care facilities and go underground to escape rules and restrictions that threaten their welfare. (UNFPA)

159

Inventory and analysis of country documents

Country: ____________________________________

Date completed: _________________________

Name of data collector __________________________________________________________________

Position: _____________________________________________________________________________

Contact information for data collector: Email address:_________________________________________________________________________

Telephone/fax: ________________________________________________________________________

Instructions to data collector: Please fill out this page and indicate the best way to contact you (email, telephone, fax, etc.) should we need further information from you. Refer to the instructions page for directions on how to fill out the inventory. Please provide information only on those areas that you are familiar with or have been assigned to research and leave the others blank. Within the areas that you are working on, please be sure to answer yes or no to each item. All data collectors should address the open-ended question at the end of the areas they are working on. If you come across a policy document that addresses areas that you are not working on, send the document or citation to the team leader. They will share this information with the individual who has primary responsibility for that section. When you have completed the inventory, please send all the pages and all the documents you have referenced to [team leader should fill this in before distributing to team members].

160

22. Sexually Transmitted Infection Services (STI) a. Collect all policy documents that authorizing STI services (WHO, 2002b)
Policy: Policy guarantees state funding for STI services (Y) Policy fails to mention access or funding for STI (N) Policy guarantees access to STI services for SW regardless of the ability to pay (Y) Policy fails to identify free services for SW or identifies fees for testing, treatment, or status certification (N) Policy guarantees access to STI services for TG regardless of the ability to pay (Y) Policy fails to identify free services for TG or identifies fees for testing, treatment, or status certification (N) Policy guarantees access to STI services for MSM regardless of the ability to pay (Y) Policy fails to identify free services for MSM or identifies fees for testing, treatment, status certification (N) Policy provides for specialized clinics to serve SW (Y) Policy does not provide for specialized clinics for SW (N) Policy provides for specialized clinics to serve TG (Y) Policy does not provide for specialized clinics for TG (N) Policy provides for specialized clinics to serve MSM (Y) Policy does not provide for specialized clinics for MSM (N)
Community Settings Prison Settings

1) 3)

2) 4)

5)

6)

7)

8)

9) 10) 11)

b. Collect all policy documents that describe eligibility for STI services
Policy states that criminalized status (individual or behavior) does not preclude one from being eligible for STI programs (Y) Policy identifies criminalized status (individual or behavior) as excluding one from eligibility in STI programs (N) Policy assures that TG are eligible to seek STI services in clinics targeting members of their gender identity (F2M seeking services in a Mens Clinic, and M2F seeking services in a Womens Clinic) (Y) Policy restricts the ability of TG to select service providers (N) 1)

2)

c. Collect all policy documents that describe STI diagnosis and treatment protocols (WHO, 2008c), (WHO,
2007f, p. 26), (CDC, 2006), (CDC, 2011), (WHO, 2006c) Community Prison

Guarantees access to free HAV and HBV vaccination for all SW (Y) Fails to guarantee free access or identifies fees for HAV and HBV vaccination for SW (N) Guarantees access to free HAV and HBV vaccination for all TG (Y) Fails to guarantee free access or identifies fees for HAV and HBV vaccination for TG (N) Guarantees access to free HAV and HBV vaccination for all MSM (Y) Fails to guarantee free access or identifies fees for HAV and HBV vaccination for MSM (N) Policy authorizes HCT services in STI clinics (Y) Policy fails to provide for HCT in STI clinics (N) Policy authorizes syndromic STI management services (Y)

1)

2)

3)

4)

5)

6)

7) 9)

8) 10)

161

Policy fails to provide for syndromic STI management (N) Policy authorizes Periodic Presumptive Treatment (PPT) with combination therapy/single dose regimes (Y) Policy fails to provide for or allow PPT or calls for mono-therapy and/or multiple dose regimes (N) Policy authorizes Expedited Partner Therapy (EPT) for cases of gonorrhea and chlamydial infection (Y) Policy fails to authorize or restricts EPT for gonorrhea and chlamydial infection (N) Policy protects providers from liability for use of syndromic STI management, PPT, and EPT except in cases of willful or wanton misconduct (Y) Policy provide no protection from liability for providers (N) Policy assures that the most effective medicines are available at all levels of the medical system (Y) Policy restricts most effective medicines from peripheral health-care levels to referral levels (N) Policy calls for oral, vaginal, and anal STI screening (Y) Policy fails to call comprehensive screening for or restricts STI screening (N)

11)

12)

13)

14)

15)

16)

17)

18)

19)

20)

d. Collect all policy documents that mention STI services (UNFPA), (WHO, 2002b)
Policy requires that accessing STI services be voluntary for SW (Y) Fails to assure voluntary nature of STI access or makes STI diagnosis or treatment a requirement for SW licensing (N) Policy focuses on prevention, diagnosis and treatment of STI among SW (Y) Policy takes a punitive approach to STI among SW (e.g. removal of work license or deportation if diagnosed with STI) (N) Policy authorizes pharmacists and other providers of informal health care to deliver STI syndromic management (Y) Policy does not authorize, or restricts provision of syndromic management services in the informal sector (N) Policy authorizes pharmacists and other providers of informal health care to deliver STI periodic presumptive treatment (Y) Policy does not authorize, or restricts provision of periodic presumptive treatment in the informal sector (N) 1)

2)

3)

4)

162

Intervention design, access, and implementation Condoms and Lubrication HIV prevention must be evidence-informed based on methods that are proven effective (UNAIDS 2009). Consistent use of condoms and water-based lubricants (WBL) has a direct effect on reducing HIV risk and transmission (UNAIDS 2011b.UNAIDS/UNFPA/WHO 2009). Prevention efforts cannot work without guaranteed, uninterrupted access to reliable and affordable high-quality condoms and water-based lubricants. Lack of availability of free condoms is sometimes cited by sex workers as a reason for unprotected sex (WHO 2011), and 40% of SW interviewed in Burkina Faso reported problems with torn condoms (Drabo et al 2010). FGD (Focus Group Discussions) with MSM in Burkina Faso revealed access to WBL as an impediment to prevention (Soulama 2011). For SW, successful programs that focus on empowering SW to negotiate condom use and on increasing client acceptance of condoms have increased condom use in many communities (UNAIDS Advisory Group 2011). Empowering and educating SW is preferable to 100% condom programs that put condom use in the hands of law enforcement.

163

Inventory and analysis of country documents

Country: ____________________________________

Date completed: _________________________

Name of data collector __________________________________________________________________

Position: _____________________________________________________________________________

Contact information for data collector: Email address:_________________________________________________________________________

Telephone/fax: ________________________________________________________________________

Instructions to data collector: Please fill out this page and indicate the best way to contact you (email, telephone, fax, etc.) should we need further information from you. Refer to the instructions page for directions on how to fill out the inventory. Please provide information only on those areas that you are familiar with or have been assigned to research and leave the others blank. Within the areas that you are working on, please be sure to answer yes or no to each item. All data collectors should address the open-ended question at the end of the areas they are working on. If you come across a policy document that addresses areas that you are not working on, send the document or citation to the team leader. They will share this information with the individual who has primary responsibility for that section. When you have completed the inventory, please send all the pages and all the documents you have referenced to [team leader should fill this in before distributing to team members].

164

23. ondoms and lubrication (C/L) a. Collect all policy documents that authorizing C/L services
Policy:
Community Settings Prison Settings 2) 4)

Policy guarantees state funding for C/L services (Y) Policy fails to mention access or funding for C/L (N) Policy guarantees access to C/L services for SW regardless of the ability to pay (Y) Policy fails to identify free services for SW (N) Policy guarantees access to C/L services for TG regardless of the ability to pay (Y) Policy fails to identify free services for TG(N) Policy guarantees access to C/L services for MSM regardless of the ability to pay (Y) Policy fails to identify free services for MSM (N)

1) 3)

5)

6)

7)

8)

b. Collect all policy documents that mention eligibility for C/L services
Policy states that criminalized status (individual or behavior) does not preclude one from being eligible for condom and lubricant programs (Y) Policy identifies criminalized status (individual or behavior) as excluding one from eligibility in condom and lubricant programs (N) Policy directs that condom programs also supply water- and/or silicone-based lubricants (Y) Policy fails to direct or restricts provision of water- or silicone-based lubricants (N) Condom programs for SW provide support and guidance but allow SW to retain control over their decision regarding condom use (Y) Condom programs mandate 100% utilization of condoms for sex with clients (N) Monitoring of uptake and effectiveness of condom programs is undertaken by public health authorities (Y) Monitoring of uptake and effectiveness of condom programs is undertaken by law enforcement (N) Policy directs that condom programs address condom use with both casual and regular partners (Y) Policy does not address all sexual partners (N) Policy emphasizes the importance of condom use alone or in addition to other family planning methods (Y) Policy fails to mention the importance of condom use (N) 1)

c. Collect all policy documentation that describe C/L program protocols (CHALN, 2007, pp. 11-13)
1)

2)

3)

4)

5)

d. Collect all policy document that describe procurement processes for condoms and lubrication
(WHO, 2010f), (WHO, 2011, p. 33)

Condom procurement policies reference WHO/UNFPA specifications (Y) Condom procurement policies fail to reference WHO/UNFPA specifications (N)

1)

165

Intervention design, access, and implementation Information, Education, Communication (IEC) Basic activities for SW, MSM and TG must include focused communication and education that are adapted to the needs of these populations (UNAIDS, p.5. 2011). These key populations can be extremely heterogeneous. In the AWARE II region, studies report MSM working in the sex industry (Mah and Dibba 2008. World Bank/NACA 2008) and others who have sex with women, are married and/or have children (Larmarange 2010; Larmarange, Wade et al. 2010. CCM Burkina Faso 2010). Studies in the region also point to heterogeneity among sex workers and their clients ((Lowndes, Alary et al. 2008; WHO 2011). Access to IEC information must be specific to the population with protocols for delivery of IEC services (WHO 2011) including relevant information on HIV transmission

167

Inventory and analysis of country documents

Country: ____________________________________

Date completed: _________________________

Name of data collector __________________________________________________________________

Position: _____________________________________________________________________________

Contact information for data collector: Email address:_________________________________________________________________________

Telephone/fax: ________________________________________________________________________

Instructions to data collector: Please fill out this page and indicate the best way to contact you (email, telephone, fax, etc.) should we need further information from you. Refer to the instructions page for directions on how to fill out the inventory. Please provide information only on those areas that you are familiar with or have been assigned to research and leave the others blank. Within the areas that you are working on, please be sure to answer yes or no to each item. All data collectors should address the open-ended question at the end of the areas they are working on. If you come across a policy document that addresses areas that you are not working on, send the document or citation to the team leader. They will share this information with the individual who has primary responsibility for that section. When you have completed the inventory, please send all the pages and all the documents you have referenced to [team leader should fill this in before distributing to team members].

168

24. Information, Education, Communication (IEC) a. Collect all policy documents that authorizing IEC programs
Policy: Policy guarantees state funding for IEC programs (Y) Policy fails to mention access or funding for IEC (N) Policy guarantees access to IEC information specific to SW (Y) Policy fails to identify IEC or restricts information for SW (N) Policy guarantees access to IEC information specific to TG(Y) Policy fails to identify IEC or restricts information for TG(N) Policy guarantees access to IEC information specific to MSM (Y) Policy fails to identify IEC or restricts information for MSM (N)
Community Settings Prison Settings

1) 3) 5) 7)

2) 4) 6) 8)

b. Collect all policy documents that mention eligibility for IEC

Policy states that criminalized status (individual or behavior) does not restrict IEC programs (Y) Policy identifies populations with criminalized status (individual or behavior) as excluded from IEC programs (N) Policy identifies information on HIV transmission in the following content areas to be included in IEC materials (Y) Policy fails to require this content in IEC materials (N) Risks and benefits of reducing the number of sexual partners Risks and benefits of condom use Risks and benefits of sero-sorting and sero-positioning Risks and benefits of suppressive HIV therapy 1)

c. Collect all policy documents that describe protocols for the delivery of IEC services (WHO, 2011, p. 36)
Community Prison

1) 3) 5) 7) 1)

2) 4) 6) 8)

d. Collect all policy documents that describe public decency or public morality (HRC, 2011, p. 21)
Policy places no restriction on IEC content related to sexual orientation or gender identity (Y) Policy places restrictions on IEC content related to sexual orientation or gender identity (N) Policy place no restriction on IEC content related to criminalized behaviors (Y) Policy restricts IEC information on criminalized behaviors (N)

2)

169

Intervention design, access, and implementation Outreach Outreach activities increase the impact of basic programs (UNAIDS 2011). Moreover, Stigma, discrimination and criminalization of sex work and same-sex sexual relations can be major impediments for access to HIV services. Outreach through networks, communities and peer-educators is often the best or even the only way to reach these populations who may be forced to hide their behavior and be afraid to access services. Policies that guarantee access to tailored approaches with protocols for outreach services (CHALN 2007) and that ensure the safety and engagement of key populations are needed.

170

Inventory and analysis of country documents

Country: ____________________________________

Date completed: _________________________

Name of data collector __________________________________________________________________

Position: _____________________________________________________________________________

Contact information for data collector: Email address:_________________________________________________________________________

Telephone/fax: ________________________________________________________________________

Instructions to data collector: Please fill out this page and indicate the best way to contact you (email, telephone, fax, etc.) should we need further information from you. Refer to the instructions page for directions on how to fill out the inventory. Please provide information only on those areas that you are familiar with or have been assigned to research and leave the others blank. Within the areas that you are working on, please be sure to answer yes or no to each item. All data collectors should address the open-ended question at the end of the areas they are working on. If you come across a policy document that addresses areas that you are not working on, send the document or citation to the team leader. They will share this information with the individual who has primary responsibility for that section. When you have completed the inventory, please send all the pages and all the documents you have referenced to [team leader should fill this in before distributing to team members].

171

25. Outreach a. Collect all policy documents that authorizing Outreach programs
Policy:
Community Settings Prison Settings 2) 4) 6) 8)

Policy guarantees state funding for outreach programs (Y) Policy fails to mention access or funding for outreach (N) Policy guarantees access to outreach approaches specific to SW (Y) Policy fails to identify outreach approaches or restricts outreach for SW (N) Policy guarantees access to outreach approaches specific to TG (Y) Policy fails to identify outreach approaches or restricts outreach for TG (N) Policy guarantees access to outreach approaches specific to MSM (Y) Policy fails to identify outreach approaches or restricts outreach for MSM (N)

1) 3) 5) 7)

b. Collect all policy documents that describe eligibility for outreach services
Policy states that criminalized status (individual or behavior) does not restrict outreach programs (Y) Policy identifies populations with criminalized status (individual or behavior) as excluded from outreach programs (N)
SW TG

1)

c. Collect all policy documents that describe protocols for outreach services (CHALN, 2007, p. 16)
MSM

Policy identifies regular activities that document the types of sex work (Y) Policy does not identify regular activities to document the context of sex work(N) Policy identifies regular activities that map the establishments where sex work takes place (Y) Policy does not identify regular activities to document the context of sex work (N) Policy identifies regular activities that map places of socialization (Y) Policy does not identify regular activities to document places of socialization (N) Policy identifies regular activities that estimate population size (Y) Policy does not identify regular activities to estimate population size the number of sex work (N) Policy identifies regular activities that document health seeking behaviors (Y) Policy does not identify regular activities to document health seeking behaviors (N) Policy aligns types of outreach (drop-in center, mobile clinic, etc) with the health-seeking behaviors and context identified for population in that area (Y) Policy does not align types of outreach with health-seeking behavior and context (N) Policy directs that peer-leaders and outreach workers are compensated for their work (Y) Policy restricts peer-leaders and outreach workers to unpaid volunteer status (N) Policy engages owners of entertainment establishments or pimps as partners (Y) Policy fails to engage owners or entertainment establishment or pimps as partners (N) Policy engages police as partners (Y) Policy fails to engage police as partners (N)

1)

2)

3)

4)

5)

6)

7)

8)

9)

10)

11)

12)

13)

14)

15)

16)

17)

18)

19)

20)

21)

22)

23)

172

Policy authorizes outreach in prisons (Y) Policy fails to authorize outreach in prison (N) Outreach workers are provided with condoms, lubricants, and a dildo for demonstration (Y) Outreach workers are not allowed to carry dildos or carry and distribute condoms and lubricants (N) Outreach workers are provided with informational materials that include information on harm reduction and available services (Y) Outreach workers are not allows to carry informational materials (N)

24) 27)

25) 28)

26) 29)

30)

31)

32)

173

Intervention design, access, and implementation Alcohol Harm Reduction Alcohol use among SW and their clients is commonplace. Focus Group Discussions among male SW in Burkina Faso reveal that stigma, discrimination and poor work conditions influence alcohol and drug use (Soulama 2011). Among all populations, alcohol use hampers condom negotiation skills and negatively affects sexual decision-making and judgment (WHO 2011). Access to alcohol harm reduction approaches for key populations is essential to HIV prevention efforts.

175

Inventory and analysis of country documents

Country: ____________________________________

Date completed: _________________________

Name of data collector __________________________________________________________________

Position: _____________________________________________________________________________

Contact information for data collector: Email address:_________________________________________________________________________

Telephone/fax: ________________________________________________________________________

Instructions to data collector: Please fill out this page and indicate the best way to contact you (email, telephone, fax, etc.) should we need further information from you. Refer to the instructions page for directions on how to fill out the inventory. Please provide information only on those areas that you are familiar with or have been assigned to research and leave the others blank. Within the areas that you are working on, please be sure to answer yes or no to each item. All data collectors should address the open-ended question at the end of the areas they are working on. If you come across a policy document that addresses areas that you are not working on, send the document or citation to the team leader. They will share this information with the individual who has primary responsibility for that section. When you have completed the inventory, please send all the pages and all the documents you have referenced to [team leader should fill this in before distributing to team members].

176

26. Alcohol Harm Reduction a. Collect all policy documents that authorizing alcohol harm reduction programs
Policy:
Community Settings Prison Settings 2) 4)

Policy guarantees state funding for alcohol harm reduction programs (Y) Policy fails to mention access or funding for alcohol harm reduction (N) Policy guarantees access to alcohol harm reduction approaches specific to SW (Y) Policy fails to identify specific approaches or restricts services for SW (N) Policy guarantees access to alcohol harm reduction approaches specific to TG (Y) Policy fails to identify specific approaches or restricts services for TG (N) Policy guarantees access to alcohol harm reduction approaches specific to MSM (Y) Policy fails to identify specific approaches or restricts services for MSM (N)

1) 3)

5)

6)

7)

8)

b. Collect all policy documents that describe eligibility for alcohol harm reduction services
Policy states that criminalized status (individual or behavior) does not preclude one from being eligible for alcohol harm reduction programs (Y) Policy identifies criminalized status (individual or behavior) as excluding one from eligibility in alcohol harm reduction programs (N) 1)

177

Intervention design, access, and implementation Reproductive Health/Family Planning (FP/RH) Access to FP/RH with approaches specific to SW and TG is not only essential for their human rights and health but can be a point of entry for HIV prevention, care and treatment. Integrating HIV and STI services with reproductive health programs can ensure more SW and TG, who may avoid HIV and STI clinics due to stigma and discrimination, are reached. Moreover, service integration has been shown to significantly reduce HIV infection (UNAIDS 2011).

178

Inventory and analysis of country documents

Country: ____________________________________

Date completed: _________________________

Name of data collector __________________________________________________________________

Position: _____________________________________________________________________________

Contact information for data collector: Email address:_________________________________________________________________________

Telephone/fax: ________________________________________________________________________

Instructions to data collector: Please fill out this page and indicate the best way to contact you (email, telephone, fax, etc.) should we need further information from you. Refer to the instructions page for directions on how to fill out the inventory. Please provide information only on those areas that you are familiar with or have been assigned to research and leave the others blank. Within the areas that you are working on, please be sure to answer yes or no to each item. All data collectors should address the open-ended question at the end of the areas they are working on. If you come across a policy document that addresses areas that you are not working on, send the document or citation to the team leader. They will share this information with the individual who has primary responsibility for that section. When you have completed the inventory, please send all the pages and all the documents you have referenced to [team leader should fill this in before distributing to team members].

179

27. Reproductive Health/Family Planning (FP/RH) a. Collect all policy documents that authorizing FP/RH programs
Policy:
Community Settings Prison Settings 2) 4) 6)

Policy guarantees state funding for FP/RH programs (Y) Policy fails to mention access or funding for FP/RH (N) Policy guarantees access to FP/RH approaches specific to SW (Y) Policy fails to identify specific approaches or restricts services for SW (N) Policy guarantees access to FP/RH approaches specific to TG (Y) Policy fails to identify specific approaches or restricts services for TG (N)

1) 3) 5)

b. Collect all policy documents that describe eligibility for FP/RH services Policy states that criminalized status (individual or behavior) does not preclude one from being eligible for FP/RH programs (Y) Policy identifies criminalized status (individual or behavior) as excluding one from eligibility in FP/RH programs (N) c. Collect all policy documents that describe protocols for FP/RH services (WHO, 2006c)

1)

Community

Prison

Policy emphasizes the importance of condom use alone or in addition to other family planning methods (Y) Policy fails to mention the importance of condom use (N) Policy authorizes STI services in all reproductive health/family planning settings (Y) Policy restricts or does not allow STI services in reproductive health/family planning settings (N) Policy authorizes HCT in all reproductive health/family planning settings (Y) Policy restricts or does not allow HCT in reproductive health/family planning settings (N) Policy authorizes counseling on legal options to terminate pregnancy (Y) Policy fails to authorize or restricts counseling on legal options for pregnancy termination (N) Policy ensures that the decision to terminate pregnancy lies solely with the woman (Y) Policy fails to specifically identify that pregnancy termination is the sole decision of the woman or provides for involuntary termination of pregnancy (N)

1) 3)

2) 4)

5) 7) 9)

6) 8) 10)

180

Works Cited
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ANNEX 4: SW AND MSM POLICY ASSESSMENT INTERVIEW GUIDE

Key Informant Interview Informed consent instructions Good morning/afternoon/evening. My name is __________ and I work with __________. We are interviewing knowledgeable people such as yourself to learn about the availability of services for Sex Workers, Transgender, and Men who have Sex with Men in [country], the policies around sex work and sexual minorities and the groups that participated in developing the policies, and attitudes towards SW, TG, and MSM. The purpose of our work is to make recommendations to expand services and improve the quality of services provided in [country]. This work is funded by the US Agency for International Development (USAID) [or other donor]. We invite you to take part in a survey about these topics. All information will be kept confidential. We will not ask for your name or for any other information that could identify you. We will not share your answers with anyone outside the project. Our report will combine all the interviews we collect and not single out any individual. Taking part in this activity is entirely voluntary. The interview should take no more than 30 minutes of your time. You are free to decline to answer any question or to terminate the interview at any time. We anticipate no risk to you as a result of your participation in this survey other than the inconvenience of the time to complete the questionnaire. Do you consent to participate in the survey? [ ] Consent to participate [ ] Decline to participate (Thank client and terminate interview.)

Identification number_____________________ Information: City/country: __________________________________________________________________

Personal/professional affiliation(s) (Check at least one and all that apply)

[ ] Policy maker: specify ______________________________________________________

[ ] Service provider: specify____________________________________________________

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[ ] Organization of sex workers [ ] Organization of men who have sex with men [ ] Organization of transgender [ ] Organization of people living with HIV [ ] Other advocacy group: specify _______________________________________________

[ ] Organization of health professionals: specify ____________________________________

[ ] Organization of lawyers

[ ] Other: specify ____________________________________________________________

Primary area of technical oversight, authority, or expertise check all that apply

HIV
Enforcement

Drug Treatment Harm Reduction Courts/Justice

Human Rights

Law

Prison

Other_____________________________

188

1. a.

Coordination and collaboration How would you describe the coordination of the following sectors with the continuum of health services for SW, clients of SW, TG, and MSM (FP/RH, STI, HIV) a. Aligne b. No c. Contradi d regulations coordination ctory and outcome regulations and targets outcome targets 1) Education sector coordination with FP/RH, STI, HIV programs

2) Labor sector coordination with FP/RH, STI, HIV programs

3) Commerce sector coordination with FP/RH, STI, HIV programs

4) Transportation sector coordination with FP/RH, STI, HIV programs 5) Immigration/migration sector coordination with FP/RH, STI, HIV programs 6) Prison sector coordination with FP/RH, STI, HIV programs

7) Military sector coordination with FP/RH, STI, HIV programs

8) Please cite one example of good coordination and one example of bad coordination between health and other sectors for services for SW

9) Please cite one example of good coordination and one example of bad coordination between health and other sectors for services for clients SW

189

10) Please cite one example of good coordination and one example of bad coordination between health and other sectors for services for TG

11) Please cite one example of good coordination and one example of bad coordination between health and other sectors for services for MSM

12) Notes/anecdotes :

190

b.

How would you describe the coordination between health services for SW and law enforcement programs at the local level a) Aligne b) No c) Contradictor d regulations coordination y regulations and and outcome outcome targets targets 1) At the local level 2) Please cite one example of good coordination

3) Please cite one example of poor coordination

Notes/anecdotes :

c.

How would you describe the coordination between health services for clients of SW and law enforcement programs at the local level a) Aligned b) No c) Contradictor regulations coordination y regulations and and outcome outcome targets targets 1) At the local level 2) Please cite one example of good coordination

191

3) Please cite one example of poor coordination

4) Notes/anecdotes :

192

d.

How would you describe the coordination between health services for TG and law enforcement programs at the local level a) Aligned b) No c) Contradictor regulations and coordination y regulations and outcome targets outcome targets 1) At the local level 2) Please cite one example of good coordination

3) Please cite one example of poor coordination

4) Notes/anecdotes:

e.

How would you describe the coordination between health services for MSM and law enforcement programs at the local level a) Aligned b) No c) Contradictor regulations and coordination y regulations and outcome targets outcome targets 1) At the local level 2) Please cite one example of good coordination

193

3) Please cite one example of poor coordination

4) Notes/anecdotes:

f. Differences between community and prison services for FP/RH, STI, and HIV programs 1) Identify any services that are available in the community that arent available in prison settings a) FP/RH

b) STI

c)

HIV

194

2) Identify any coverage and/or outcome targets that are different between the community and prison settings a) FP/RH

b) STI

c)

HIV

3) Identify any levels of financial resources that are different between the community and prison settings a) FP/RH

b) STI

c)

HIV

4) Notes/anecdotes:

195

2. a.

Data used in decision making processes Describe your perception of how the government sets funding level and service delivery targets a. Historic funding levels/support for existing physical infrastructure and staffing levels c. Community level epidemiological data

b. Utilization data

1) FP/RH Programs

2) STI Programs

3) HIV Programs

4) Other, please describe:

5) Notes/anecdotes:

196

d. Dont know

b.

If applicable, describe how you use the following data in programming, funding, or advocacy decisions a) Use it b) Would c) Don regularly like to use it but it t need this is not available level of data 1) Population size estimates of SW

2) Coverage targets for SW

3) Health seeking behaviors of SW

4) International best practices and standards for services for SW 5) Population size estimates of SW clients

6) Coverage targets for SW clients

7) Health seeking behaviors of SW clients

8) International best practices and standards for services for SW clients 9) Population size estimates of TG

10) Coverage targets for TG

11) Health seeking behaviors of TG

12) International best practices and standards for services for TG 13) Population size estimates of MSM

14) Coverage targets for MSM

15) Health seeking behaviors of MSM

16) International best practices and standards for services for MSM 17) Notes/anecdotes:

197

3. Partnerships and engagement of key populations in decision making a. Please list any advisory bodies/processes for the following services and indicate (Y/N) if they engage individual or organizational representation of SW, TG, or MSM SW TG MSM FP/RH 1)
a) I b) individ org ual O c) I d) individ org ual O e) I f) individ org ual O

2)

3)

STI 4)

5)

6)

HIV 7)

8)

9)

10) For areas above that have no participation from individuals or organizations please describe barriers to engaging target populations in the decision making process

198

11) Notes/anecdotes:

199

4. Authorization of FP/RH, STI, and HIV Programs a. Specific, legal authorization is important to support provision of FP/RH, STI, and HIV services. For the following, please identify any specific services that you feel are not authorized, supported, or allowed by the current legal code, please think specifically about services that are important to SW, SW clients, TG, and MSM 1) FP/RH

2) STI

3) HIV

4) Notes/anecdotes:

200

b.

Please describe which agencies have primary authority, coordination and jurisdiction over health and harm reduction programs and give examples. If multiple agencies have jurisdiction, please give examples under each 1) Health and harm reduction services for SW a) Public Health b) Law enforcement and/or c) Other judicial agencies

2) Health and harm reduction services for SW clients a) Public Health b) Law enforcement and/or judicial agencies

c)

Other

3) Health and harm reduction services for TG a) Public Health b) Law enforcement and/or judicial agencies

c)

Other

201

4) Health and harm reduction services for MSM a) Public Health b) Law enforcement and/or judicial agencies

c)

Other

a.

5. Consent Please describe any circumstances under which the following populations are compelled to undergo interventions or mandatory medical testing/treatment regardless of individual consent or where consent is coerced. Describe related procedures a) SW

b) SW Clients

202

c)

TG

d) MSM

203

a.

6. Privacy and confidentiality of personal medical treatment/services utilization data Do you know of circumstances where individual medical, psychological, and or drug treatment/service utilization information is shared beyond the providers directly involved in the care of the client without the consent of the client? 1) No, information is not shared

If yes, with whom is this information shared? 2) 3) 4) 5) 6) 7) Government health agencies or personnel Government administrative agencies or personnel Law enforcement or security agencies or personnel Employers Family Other

8) For any Yes answers above, please describe

204

b.

Do the professional bodies that represent you or your staff (e.g., teachers, lawyers, health care workers, etc) have codes of conduct and use them to discipline breaches of confidentiality and unreasonable invasion of privacy as professional misconduct? 1) Dont know/not applicable 2) No 3) Yes, please describe

4) Notes/anecdotes :

205

8.

Policy documents that address HIV and drug-use stigma and discrimination

a.

Describe the mechanisms that the government uses to measure stigma and discrimination against SW

b.

Describe any national activities that are being undertaken to reduce stigma and discrimination against SW

c.

Describe the mechanisms that the government uses to measure stigma and discrimination against TG

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d.

Describe any national activities that are being undertaken to reduce stigma and discrimination against TG

e.

Describe the mechanisms that the government uses to measure stigma and discrimination against MSM

f.

Describe any national activities that are being undertaken to reduce stigma and discrimination against MSM

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9. Definitions of sex work, TG, and MSM a. How would you describe sex work? Check all that apply 1) sex work is a legitimate occupation 2) sex work is a criminal occupation or behavior 3) sex work is a socially unacceptable occupation or behavior 4) other________________________________________________________________________________ b. How would you describe human trafficking? Check all that apply 1) trafficking involves acquisition of people by means such as force, fraud or deception 2) trafficking involves the goal of exploitation 3) there is no difference between trafficking and consensual sex work 4) other________________________________________________________________________________ c. How would you describe homosexuality or sexual orientation? Check all that apply 1) homosexuality is a naturally occurring, normal expression of sexual attraction 2) same-sex sexual attraction is deviant, criminal, or an illness 3) other________________________________________________________________________________ d. How would you describe gender identity? Check all that apply 1) 2) 3) 4) 5) gender identity is an individual experience of gender gender identity may or may not correspond with the sex assigned at birth gender non-conformity is deviant, criminal or an illness other________________________________________________________________________________ Notes/anecdotes :

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10. Criminalization and punishment a. Is information provided in any of the following circumstances used for the initiation of criminal charges or investigations against SW, TG, or MSM? a) Yes b) No c) Dont know 1) Presence of disease or the mode of transmission 2) Condoms and other safer sex materials 3) Information provided in the process of reporting violence 4) Information provided in the process of reporting blackmail 5) Information provided in the process of filing a discrimination complaint 6) Other

7) Notes/anecdotes:

b.

What are the charges that are used to fine, arrest, harass, or detain sex workers? (Check all that apply) a) Yes b) No c) Dont know 1) Transmission of communicable disease 2) Sex work, prostitution, solicitation, etc 3) Crimes against nature, sodomy, etc 4) Loitering 5) Public morality 6) Public scandal 7) Cross dressing 8) 9) 10) Notes/anecdotes:

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c.

What are the charges that are used to fine, arrest, harass, or detain clients of sex workers? (Check all that apply) a) Yes b) No c) Dont know 1) Transmission of communicable disease 2) Sex work, prostitution, solicitation, etc 3) Crimes against nature, sodomy, etc 4) Loitering 5) Public morality 6) Public scandal 7) Cross dressing 8) 9) 10) Notes/anecdotes:

d.

What are the charges that are used to fine, arrest, harass, or detain TG? (Check all that apply) a) Yes b) No c) Dont know 1) Transmission of communicable disease 2) Sex work, prostitution, solicitation, etc 3) Crimes against nature, sodomy, etc 4) Loitering 5) Public morality 6) Public scandal 7) Cross dressing 8) 9) 10) Notes/anecdotes:

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e.

What are the charges that are used to fine, arrest, harass, or detain MSM? (Check all that apply) a) Yes b) No c) Dont know 1) Transmission of communicable disease 2) Sex work, prostitution, solicitation, etc 3) Crimes against nature, sodomy, etc 4) Loitering 5) Public morality 6) Public scandal 7) Cross dressing 8) 9) 10) Notes/anecdotes:

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f.

What are the charges that are used to fine, arrest, harass, or detain individuals or organizations that provide services to SW, TG, and MSM? (Check all that apply) a) Yes b) No c) Dont know 1) Transmission of communicable disease 2) Sex work, prostitution, solicitation, etc 3) Crimes against nature, sodomy, etc 4) Loitering 5) Public morality 6) Public scandal 7) Cross dressing 8) Promotion, facilitation or aiding and abetting of criminal offenses 9) 10) 11) Notes/anecdotes:

a.

11. Domestic, sexual and gender-based violence Please indicate which of the following services are available to each population (Y/N) a) SW b) TG 1) Full protection and prosecution of honor killings 2) Sexual harassment complaint processes against employers or client 3) Medical assistance 4) Post-exposure prophylaxis 5) Domestic violence shelters 6) 7)

c)

MSM

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8) Notes/anecdotes:

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a.

13. Monitoring and enforcement of human and legal rights Please describe elements of the professional codes of conduct for professions (e.g. healthcare workers, lawyers, and teachers 1) Im not aware of these codes of conduct 2) There are no codes of conduct 3) There are codes of conduct, but I am not familiar with their content If there are codes of conduct identify primary components. 4) 5) 6) 7) 8) 9) 10) First, do no harm Obligation to provide services, regardless of criminalized identity or behavior Confidentiality Adherence to research and best practices of my profession Addressing and mitigating stigma and discrimination Adherence to research and best practices of my profession Acknowledging and prioritizing disease prevention over treatment

11) other________________________________________________________________________________ 12) other________________________________________________________________________________

b. 1) 2) 3) 4)

Please describe your perception of compensation of civil servants and political leaders compared with similar positions in the private sector Compensation levels are about the same Compensation levels are lower, but individuals are allowed to supplement their income through supplemental fees collected from members of the public Compensation levels are lower and individuals are forbidden to supplement their income through supplemental fees collection from members of the public other________________________________________________________________________________

214

c. 1) 2) 3) 4) 5)

Please describe the role that adopted international conventions/treaties plan in the legislative process Dont know Adopted international conventions/treaties have overall supremacy over country legislation Country legislation attempts to align with adopted international conventions/treaties Im not aware of any international conventions/treaties that we have adopted There is no role for international conventions/treaties to plan in country legislation

6) other________________________________________________________________________________

a.

14. Procurement and Supply Management Are you aware of stock outs of medical supplies, medicines, or harm reduction commodities (condoms/lubricant, etc) for FP/RH, STI, and HIV in the following types of facilities in the last six months? If so, please describe 1) Government run medical facilities

2) Non-government run medical facilities

3) Non-government run health promotion/harm reduction programs

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a.

15. Overall services design Please describe any barriers to access or quality services for the following service areas for SW, TG, and MSM. 1) HCT

2) ART

3) STI

4) STI for SW clients

5) Condoms AND Lubrication

6) Information and education materials

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7) Outreach

8) Alcohol harm reduction

9) FP/RH

10) Notes/anecdotes

217

b.

When was the last time you received training in any of the following topic areas. a) Last 6 b) 6-12 mo c) > 12 mo mo 1) Ethics and human rights including consent and confidentiality 2) Avoiding stigma and discrimination 3) Domestic and sexual violence 4) Human sexuality 5) Specific needs of SW, TG, or MSM 6) Referral between law enforcement, medical, and harm reduction services 7) Training on FP/RH, STI, or HIV 8) Notes/anecdotes

d) Never/dont remember

Thank you for your time, is there anything else you would like to tell me??

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USAID Action for West Africa Region Project II (USAID AWARE II) 16 Ridge Road, Roman Ridge Accra Adjacent Akai House Opposite Bernswett Pharmacy P.O. Box KN 279, Kaneshie, Accra Phone: +223-302-771381/597 Fax: +223-302-771720