Ending New HIV Infections by 2022

Royal Eswatini Police Service Health and Inclusiveness Training Manual

December 2018

Royal Eswatini Police Services, 2018

©Royal Eswatini Police Service

This training manual is a publication of the Royal Eswatni Police Services (REPS) in collaboration with Eswatini National AIDS Program (ENAP)-Ministry of Health, Eswatini and other partners. The text of this publication may be freely quoted or reprinted with proper acknowledgement.

Recommended citation for this manual: Royal Eswatini Police Service (2018). Royal Eswatini Police Service Health and Inclusiveness manual, Learner manual. Mbabane, Eswatini.

Disclaimer

The opinions expressed in this document do not necessarily represent the officeial position or policy of Royal Eswatini Police Services or Eswatini National AIDS Program.

Foreword As a Royal Eswatini Police Service, we remain unrelenting in our commitment to make an effective contribution in the fight against the HIV and AIDS scourge in the country. To that effect, we cherish and are humbled by the recognition accorded by the Ministry of Health, that our organization is one of the key stakeholders for broader success in reversing the frontier of this nemesis.

To further escalate our efforts, as well as hearken to the call by His Majesty The King for all sectors in Eswatini society to join hands to put an end to new HIV infections by 2022 in consonance with the macro National 2022 Vision of a “First World Eswatini”, we have developed a multi-prolonged HIV and AIDS counteracting Strategy.

The Strategy aside from addressing issues relating to the holistic support for members of the Police Service and their families who may be afflicted and affected by HIV and AIDS, also focuses on the critical aspect of creating a non-stigmatisation and non-discriminatory environment. The implementation of the Strategy remains on course and is yielding tangible results.

To complement the aspirations of the Strategy, especially with hindsight of the law enforcement responsibilities of Police officers which more often than not, means that they interact with marginalised groups in society, Health and Inclusiveness Training Manual has been conceptualized.

The Manual seeks primarily to improve how Police officers respond to their health needs through providing information on sexual reproductive health (SRA), prevention, care and treatment for HIV, sexual transmitted infections (STI’s), tuberculosis (TB), and selected cancers as well as mental health and related health services. It is also designed as a tool of furthering service provision towards vulnerable and marginalised groups including key populations (KPs) within the obligations of the Police under the relevant country’s regulations.

It is our fervent hope that this training manual will provide the requisite guidance and impetus for Police officers in their diverse operational capacities, to make a meaningful contribution towards ending HIV and AIDS.

W. W. Dlamini

ACTING NATIONAL COMMISSIONER OF POLICE

iii

Acknowledgements

The Kingdom of Eswatini has made major strides in its HIV response, reducing new HIV infections through initiating those people living with HIV (PLHIV) on antiretroviral therapy (ART) both as a measure for reducing new infections and for improving the quality of life of those infected. However, more work still needs to be done as the epidemic has shifted from what is commonly known as a generalised epidemic to a micro-epidemic impacting different groups in different ways. The sub-populations who are most affected by HIV have previously been left behind in the response for HIV, including vulnerable and marginalized groups including KPs. In response the government of Eswatini has engaged a multi-sectoral response to HIV, in accordance to His Majesty’s call.

We would like to thank the Royal Eswatini Police Services (REPS) for taking a lead in responding to HIV in accordance wtih His Majesty’s call. Special thanks goes to the The National Commissioner of Police as well as the police executive committee; the police officers from the regions, stations and posts; the police health department; the basic training and in-service division; the faculty of management and leadership; the curriculum design and examination unit; and the domestic violence, child protection and sexual offences unit.

We would also like to thank all partners who have supported in developing this training manual. We would like to thank African Men for Sexual Health and Rights (AMSHeR) through the KPREACH programme for their technical and financial support; FHI 360; council of Assemblies of Nongovernmental Organizations(CANGO); Fammily Life Association of Swaziland (FLAS); Key populations (KP) Community-bsed Organisations; and the UN agencies, especially UNAIDS for their technical support and UNDP for their contribution in rolling out trainings based on the manual. We would also like to thank our consultant, Sibusiso Nhlabatsi, for his contribution as a consultant.

In addition we would like to thank all the members of the KP Technical Working Group and stakeholders who participated in the development and validation process of the training manual. Lastly, we thank our own Key Populations Unit within ENAP for their coordination role in all our interventions, including this initiative.

Dr Vusi Magagula

DIRECTOR OF HEALTH SERVICES MINISTRY OF HEALTH

Acronyms ACHPR African Charter on Human and People’s Rights AIDS acquired immune deficiency syndrome AGYW adolescent girls young women AMSHeR African Men for Sexual Health and Rights ANC antenatal clinic ART antiretroviral therapy ARV antiretroviral (drug) BMI body mass index BP blood pressure CAG community-based ART groups CANGO Council of Assemblies of Nongovernmental Organizations CEDAW convention of elimination of all forms of discrimination against women CIHTC client-initiated HIV testing and counselling CRC convention of the rights of the child DOT directly observed therapy EC expert client FHI Family Health International FLAS Family Life Association of Swaziland FTC facility-based treatment club GBV gender-based violence HCW health care worker HPV human papillomavirus HTS HIV testing Services HIV human immunodeficiency virus HIVST HIV self-testing HTS HIV testing services ICCPR international covenant for socioeconomic rights ICSER international covenant for civil and political rights KP key population LGBTQI lesbian, gay, bisexual, transgender, queer, and intersex MICS multiple indicator cluster surveys

MSM men who have sex with men MTCT mother-to-child tranmission NCD noncommunicable disease NSE Needle and syringe exchange NSF National Multisectoral HIV and AIDS Strategic Framework NSP needle and syringe program OI opportunistic infections PEP post-exposure prophylaxis PHT post-menopausal hormone therapy PIHTC provider-initiated HIV testing PLHIV people living with HIV PrEP pre-exposure prophylaxis PWID people who inject drugs REPS Royal Eswatini Police Service SARPCCO southern african regional police chiefs cooperation organisation SDHS Swaziland Demographic and Health Survey SHIMS Swaziland HIV Incidents Measurements Survey SRH sexual and reproductive health STIs sexually transmitted infections SW sex worker TB tuberculosis TG transgender people UDHR universal declaration of human rights UN united nations UNAIDS joint united nations programme on HIV/AIDS UNCAT convention against torture and other cruel, inhuman or degrading treatment or punishment VIA visual inspection with acetic acid VL viral load VMMC voluntary medical male circumcision WHO World Health Organization

Glossary AIDS AIDS stands for acquired immunodeficiency syndrome: A - Acquired. This condition is acquired, meaning that a person becomes infected with it. I - Immuno. HIV affects a person's immune system, the part of the body that fights off germs, such as bacteria or viruses. D - Deficiency. The immune system becomes deficient and does not work properly. S - Syndrome. A person with AIDS may experience other diseases and infections because of a weakened immune system.

AIDS is, therefore, a disease in which there is a severe loss of the body's cellular immunity as a result of destruction of T-cells by HIV, greatly lowering the resistance to infection and malignancy. Not every person infected with HIV has AIDS. It is only when the immune system of the person is so weakened that the person gets infections because his or her immune system is no longer able to fight them off. At this stage the person will be said to have AIDS.

Alcohol This includes beer, wine, and spirits. These substances act as a central nervous system depressant. Alcohol is usually ingested orally as a drink.

Anal Sex Sex that involves the insertion of the penis into the anus (penile- anal penetrative sex).

Antiretroviral drugs Medication used in the prevention or treatment/management of (ARVs) HIV.

Antiretroviral Antiretroviral therapy is the combination of several antiretroviral therapy/treatment (ART) medicines used to slow the rate at which HIV makes copies of itself (multiplies) in the body. A combination of three or more antiretroviral medicines is more effective than using just one medicine (monotherapy) to treat HIV. It also involves ensuring that a person adheres to treatment, attends clinic appointments, and meets other requirements of the therapy.

Bisexual Having sexual partners of both the same and the opposite sex.

Bisexuality The sexual orientation in which an individual has romantic and/or sexual feelings toward both males and females at a point in time.

Chancroid A STI caused by the bacterium Haemophylisducreyi, resulting in ulceration and swollen lymph nodes.

Chlamydia A group of sexually transmitted bacteria commonly responsible for urethritis/proctitis.

Concurrent sexual People with concurrent sexual partnerships are involved in partners overlapping sexual partnerships where intercourse with one partner occurs between two acts of intercourse with another partner.

Condom This is a thin, stretchy, latex sheath worn on a man's penis (male condom) or inserted into a woman’s vagina (female condom) during sexual intercourse as protection against pregnancy and/or HIV and STIs.

Co-infection When an individual presents with signs and symptoms for two co-occurring conditions (such as HIV and TB), each requiring specific treatment and management.

Depression Refers to a low mood with loss of interest or pleasure in life and activities, which lasts for a period of two weeks or more and is disruptive to everyday functioning. It is characterised by multiple signs and symptoms, including: sadness, inactivity, difficulty concentrating and thinking, significant increase or decrease in appetite, difficulty sleeping, and/or suicidal thoughts.

Discharge Fluid oozing from an area of inflammation, which includes cells aimed at fighting infection and the infectious agent. Discharge may be seen coming from the penis, anus, vagina, or throat as a result of selected STIs.

Discrimination The unjust or prejudicial treatment of different categories of people on the grounds of race, age, sex, sexual orientation, gender, and gender identity and presentation.

Drug A drug is a chemical substance that influences the normal functioning of the central nervous system and results in both physical and mental effects.

Female condom Loose-fitting polyurethane sheath with an inner ring at the closed end, and an outer ring at the open end, inserted inside the vagina or anus, for protection against pregnancy and/or HIV and STIs.

Female-to-male/trans A trans man, or female-to-male transsexual, starts his life with a man female body, but his gender identity is male. Always use male pronouns in reference.

Gay Refers to a man who has romantic, sexual, and/or intimate feelings for other men. The term ‘gay’ is generally a more commonly used term for homosexual. The term men who have sex with men (MSM) should be used unless individuals or groups self-identify as gay.

Gender Social attributes and opportunities associated with being male and female and the relationships between women and men and girls and boys, as well as the relations between women and those between men. These attributes, opportunities and relationships are socially constructed and are learned through socialization processes. They are context/time-specific and changeable. Gender determines what is expected, allowed and valued in a woman or a man in a given context. In most societies, there are differences and inequalities between women and men in responsibilities assigned, activities undertaken, access to and control over resources, as well as decision-making opportunities.

Gender identity A person’s internal, deeply felt sense of being male, female an alternate gender or a combination of genders. A person’s gender identity may or may not correspond with her or his sex assigned at birth.

Gender-based violence GBV encompasses various forms of violence directed at women, (GBV) because they are women, and men, because they are men, depending on the expectations of each in a given community. For MSM and transgender individuals, the violence is directed toward them because of their nontraditional notions of sexuality and gender identity and expression.

Gender role Socially-constructed or learned behaviors that condition activities, tasks, and responsibilities viewed within a given society as ‘masculine’ or ‘feminine.’

Genital Relating to sexual organs such as the vagina, penis, etc.

Gonorrhoea A STI caused by the bacteria Neisseria gonorrhoea, commonly affecting the penis, anus, and vagina, and less commonly the throat.

Hepatitis Inflammation of the liver, which may be caused by a virus, drugs, or rarely diseases of the immune system.

Herpes A group of viruses that are spread through direct contact. Herpes simplex type 1 is responsible for ‘cold sores’ – superficial ulcers around the mouth and nose. Herpes simplex type 2 causes most cases of painful sores found around the penis, anus, or vagina (genital herpes).

iii

Heteronormative A social construct that views all human beings as either male or female with the associated behavior and gender roles assigned, both in sex and gender, where sexual and romantic thoughts and relations are viewed as “normal” only between people of opposite sexes. All other behavior is viewed as ‘abnormal.’

Heterosexuality The sexual orientation in which an individual has romantic or sexual feelings toward members of the opposite sex.

Homophobia An irrational fear of, aversion to, or discrimination against persons known or assumed to be homosexual, or against homosexual behaviour or cultures.

Homosexual Attraction between two people of the same sex on various levels: emotional, physical, intellectual, spiritual and, most prominently, sexual.

Human HIV is a retrovirus that causes AIDS by infecting helper T cells of immunodeficiency virus the immune system. The most common serotype, HIV-1, is (HIV) distributed worldwide, while HIV-2 is primarily confined to West Africa. It is one of many STIs.

Human papillomavirus The virus responsible for genital warts. Different subtypes exist, (HPV) some of which are associated with the development of anal, penile, and cervical cancer.

Human rights The basic rights and freedoms that all people are entitled to regardless of nationality, sex, age, ethnic origin, race, religion, language, or other status. The other status refers to, for example, a person’s HIV status. Freedoms around sexual orientation and gender identity are also basic human rights.

Incidence The rate of newly diagnosed people who develop a condition or disease during a particular time period. It is expressed in percentages/proportions and is different from prevalence.

Identity The distinguishing characteristics of a person or group; that is, the qualities that make them different from others.

Intersex people An intersex person is one who was born with sexual anatomy, reproductive organs or chromosome patters that do not fit the typical definition of male or female. Previously referred to as “hermaphrodites”.

Internalized When a homosexual individual internalizes (makes their own) homophobia the shame and hatred projected onto gays and lesbians by a homophobic society.

Key populations (KP) Groups of people most likely to be exposed to HIV or to transmit it. Their engagement is critical to a successful HIV response, i.e., they are key to the epidemic and key to the response. In our settings, men who have sex with men, transgender persons, people who inject drugs, and sex workers and their clients are at higher risk of exposure to HIV than other people.

LGBTQI Abbreviation for lesbian, gay, bisexual, transgender, queer, intersex.

Lesbian A woman who has romantic, sexual, and/or intimate feelings for other women. The term “women who have sex with women” (WSW) should be used unless individuals or groups self-identify as lesbians.

Lubricant Substance that reduces friction during sexual intercourse. Lubricants can be water-based (e.g., KY Jelly®) or oil-based (e.g., Vaseline®, body cream, cooking oil). Latex male condoms should only be used with water-based lubricants, as oil-based lubricants deteriorate latex.

Men who have sex with This term includes not only men who self-identify as gay or men (MSM) homosexual and have sex only with other men, but also bisexual men and those who self-identify as heterosexual but have sex with other men.

Multiple stigma Stigmatizing because of two or more perceived differences, e.g., sexual orientation, HIV-positive status, and race.

Needle (syringe): A medical instrument to deliver liquids into the bloodstream that is commonly used among PWID to inject drugs.

Needle and syringe Needle and syringe programs provide sterile syringes and programs (NSP) needles in exchange for used ones to reduce transmission of HIV and other blood-borne infections associated with re-use of contaminated syringes and needles by PWID. The programs help to prevent blood-borne pathogen transmission by increasing access to sterile injecting equipment and enabling safe disposal of used syringes and needles. Programs often also provide other public health services, such as HIV testing, risk-reduction education, and referrals for substance-abuse treatment. Also referred to as needle and syringe exchange (NSE).

People who inject drugs People who inject drugs or a person who injects drugs. (PWID)

Phobia Excessive anxiety or fear about a specific object or situation.

Post-exposure The use of medication to prevent infection after exposure to an prophylaxis (PEP) infectious agent. Preventive treatment (antiretroviral drugs typically taken for four weeks) started immediately (within 72 hours) after exposure to the HIV virus to prevent the virus from developing inside the body.

Prejudice An irrational, preconceived opinion, not based on reality or actual experience. It often results in dislike, hostility, and unjust behavior.

Pre-exposure A strategy of using combinations of antiretroviral medications in prophylaxis (PrEP) HIV-negative individuals to lower their risk of becoming HIV positive if they are exposed to the virus.

Prevalence The number of people in a population having a particular condition or disease at a given time. It is expressed as a proportion and is different from incidence.

Queer An umbrella term for sexual and gender minorities who are not heterosexual or cisgender

Rectum The lower region of the intestines linking the descending colon to the anus.

Serial monogamy An individual who has a sexual relationship with only one partner, with no overlap in time with subsequent partners.

Serodiscordant A romantic or sexual relationship between two people of relationship differing HIV status (e.g., one could be HIV positive and the other HIV negative).

Sex Sex is a medical term used to refer to the chromosomal, hormonal, and anatomical characteristics that are used to classify an individual as female or male or intersex. Sex refers to the biological aspects of a person.

Sexual behavior The manner in which people express their sexuality. Examples include physical or emotional intimacy and sexual contact.

Sexual identity The overall sexual self-identity, which includes how the person identifies as male, female, masculine, feminine, or some combination of these, and the person’s sexual orientation.

Sexual minority A group whose sexual identity, orientation, and gender identity, expression, or practices differ from the majority of the surrounding society.

Sexual orientation The set of emotional, physical, and romantic feelings an individual has toward others. These feelings and behaviors are

usually directed toward men or women, but could be toward both men and women.

Sexuality How people experience and express themselves as sexual beings within the concepts of biological sex, gender identity and presentation, attractions, and practices. Culture and religion have a huge impact on how individuals see themselves as sexual beings, especially within relations of power.

Sex work Any agreement between two or more adult persons in which the objective is limited to a consenting sexual act, and which involves preliminary negotiations for a price. Hence, there is a distinction from marriage contracts, sexual patronage, and agreements between lovers that could include in-kind presents or money, but the value has no connection with the sexual act, and the agreement does not depend exclusively on sexual services.

Substance dependence A pattern of habitual substance use that involves physical dependence (with increased tolerance and withdrawal if stopped), psychological dependence, and behavioral dependence.

Stereotype A standardized mental picture that represents an oversimplified characteristic of a person or group and may be a prejudiced attitude; usually driven by stigma.

Stigma Shame or disgrace that is directed toward something regarded as socially unacceptable.

Stigmatize The action of treating someone differently or unfairly because of some perceived difference (e.g., sexual behavior, gender).

Transgender Persons whose gender identity is different from the sex assigned at birth. Transgender is an umbrella term that describes a wide variety of cross-gender behaviours and identities.

Transition Process trans people undergo to live authentically in their gender identiy. This may involve changes to outward appearance, clothing, mannerisms or to the name someone uses in everyday interactions. Transitioning may also involve medical steps that help to align a person’s anatomy with their gender identity. Transition is not defined by medical steps taken or not taken.

Trans man A transgender person who was born female but identifies as male.

vii

Transphobia A prejudice directed at trans people because of their actual or perceived gender identify or expression. Transphobia can be structural, i.e. manifest in policies, laws and socio-economic arrangements that discriminate against trans people. It can be societal when trans people are rejected or mistreated by others. Transphobia can also be internalized, when trans people accept and reflect such prejudicial attitudes about themselves or other trans people.

Transsexual A transgender person in the process of seeking or undergoing some form of medical treatment to bring their body and gender identity into closer alignment. Not all transgender people undergo reassignment surgery.

Transvestite A person who wears clothes associated with the opposite gender to enjoy the temporary experience of belonging to that gender. A transvestite does not necessarily desire a permanent sex change or other surgical reassignment.

Trans woman A transgender person who was born male but identifies as female.

Transactional sex The process of exchanging sex for goods, money, shelter, food, or other items or services.

Vaginal sex Sex which usually involves the insertion of the penis into the vagina (penile-vaginal sex).

viii

Contents Foreword ...... iii Acknowledgements ...... iv Acronyms ...... v Glossary ...... i Contents ...... ix List of Figures ...... xiii List of Table...... xiii Background ...... 1 Aim of the manual...... 1 Objectives: ...... 1 Target audience ...... 2 Why a training on inclusive policing ...... 2 Why engage police services personnel on health issues of vulnerable groups ...... 2 How is the manual structured? ...... 3 Module 1: Communicable Diseases: HIV and AIDS, STIs, and TB ...... 4 Introduction ...... 4 Module Objectives ...... 4 Unit 1: HIV and AIDS ...... 4 Introduction ...... 4 Unit Objectives ...... 4 HIV and AIDS epidemiology ...... 5 Situational analysis of HIV and AIDS in Eswatini ...... 5 HIV incidence ...... 5 HIV prevelance ...... 6 HIV and opportunistic infection and comorbidities ...... 6 Drivers of the HIV epidemic ...... 6 The national HIV, TB, and STIs response ...... 8 Basic facts on HIV and AIDS ...... 9 Transmission of HIV ...... 9 Common Opportunistic Infections (OIs) among PLHIV ...... 10 Misconceptions and Facts about HIV and AIDS ...... 11

HIV Prevention ...... 11 HIV testing ...... 16 HIV testing and counselling (HTC) modalities ...... 17 Benefits of HIV testing ...... 17 Management of HIV and AIDS ...... 18 Unit 2: Sexually Transmitted Infections (STIs) ...... 23 Introduction ...... 23 Objectives ...... 23 Basic facts on STIs ...... 23 Transmission of STIs ...... 23 Complications of STIs ...... 24 Treatment of STIs ...... 25 STI affects women, babies, and men...... 26 Unit 3: Tuberculosis ...... 27 Introduction ...... 27 Objectives ...... 27 Basic facts on TB ...... 27 Transmission of TB ...... 27 Prevention of TB ...... 28 Management of TB ...... 28 Module 2: Non-communicable Diseases(Cancer, Hypertension& Diabetes mellitus) ...... 30 Introduction ...... 30 Objectives ...... 30 Unit 1: Cancer ...... 31 Introduction ...... 31 Objectives ...... 31 Basic facts on Cancer ...... 31 Risk factors ...... 31 Examples of cancer...... 32 Treatment of cancer ...... 33 Prevention of cancer ...... 33 Unit 2: Diabetes ...... 35

Introduction ...... 35 Objectives ...... 35 Basic facts on Diabetes ...... 35 Management of diabetes ...... 36 Unit 3: Hypertension ...... 37 Introduction ...... 37 Objectives ...... 37 Basic facts on Hypertension ...... 37 Management of Hypertensive Patients ...... 38 Lifestyle modification ...... 38 Medications ...... 38 Module 2: Non-communicable Diseases Review ...... 39 40 Module 3: Human Sexuality, Stigma, Discrimination, and Violence ...... 40 Introduction ...... 40 Objectives ...... 40 Unit 1: Human sexuality ...... 40 Introduction ...... 40 Objectives ...... 40 Concepts of sexuality ...... 42 Unit 2: Stigma and Discrimination ...... 44 Introduction ...... 44 Objectives ...... 44 What is stigma?...... 44 Typs of stigma ...... 45 Unit 3: Violence ...... 47 Introduction ...... 47 Objectives ...... 47 Types of Violence: ...... 47 Violence in the Kingdom of Eswatini ...... 48 Violence among KPs ...... 48 The link between stigma, discrimination, and violence ...... 49

Module 4: Human Rights, KPs, and HIV ...... 51 Introduction ...... 51 Objectives ...... 51 Unit 1: Law and Human rights ...... 51 Introduction ...... 51 Objectives ...... 52 Definition of human rights ...... 52 Human rights in Eswatini ...... 53 Fundamental rights and freedoms ...... 53 Sexual Offences and Domestic Violence Act on sex work in Eswatini ...... 57 International law obligations ...... 57 Unit 2: Importance of human rights to police ...... 58 Introduction ...... 58 Objectives ...... 58 Police As Protectors Of Human Rights ...... 58 Unit 3: Human rights, Health, and HIV ...... 61 Introduction ...... 61 Objectives ...... 61 Role of police in protecting human rights ...... 61 Human rights approach in daily practice and work among KPs and the general public ..... 62 HIV and the police: Best practices of police, HIV, and KP programs globally–a comparative analysis ...... 62 References, Resources and Further Reading ...... 64

xii

List of Figures Figure 1: How to use a male condom correctly ...... 12 Figure 2:How to use a female condom correctly ...... 13 Figure 3: Example of self examination ...... 34 Figure 4: Concepts of Sexuality ...... 41

List of Table Table 1: structure of the manual ...... 3 Table 2: Common STIs ...... 24

xiii

Background Introduction His Majesty King Mswati III announced an HIV-Free Kingdom of Eswatini by encouraging all Emaswati to eliminate stigma related to HIV and new infections by 2022. A vision for ending AIDS as a public health threat has been established and is driven at the highest level.

The country has made major strides in its HIV response, reducing new HIV infections by 44 percent in five years. Initiation of people living with HIV (PLHIV) on ART has been accelerated to reach 84 percent by 2017, both as a measure for reducing new infections and improving the quality of life of those infected. However, more work still needs to be done as the generalized epidemic has shifted to a microepidemic impacting different groups in different ways. Recognizing the broad implications of HIV/AIDS on all sectors of the population, the government mobilized all sectors to contribute toward the fight against HIV and AIDS.

In response, the police service launched its HIV and AIDS strategy as an important step in addressing HIV and AIDS and creating a nonstigmatization and nondiscriminatory environment in the police service and the provision of care and support to personnel and family members living with HIV and AIDS. Police services are key in enforcing laws and protecting the public. However, it is crucial that in the discharge of their duties they support the efforts of other sectors to reduce the impact of HIV as a public health threat, especially when dealing with vulernable and marginalized groups.

Aim of the manual The aim of this manual is to improve participants’ understanding of the Kingdom of Eswatini’s approach to tackling HIV/AIDS and to examine how the police service fits into the national response.

Objectives:  Provide information on SRH; prevention, care, and treatment for HIV, STIs, TB, and selected cancers; as well as mental health and related health services.  Provide information on health and social welfare needs of marginalised and vulnerable populations.  Improve understanding on how to interact with people from marginalised and vulnerable populations, especially those who are perceived to be different or who act differently from common society norms and practices  Provide information on how police can create an enabling environment that will improve access to nondiscriminatory and nonstigmatizing services.  Share best practices from other countries that can be learned and adapted for Eswatini.  Seeks to improve how police officers respond to health needs on a personal level and to those of margianlized groups,including KP.

Target audience The manual is designed for all Royal Eswatini Police Services (REPS) personnel to assist them to have a foundation for understanding different aspects of health as it relates to them as individuals, service providers to all citizens, including vulnerable and marginalized groups, within the obligations of the police under the relevant country regulations. Why a training on inclusive policing Police service is closely intertwined in the fabric of society and is considered a significant link between vulnerable, marginalized groups and the justice system. Research has shown that KPs are at higher risk of HIV exposure, and they face stigma, discrimination, exclusion, harassment, violence, and drug use. Discriminatory laws and policies, such as the criminalization of sex work, drug use, sexual orientation or gender identity, contribute to and reinforce low levels of access to health services. This increases the risk of mental health problems and mental illness among these population groups, leading to a cycle of abuse, high morbidity, and poor health outcomes.1 When public health experts describe people who are most at risk for HIV infection as hard-to-reach populations, law enforcement personnel have little trouble finding them because they work with all sectors of society.

Furthermore, police officers as law enforcers are enjoined by the law to treat all members of society with respect and dignity as stated in the Constitution of the Kingdom of Eswatini,2 including that all have the right to fair treatment in criminal proceedings.3

As the Eswatini community becomes more aware of diverse populations and their health needs, law enforcement personnel need to increase their knowledge and understanding of the unique needs of each member of the community to ensure effective and efficient service delivery.

Why engage police services personnel on health issues of vulnerable and marginalized groups?  To recognize the essential role of police services personnel in achieving positive health and social outcomes  To appreciate the HIV-related service needs of police services personnel, as they form part of the sexually active age group  To engage police services personnel from a positive and enabling perspective that contributes to the realization of human rights and gender equality for all  To involve police services personnel as active partners in the HIV response  Engage police service personnel as change agents for social environments and practices that encourage or condone violence against KPs, women, and girls, and hinder access to HIV services  To promote alliances and partnerships between police services personnel and organizations of key populations and civil society partners

1 Swaziland HIV Integrated Biobehavioural Surveillance Study (IBBSS), 2012. 2 18. (1) The dignity of every person is inviolable. (2) A person shall not be subjected to torture or to inhuman or degrading treatment or punishment. 3 Act No. 1 of 2005. 2

 To create linkages between police service and evidence, United Nations mandates, and international commitments  Each police service personnel member has a role for their own health and the health of all those with whom they are in contact  The police service as an organized social system is responsible for protecting its member and the citizens

How is the manual structured? This manual is divided into four modules (shown in Table 1) that should be completed sequentially. Each module begins with a brief introduction, followed by objectives. Some modules include case studies taken from practical scenarios, which provides an opportunity for personal reflection and assessment of knowledge, attitudes, and beliefs. Each module concludes with a brief summary review of basic information, important facts, and skills covered.

Table 1: structure of the manual

Title or focus Units

Unit one: HIV and AIDS Communicable Diseases: HIV Module 1 Unit two: Sexually transmitted infections (STIs) and AIDS, STIs, and TB Unit three: Tuberculosis

Unit one: Cancer Module 2 Noncommunicable Diseases Unit two: Diabetes Unit three: Hypertension

Unit one: Human sexuality Human Sexuality, Stigma, Module 3 Unit two: Stigma and discrimination Discrimination, and Violence Unit three: Violence

Unit one: Definition of human rights and importance of human rights to police Module 4 Human Rights, KPs, and HIV Unit two: Human rights, KPs, health, and HIV Unit three: Role of police in protecting human rights

Module 1: Communicable Diseases: HIV and AIDS, STIs, and TB

Introduction This module discusses HIV and AIDS epidemiology and response in the Kingdom of Eswatini. It also includes issues related to HIV, STIs, and TB, their mode of transmission, and the methods of prevention, care, and treatment.

Module Objectives By the end of this module participants will be able to:  Understand the epidemiology of HIV and AIDS  Explain basic facts about HIV and AIDS, STIs, and TB including basic terminology  Identify the modes of transmission; methods of prevention; treatment, care, and support for HIV, STIs, and TB  Demonstrate an understanding of the linkages between police service personnel vulnerability with HIV and TB

Unit 1: HIV and AIDS Introduction This unit discusses HIV and AIDS, the epidemiology at a global level and a look at the epidmic and the response within Eswatini. It also covers an introduction to the drivers of the HIV epidemic, provides basic facts on HIV and AIDs, a review of common infections, a review of HIV prevention, HIV testing and management of HIV and AIDS.

Unit Objectives By the end of this module participants will be able to:  Understand the national response to HIV  Understand the epidemiology of HIV and AIDS  Explain basic facts about HIV and AIDS including basic terminology  Identify the modes of transmission; methods of prevention; treatment, care, and support for HIV.  Demonstrate understanding of police service personnel vulnerabilities with HIV.

HIV and AIDS epidemiology HIV continues to be a major global public health issue. Since the start of the epidemic, an estimated 78 million people have become infected and 35 million people have died of AIDS-related illnesses.4 Despite challenges, significant progress has been made in prevention and treatment with the number of people receiving HIV treatment increasing dramatically. In 2016, 19 million people living with HIV were receiving antiretroviral treatment (ART), and roughly 1.8 million were newly infected. In 2017, 940,000 people died from HIV-related causes globally.5 Approximately 36.9 million people were living with HIV at the end of 2017 with 1.8 million people becoming newly infected globally. In 2017, 59 percent of adults and 52 percent of children living with HIV were receiving lifelong ART. Global ART coverage for pregnant and breastfeeding women living with HIV is high at 80 percent.6 Over 25.6 million people are currently living with HIV in sub-Saharan Africa.7 This accounts for two- thirds of the recent number of people with HIV infections in the world. In addition, more than 70 percent of all AIDS-related deaths in 2017 occurred in Sub-Saharan Africa.

In sub-Saharan Africa and other parts of the world, KPs experience a disproportionate burden of HIV, TB, STIs, and other health problems. In 2016, 25 percent of new HIV infections occurred among KPs.8 As shown, HIV prevalence is relatively higher among KPs, as are mental health problems. A significant number of new HIV infections occur among KP members, yet they often have the least access to health services including prevention, treatment, and care. In the context of this manual, KPs refers to men who have sex with other men (MSM), sex workers (SWs), transgender people (TG) and gender non-conforming people, and people who inject drugs (PWID).9

Given the high HIV prevalence among KPs and vulnerable groups, the World Health Organization (WHO) and the Joint United Nations Programme on HIV and AIDS (UNAIDS) have made a public health call for countries to address their needs in order to achieve a sustainable response to HIV.

Situational analysis of HIV and AIDS in Eswatini HIV incidence The Kingdom of Eswatini has a mature and generalized HIV epidemic primarily driven by heterosexual sex10. According to the Swaziland HIV Incidence Measurements Survey (SHIMS), HIV .incidence among people 15 years and older decreased from 2.70 percent in 2011 to 1.14 percent in 2017. However, the incidence among women and man aged 15 and above is higher estimated at

4 World Health Organization (WHO) available at http://www.who.int/news-room/fact-sheets/detail/hiv-aids (Date of use August 04, 2018). 5 World Health Organization (WHO) available at http://www.who.int/news-room/fact-sheets/detail/hiv-aids. 6 As above. 7 HIV/AIDS in sub-Saharan Africa: Current status, challenges and prospects. 8 UNAIDS available at http://www.unaids.org/en/topic/key-populations. 9 Ayesha B.M. Kharsany HIV Infection and AIDS in Sub-Saharan Africa: Current Status, Challenges and Opportunities available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893541/ . 10 Swaziland HIV Incidence Measurements Survey (SHIMS), 2016. 5

1.37 and 0.9 respectively. The variation in incidence by sex is most pronounced among adolescents and young people 15–24 years with females having an incidence of 1.96 percent compared to 0.27 percent among males. The number of annual new infections was estimated at 6,500.

HIV prevelance According to SHIMS 2016/17 HIV prevalence among those 15 years and older is estimated at 27.0 percent.11 However, women are disproportionately affected by HIV than men, with a prevalence of 32.5 percent, and 20.4 percent respectively. The HIV prevalence among children is estimated at 2.8 percent (2.6 percent among females and 3.0 percent among males).12 HIV prevalence among FSWs is estimated at 70.3 percent while prevalence among MSM is 17.7 percent13.

At a Glance of the HIV/AIDS prevelence in Eswatini  PLHIV estimated at 219,5501  Adults 15+: 206,845  Children 0-14: 12,705  84% of PLHIV know their status  87.4% that known their status are on ART  91.9% on ART are virally suppressed1.  4,246 AIDS-related deaths in 2017  53% of AIDS-related deaths are males due to poor health seeking behaviour

HIV and opportunistic infection and comorbidities TB and HIV co-infection is estimated at 70 percent, and mortality among co-infected persons is 14 percent. Of PLHIV 15 years and older, 60 percent are TB/HIV co-infected (69.7 percent males; 54.6 percent females), while 97 percent of PLHIV who have TB are treated for TB. With an increasing number of people ageing with HIV, noncommunicable diseases (NCDs) are emerging as a major concern. These include cancers, diabetes, hypertension, and mental illnesses. With regard to STIs, in 2016, 89 percent of pregnant women were screened. The positivity rate for women screened for syphilis was 2 percent; yet 15 percent of them were not treated.

Drivers of the HIV epidemic Early sex debut: Swaziland Demographic and Health Survey (SDHS) 2007 and Multiple Indicator Cluster Surveys (MICS) 2010 and 2014 show that more females 15–24 years of age (6.9 percent, 3.8 percent, and 3.0 percent, respectively) have sex before age 15 compared to males (4.8 percent, 2.6 percent, and 2.8 percent, respectively). This shows a downward trend of young people starting sex by age 15. However, SDHS 2007 further shows that 48 percent of females 15–24 years and 34

11 SHIMS 2016/17. 12 SHIMS 2016/17. 13 IBBSS, 2012 6

percent of males start sex by age 18 indicating a rapid increase in females and males who have their first sex between age 15 and 18.

Low knowledge about HIV among adolescents and young people: Knowledge about ways of preventing HIV infection is critical for influencing an individual’s perception of risk and sexual behavior. The level of knowledge about HIV prevention among young people declined from 58.2 percent in 2010 to 49.1 percent in 2014 among females and from 53.6 percent to 50.9 percent among males in the same period. Further, knowledge levels among children 10–14 years is estimated at 34.62 percent with a slight difference between males and females.

Poverty and unemployment: Unemployment among adolescents and young people 15–24 is estimated at 51.6 percent according to the labor force survey of 201614. Poverty levels, among the general population, are estimated at 63.0 percent based on the 2009–10 survey. Poverty and unemployment are two interrelated factors that deprive adolescents and young people (especially adolescent girls and young women) access to secure livelihoods and expose them to risky sexual relationships with power imbalances, which skews condom use negotiation.

Multiple sexual partnerships and condom use: Condom use among adults 15–49 years during high- risk sex declined in the last five years15. The proportion of men 15–49 years with more than one partner within 12 months and using a condom for the last sexual encounter declined from 82.6 percent in 2014 to 66.2 percent in 2017 while the decline among women was from 66.0 percent to 63.5 percent during the same period16. Innovative strategies for demand creation, developing positive risk perception, and promoting consistent condom use are required to improve scale-up. Barriers to condom use will be investigated to develop approaches.

Intergenerational sex: The occurrence of adolescent girls and young women (AGYW) aged 15–24 having intergenerational sex with older men has declined from 14.4 percent in 2011 to 8.7 percent in 201717. It remains a significant problem because HIV prevalence starts increasing at a higher rate when men reach age 25. AGYW are vulnerable to risky sexual interactions partly due to gender norms making it difficult to negotiate safe sex, as well as poverty, unemployment, and minimal knowledge about HIV prevention18.

High onward transmission rate from those recently infected and not yet on treatment: It is estimated 15 percent of PLHIV are not on ART19, and it is becoming harder to identify this cohort, provide testing, and get them started on ART. This group of PLHIV are likely to be those recently infected, with no knowledge of their HIV status, and involved in onward transmission of HIV.

14 The Swaziland Intergrated Labour Labour Survey 15 The Extended National Multisectoral HIV and AIDS Framework (eNSF) 2014-2018. 16 The Extended National Multisectoral HIV and AIDS Framework (eNSF) 2014-2018. 17 The Extended National Multisectoral HIV and AIDS Framework (eNSF) 2014-2018. 18 The Extended National Multisectoral HIV and AIDS Framework (eNSF) 2014-2018. 19 The Extended National Multisectoral HIV and AIDS Framework (eNSF) 2014-2018. 7

Finding PLHIV who do not know their status and initiating them on treatment is a key strategy for reducing new infections.

Low levels of male circumcision: The prevalence of circumcision among males 15 years and older is relatively low (26.7 percent)20. The prevalence decreases with age, from 38.2 percent among 15- to 19-year-olds to 7.5 percent among males 65 years and older21. Negative social norms and cultural and traditional beliefs are key barriers to uptake of male circumcision.

Gender-based violence (GBV): One in three women experience some form of sexual violence by the time they are 18 years old22. Recent evidence shows that 6.6 percent of adults 15 years and older experience sexual abuse; 1.9 percent of children aged 10–14 experience sexual abuse while about 4.6 percent of ever-married women aged 15–49 experience physical and sexual violence from a male intimate partner23. This shows that children start experiencing violence very early in their lives. Experience from GBV programs shows that coercion and fear of repercussions prevent survivors of SGBV from reporting and seeking care and redress.

HIV stigma and discrimination: Although recent data on stigma is not available, focus group discussions held with men, adolescents, young people, community leaders, and PLHIV indicated that self-stigma prevalence is high, and it hinders these groups from accessing HIV services.

The national HIV, TB, and STIs response The Eswatini National Multisectoral HIV and AIDS Strategic Framework (NSF) 2018–2022 has been designed to propel the country toward ending AIDS as a public health threat. The strategy builds on the huge successes of the previous five years during which new HIV infections declined by 44 percent, 84 percent of people living with HIV started ART, and efforts were accelerated to reduce vulnerabilities to HIV infection among key and priority populations. Despite these achievements, more needs to be done to reach the last mile of reducing new infections and ensuring no one is left behind. About 6,500 new infections occurred in 2017, 15 percent of PLHIV are not on care, the TB/HIV coinfection rate is 70 percent, and other comorbidities are emerging as a threat to the life of PLHIV. There is also a compelling need to adopt approaches that effectively reach the most vulnerable groups and those least covered by services.24

The Police Health Department currently has a health strategy which encompasses HIV interventions among officers and their family members. This includes; primary prevention, treatment, care, and support. The REPS Health Policy states the need to ensure access to care and support by conducting

20 The Extended National Multisectoral HIV and AIDS Framework (eNSF) 2014-2018. 21 The Extended National Multisectoral HIV and AIDS Framework (eNSF) 2014-2018. 22 The Extended National Multisectoral HIV and AIDS Framework (eNSF) 2014-2018. 23 The Extended National Multisectoral HIV and AIDS Framework (eNSF) 2014-2018.

24 SHIMS 2016/17. 8

early diagnosis and seeking prompt treatment of injuries and illnesses that occur to police service personnel, support staff, and their immediate families. However, the limitation of the strategy is the internal focus. It does not cover the external responsibility of the police.

Basic facts on HIV and AIDS HIV is a virus that attacks the immune system. AIDS is a cluster of diseases resulting from a compromised immune system. There is currently no cure for AIDS. Transmission of HIV There are three main ways by which HIV can be transmitted:

1. Sexual transmission Unprotected sexual intercourse: A single act of unprotected sex with a person who has HIV is enough to transmit HIV from one person to another. Women are at greater risk of HIV infection through vaginal sex than men because of their anatomical structure.

Anal sex (whether male to male or male to female): Anal sex poses a high risk mainly to the receptive partner because the anatomical lining of the anus and rectum is extremely thin and filled with many blood vessels that can be easily injured during intercourse.

High viral load (VL): Higher VLs increase the risk of HIV transmission through unprotected sex.

Presence of cuts or wounds: Oral-genital contact also poses a clear risk of HIV infection, particularly when ejaculation occurs in the mouth. This risk goes up when either partner has cuts or sores, including those caused by STIs and recent tooth brushing abrasions, which can allow the virus to enter the bloodstream. Wounds or cuts on either partner’s genitals also increase the chance of HIV infection.

Presence of STIs: STIs cause sores or broken skin, which increases the chance of HIV infection.

2. Sharing of contaminated piercing/cutting objects Blood is the most potent medium of transmission of HIV. When an infected person shares needles, piercing, tattooing, or cutting objects with an uninfected person there is direct contact with infected blood.

3. Mother-to-child transmission (MTCT) An infected pregnant woman can transmit HIV to her unborn child during pregnancy, delivery, and breastfeeding. If a pregnant woman is HIV-positive, there is a 15 percent to 30 percent chance that she might transmit HIV to her unborn baby before or during birth.

Facts . For HIV transmission to take place, there must be an opening on the skin. . HIV cannot survive outside the human body for more than 72 hours. . HIV is found in the blood, semen, vaginal fluids, and breast milk of individuals who have HIV; these fluids have a greater risk of transmission. . HIV is found in small amounts, to small to transmit HIV, in saliva, vomit, feces, and urine.

Common Opportunistic Infections (OIs) among PLHIV An opportunistic infection is a disease that takes advantage of a weak immune system, which has resulted due to HIV. Some are more common than others and, depending on the CD4 count (number of white blood cells that help fight infection), some are more likely to occur. The most common opportunistic infections are:

OIs Description Shingles (Herpes A viral disease characterized by a painful skin rash with blisters in a Zoster) - libhande localized area. Typically, the rash occurs in a single stripe either on the left or right of the body or face. Oral/oesophagal A fungal infection of the mouth. It is not contagious and is usually Thrush (oral successfully treated with antifungal medication. It manifests as creamy candidiasis) white-yellow or tender red patches on tongue/mouth. Vaginal Thrush (vaginal A common yeast infection that affects most women. It may be candidiasis) unpleasant and uncomfortable, with itching in and around the vagina. It may manifest as a curd-like discharge or sores on the skin around the vagina. Pneumonia An infection in one or both lungs. It can be caused by fungi, bacteria, or viruses. Pneumonia causes inflammation in the lung air sacs, or alveoli. Meningitis An inflammation of the lining of the brain and spinal cord. In most cases meningitis is caused by a bacterial, viral, or fungal infection that began elsewhere in the body, such as in the ears, sinuses, or upper respiratory tract. Diarrhoea (umsheko) A condition of having frequently loose stools, at least three per day.

Kaposi’s Sarcoma A cancer that causes lesions (abnormal tissue) to grow in the skin; the mucous membranes lining the mouth, nose, and throat; lymph nodes; or other organs. The lesions are usually purple and are made of cancer cells. 10

Tuberculosis (TB) A bacterial infection that is spread through inhaling tiny droplets from the coughs or sneezes of an infected person. Pulmonary TB (mainly affecting the lungs) is the most common. The infection can spread via blood from the lungs to all organs, including the bones, urinary tracts, sexual organs, intestines, kidney, spine, brain and even the skin.

Misconceptions and Facts about HIV and AIDS Misconceptions Facts HIV can be transmitted through saliva, tears, HIV cannot be transmitted through saliva, tears, vomit, feces, or urine. vomit, feces, or urine, even though small amounts of HIV have been found in these fluids. HIV can pass through intact skin. HIV cannot pass through the skin unless there is an open cut. Your skin protects you. HIV can be transmitted through casual HIV cannot be transmitted through casual contact such as touching, sharing eating contact such as touching, sharing eating or utensils, or toilets seats. drinking utensils, or using the same toilet seats. HIV can be transmitted through caring for a There is no risk in caring for a person living with person living with HIV. HIV if the person follows universal precautions such as wearing gloves when cleaning up blood and keeping cuts covered. HIV can be cured by having sexual A person cannont be cured of HIV by having sex intercourse with a virgin. with a virgin. He will still have the virus in his body after sex, and he potentially could infect the virgin.

HIV Prevention There are many interventions to prevent HIV transmission. These include:

1. Abstinence Abstinence can be a commitment to refrain from sex until marriage, or delaying sex until some future time such as beginning a committed relationship. Abstaining from sex is the only method that is 100 percent protective against HIV infection.

There are two types of abstinence:

Primary abstinence refers to a situation when one has never engaged in sexual relations and maintains the decision not to have sex.

Secondary abstinence refers to a situation where one has been sexually active at one time but has now decided to abstain. 2. Faithful to one sexual partner Multiple concurrent partners (MCP) put you at risk as some may be infected with HIV or have other

partners. The more sexual partners with whom you have unprotected sexual intercourse, the higher your risk of getting infected. Faithfulness, or maintaining a monogamous relationship, requires the commitment of both partners. Individuals can show respect for their partner’s health by limiting their sexual relations to one partner. 3. Correct and consistent use of female or male condoms and lubricants Condoms are a thin, stretchy sheath (usually made of latex, a type of rubber, or a polyurethane) with a flexible ring at either end that you wear on your penis or insert in your vagina prior to initiating sex. Condoms provide protection from both pregnancy and STIs including HIV.

Figure 1: How to use a male condom correctly

Figure 2:How to use a female condom correctly

4. Voluntary medical male circumcision (VMMC) VMMC Facts VMMC is the surgical removal of the foreskin that covers the  Men should abstain from sexual intercourse head of the penis. It reduces the risk of acquiring HIV infection for at least six weeks after being 25 by 60 percent in men but it does not guarantee complete circumcised. This is necessary to ensure that protection and does not prevent unwanted pregnancy. The the wound has healed completely. benefits to VMMC include increased ease of maintaining penile  When not properly healed, the wound hygiene, decreased risk of urinary tract infections in children, provides a ready entry point for HIV, and men are at higher risk of acquiring HIV prevention of the inability to retract foreskin and return during this time. foreskin to its original location, and reduction of STIs in men.  Always return for a check-up before having 5. HIV risk reduction behaviors sexual intercourse.  Have a discussion with partner before a) Decrease the number of sexual partners proceeding with VMMC. Multiple concurrent sexual partners means having unprotected sexual intercourse with more than one sexual partner over the same period. A person may have a regular sex partner and other sex partners on the side. It is likely that these sex partners have other sex partners as well. This creates a “sexual network” in which everyone is connected to everyone else through his or her sexual partners. Other partners can be one-night stands or someone a person has had sex with once or over several weeks, months, or years.

b) Know your partner’s HIV status Know the status of your sexual partner before you engage in unprotected sexual intercourse. Testing as a couple helps to make decisions together. It is possible that one of you may be infected with HIV while the other is not (serodiscordant). It is important to share your HIV test results with your sexual partner to ensure you both stay safe.

. If you are HIV positive, abstain from sexual intercourse or use a condom to avoid re-infection or infecting others. . If both of you are HIV negative, be faithful to one another to reduce the risk of infection. . If you are serodiscordant, discuss ways you will protect the uninfected partner, such as using condoms, pre-exposure prophylaxis (PrEP), and supporting the infected partner to receive treatment, care, and support.

c) Positive living If you are HIV positive, live positively to maintain your health:

. Begin ART early. Antiretroviral drugs (ARVs) do not cure HIV, but they do reduce the amount of HIV in a person’s body. . Ensure adherence to ART; set a daily routine for taking the drugs. Ask someone in your family to remind you to take the drugs daily or find a treatment buddy. . Practice safer sex by using condoms correctly and consistently to avoid the risk of infecting other and re-infecting your partner. . If you are pregnant or breastfeeding, make sure you are taking your ARVs and following your health care provider’s advice to prevent mother-to-child transmission of HIV.

25 World Health Organisation (WHO) 2014. 14

. Eat nutritious foods that keep you healthy and help boost your immune system. . Stay active and keep in touch with people who support you.

d) Reduction of alcohol and drug use The use of drugs and alcohol impairs judgment, reduces inhibitions, and creates feelings of invincibility.26 Many people also believe that alcohol enhances sexual arousal and performance and see alcohol as a means of facilitating and improving their sexual experiences. These effects of alcohol and drugs often encourage risky sexual behavior.

A history of heavy alcohol use has been associated with a lifetime tendency toward high-risk behavior, including sex with multiple partners, sex without a condom, sex with high-risk partners such as sex workers and injecting drug users, and the exchange of sex for money and drugs. Finally, and most directly, the use of unsterilized syringes for injecting drugs can also directly introduce HIV into the bloodstream. People should not shared needles when injecting drugs. 6. Pre-Exposure Prophylaxis (PrEP) PrEP is the use of antiretroviral drugs by HIV-negative people before a potential exposure to HIV to prevent infection, often taken during periods of high risk. PrEP reduces the risk of acquiring HIV infection by over 90 percent 27 but does not protect against STIs and unwanted PrEP Facts pregnancy, thus should be used in combination with a  PrEP is not a treatment for HIV; it is a pill condom. Side effects are minimal although 10 percent of to prevent a person from becoming people who start PrEP might experience mild side effects infected. (headache or nausea) that usually go away in a few weeks.  There are many ways to protect yourself from HIV, and a combination of different methods (including condoms) is PrEP is given to: recommended when using PrEP.  HIV-negative individuals who are at substantial risk of HIV infection.  Those willing to take PrEP daily.  Those able to attend follow-up visits, which include HIV testing.  Those without contraindications to PrEP medications. 7. Post-exposure prophylaxis (PEP) PEP is the use of ARVs by HIV-negative people after an exposure to HIV to prevent infection. PEP should be started as soon as possible after exposure but within 72 hours, and it is currently the only way to prevent HIV infection in an individual who has been exposed to HIV. PEP is safe but may cause mild side effects that can be treated. 8. Management of sexually transmitted infections (STIs) Early diagnosis and treatment of STIs decreases the risk of HIV infecion. A sore or inflammation from an STI may allow infection with HIV.

26 https://clinicalservicesri.com/lowered-inhibitions-a-gateway/. 27 WHO Guidence on when to sratr antiretroviral therapy and pre-exposure prophylasis for HIV. 2013. 15

9. Universal precaution (use of gloves, protective clothing, washing hands) Universal prevention measurese are key to keeping individuals safe when coming into contact with any person’s blood or body fluids. These measures are essential for infection control for police service personnel at work. These include:

 Cover any cuts, wounds, scratches, or injuries on exposed parts of the body with a bandage or Band-Aid before any kind of work with blood or other bodily fluids is done.  Use gloves when coming in contact with body fluids including when attending to someone who is Police service personnel are predisposed to bleeding or when cleaning up blood, vomit, feces, high risk by the nature of their job. pus, urine, non-intact skin or mucous membranes (eyes, nose, and mouth). Gloves should be changed These risk events might include: after each use.  Coming into contact with human blood and  Exercise utmost caution when searching a person or fluid or contaminated objects. suspect in order to avoid getting pricked by needles  Contact with infected blood during or other sharp objects. If a prick occurs, wash the accidents. spot with running water and soap and immediately  Accidental needle pricks due to confiscation report the injury to the person in charge. of used syringes, blades, and other sharp  If a situation occurs in which emergency medical objects from injecting drug users. attention and mouth-to-mouth resuscitation (rescue  Personnel may be posted away from home breathing) is needed, medical oxygen should be and family, where loneliness, boredom, and used. If no medical oxygen is available, use a mask sometimes, peer pressure may encourage and avoid mouth-to-mouth or mouth-to-nose alcohol, recreational drug use, and exposure contact. to multiple sexual relationships.  Use disposable gloves and avoid contact with blood, bodily fluids, and excretions.  Immediately wipe off any surface on which bodily fluids have spilled and clean the surface with disinfectant.  People should also not share blades that have touched blood or piercing or tattooing tools.

HIV testing The only way to know your HIV status is to have an HIV test. All clients who receive HIV testing should be provided with their results, either positive or negative. Based on the test results, the client should be referred and linked to support, prevention, and treatment services. It is ideal that clients receive a same-day diagnosis, as well as same-day referrals and linkages to prevention and treatment services. A negative result may mean a person is not infected with HIV or antibodies for HIV are not detected at the time of testing (this is called a window period) hence the need for a retest after eight weeks, if the client has experienced a recent HIV exposure.

HIV testing and counselling (HTC) 28 modalities HIV testing services should be offered to all clients with unknown HIV status at every point of contact in health facility and community settings. Those that are known negative should retest after eight weeks, if client has experienced a recent HIV exposure. A positive test result means the person who has been tested is infected with HIV, but can still take steps to protect his/her health. They must talk to a health care provider about ART. A health care provider assists in deciding when to start ART and what HIV medicines to take. The following are the available testing modalities: Client-initiated HIV testing and counselling (CIHTC): An individual voluntarily seeks HIV testing and counselling. This approach emphasizes individualized risk assessment and management by counsellors and development of an individualized risk reduction plan. Provider-initiated HIV testing (PIHTC): A provider offers HIV testing and counselling to all patients attending health care services. HIV self-testing (HIVST): A specific process in which a person uses oral fluid and then performs a test and interprets the result, often in private or with someone they trust. HIVST has been proposed as a new approach to help countries expand access to HIV testing services and reach those at high risk who may not otherwise test, such as stigmatized KPs. By providing an opportunity for people to test themselves discreetly and conveniently, HIVST may provide people who are not currently reached by existing HTC services with information about their HIV status. HIVST is a screening test and individuals with a reactive self-test result should receive confirmatory testing with a trained provider.

Benefits of HIV testing HIV testing and counselling services are a gateway to HIV prevention, care, and treatment. The benefits of knowing your HIV status can be seen at the individual, community, and population levels. These include:

a) For the individual . Prevent new infections. . Helps keep you—and others you love, including unborn children—safe because you will be able to protect them and yourself. . A prerequisite to access both preventive and treatment services. . When one tests negative, they must continue taking steps to avoid getting HIV, such as using condoms during sex, PrEP, and VMMC (for men). . When one tests positive, they should access ART services early. b) For the community  Reduction in denial which leads to accessing treatment services.  Reduction of stigma and discrimination.  Collective responsibility and action.

c) At the population level  Influence the policy environment.  Support positive living.  Reduce stigma and discrimination.

28 2015 Swaziland Integrated HIV and AIDS Management and Treatment. 17

Management of HIV and AIDS There is no cure for HIV but ARVs are used to reduce the ability of the virus to multiply within the body. ART is a combination of drugs divided into three groups that work at different steps in the process to prevent HIV from multiplying. ARVs suppress the virus that attacks the immune system, increases the CD4 count, and boosts the immune system; all of which stop an individual from progressing toward AIDS. However, the medications should be taken daily at the prescribed time so that they work effectively. The Kingdom of Eswatini provides ARVs for free in most health care facilities. Prerequisites for starting ART The following prerequisites or conditions should be met by the client:  Diagnosed with HIV  Willing to commence treatment and is mentally ready  Understands the importance of adherence  Has a treatment supporter, if possible Benefits of ART Early initiation on ART is more beneficial than late initiation.  Slows down the progression of AIDS and reduces HIV-related deaths  Lowers the risk of infecting others with HIV (by decreasing the viral load)  Reduces mother-to-child transmission of HIV  Improves the health of PLHIV  Reduces stigma and discrimination associated with HIV as PLHIV will not look sick if they are on ART Laboratory tests related to ART The following basic laboratory tests are done when starting and during ART:  HIV test (kuhlola ligciwane le HIV engatini)  CD4 count (kuhlola linani lemasotja engatini)  Full blood count (kuhlola sisindvo sengati)  Kidney function test (kuhlola kusebenta kwetinso)  Liver function test (kuhlola kusebenta kwesibindzi)  Viral load test (kuhlola linani leligciwane engatini)

Key facts relating to ARVs  Take the prescribed medicine and right dosage at the right time; never forget to take your drugs and never stop taking them.  Keep your follow-up appointments.  If possible, have a treatment supporter.  Communicate with your health provider about side effects.  Confirm with your health provider on the use of food supplements and/or alternative medicines.  Protect yourself from infections.  Avoid excessive alcohol, smoking, and drug use.  Use condoms correctly and consistently when having sexual intercourse.

Adherence Adherence means taking the drugs correctly; the correct number of pills, taken at the correct time, and without missing doses. Strict adherence to ART is key to sustained HIV suppression, reduced risk of drug resistance, and improved overall health, quality of life, survival, and decrease risk of HIV transmission. Adherence is the most important factor in the success of ART for PLHIV.

Why adherence? When ARVs are not taken properly individuals develop drug resistance. The virus begins to change, and the drugs become less effective until they stop working altogether; therefore, it is important to avoid resistance.

Factors affecting adherence Adherence to ART can be influenced by a number of factors. It is therefore critical that each patient receives and understands information about HIV and is positively motivated to initiate and maintain therapy. The following are some factors that may affect adherence:  Forgetfulness  Side effects  Depression  High level of alcohol consumption and substance use  Fear of medications  Denial of need for treatment  Mental illness  Inconsistent access to medication  Low level of social support  Low health literacy, e.g., being unable to understand the number of tablets to be taken and whether the tablets are to be taken with or without food

Interventions to improve adherence and retention to care Effective adherence interventions vary in modalities and duration and by clinical setting provider and patient. Many options can be customized to suit a range of needs and settings. These include different adherence devices:  Medication organizers such as pillboxes  Reminder devices (alarm watches, mobile phones, etc.)  Buddy system (peer, friend, family)  Directly observed therapy (DOT)  Associating doses with daily activities  Positive reinforcement, e.g., informing patient of their low or suppressed HIV viral load level and increases in CD4 cell counts

How ARVs work concurrently with other drugs Drug interaction is when one substance affects the activity of a drug when both are taken together. If a patient is taking two drugs and one of them increases the effect of the other it is possible that an overdose may occur. The interaction of the two drugs may also increase the risk of side effects and vice versa. There are two basic important interactions of ARVs that should be known. These are:

ARVs and oral contraceptives (family planning pill) Many ARVs reduce the effectiveness of oral contraceptives (often called “the pill”). When an individual is on the pill she needs to ask the health care worker (HCW) for appropriate advice to ensure another or an additional family planning method can be used. All PLHIV are to practice safer sex (use condoms) as contraceptives do not prevent the transmission or re-infection of HIV.

ARVs and TB medication TB drugs can reduce the effectiveness of some ARVs. PLHIV should tell their health care provider if they are taking ARV medication before starting TB treatment or if they are already taking TB medication when starting ART.

Facts:  While there is no cure for HIV, ART is available for everyone infected with HIV to help them have healthier lives.  PLHIV should begin ART as soon as possible.  Effective ART depends on adherence—taking ARVs every day and exactly as prescribed.  Before starting ART, it is important to address any issues that can make adherence difficult. Once a person develops drug resistance to the first line they are then enrolled in the second line or third line, depending on the need.

Different models for delivering ART PLHIV on treatment may choose any model of ART delivery and are free to switch from model to model for as long as they are eligible for the model of delivery chosen. HCWs will assess if the eligibility criteria for the chosen model are met. ART clients who do not satisfy the specific eligibility criteria as outlined for each model at any point in time should be referred back to mainstream ART care. They can join/rejoin alternative ART models of care only when issues are resolved.

Clients’ roles and responsibilities for enrolling in the different models: • Express willingness and confirm with the HCW that he/she wants to be part of the ART models of care, agreeing on whether they meet eligibility criteria, and adhere to the procedures • Go through an educational session provided by HCWs before starting the selected model of care (stable clients) • Take ARVs and other prescribed medicines daily as prescribed • Ensure other clinical and laboratory services are fulfilled as advised by the health care provider

• Report during any visit events that may need further evaluation: pregnancy, TB screening positive • Be responsible for keeping the medication in a safe and secure location; not lending, selling, or giving the medication away to any other person • Seek medical attention when sick or as per need • Ensure they always have an ARV supply; must collect ARVs on time  Understand their treatment regimen (ART), including other medicines

Health-facility-based model Clients with certain conditions remain in mainstream ART care unless care is provided in different services.

Who should be included in this model? • Newly initiated on ART (less than 12 months on ART) • Adherence issues, including missed appointments (defaulters) • Detectable viral load • Clinical complaints • Suspected treatment failure (clinical, immunological and/or virological) • Recent regimen switch (less than six months) • Children and adolescents requiring close monitoring (unless in a facility-based family group) • Pregnant and breastfeeding women (note: pregnant women should receive ART refills during their focused antenatal (ANC) visits, breastfeeding women can be eligible for clubs under special considerations) • Comorbidities: TB disease, mental illness, and substance abuse, or other conditions as justified by the clinician • Clients missing two consecutive refills within the same ART model • Transfer-in clients with less than two ART visits at the new facility ART M ART fast-tracking model This model is offered to stable ART clients who wish to refill at the facility individually. The minimum standard is that clinical reviews must be done every six months coupled with laboratory tests if necessary. In between the clinical visits (i.e., at three months) refills should be fast-tracked. Clinically stable clients on ART are clinets who are virally supressed, do not have OIs, have CD4 ≥200cells/mm2 , are treatment adherent, do not have adverse drug reactions and are five years of age and above.

Facility-based treatment club (FTC) A club will consist of a group of stable clients (maximum 20) that meet at the facility to receive their ART refills, quick symptom screening, and counselling support. Treatment clubs meet four times per year as a club and receive their treatment refill within the club. Following every other club visit, i.e., every six months, each member of the club will have a clinical consultation following their meeting. Clients will be enrolled to an FTC by an expert client (EC) or nurse.

Adolescent/teen club These are facility-based treatment clubs that cater to HIV-positive adolescents/teens. Adolescent/teen treatment clubs provide a safe environment to share adolescent concerns and growth of adolescents/teens to responsible adults. Adolescent/teen clubs are based on respect for peers’ privacy and education about adolescents’ topical issues, which are crucial for the club to function well. It is mandatory that the six monthly clinical visits must happen as per protocols.

Family-centered clubs Family-centered clubs are comprise of family members who receive ART refill services at the same facility. Parents and/or caregivers and their children may form such clubs. Community ART groups Community-based ART groups (CAGs) are self-forming groups that provides a community-initiated strategy to reduce barriers to care. CAGs have been commonly implemented with hard-to-reach groups and in settings where there are economic difficulties in accessing care. They rely on pre- existing social networks, such as support groups, workmates, and family relations. In urban settings, it is recommended that CAGs be promoted for groups of family members and workmates.

The group members must meet at least 24 hours prior to the members’ scheduled refill date. During this initial meeting, the booklets for group members are handed over to the group representative. The representative, with the support of the group leader, will also ask general screening questions as elaborated in the standard operating procedures. Unwell group members should accompany the representative to the clinic so their conditions may be reviewed.

Outreach model Health facilities and implementing partners carry out outreach activities regularly using government and partner transport and other logistics support. This model relies on professional HCWs extending services to the communities. The team conducting the outreach activities is composed of doctors, nurses, expert clients, counsellors, and pharmacy and laboratory personnel. They visit communities and provide a comprehensive package of health care services. Sometimes targeted outreach visits are conducted to deliver defined care packages, as in the case of HIV service.

Unit 2: Sexually Transmitted Infections (STIs) Introduction The unit discusses STIs, how they may be transmitted, prevented, and treated. It also covers the different types of STIs, common myths/misconceptions, as well as the link between STIs and HIV.

Objectives By the end of this unit, participants will be able to:  Understand what STIs are  Identify common STIs and their signs and symptoms  Explain prevention methods for STIs  Understand the relationship between STIs and HIV infection  Discuss myths/misconceptions about STIs  Discuss the consequences of STIs when not treated

Basic facts on STIs An STI is an infection that can be transmitted from one person to another through sexual contact. Sexual contact is more than just sexual intercourse (vaginal, penile, and anal) and includes kissing, oral-genital contact, and the use of sexual toys, such as vibrators.

S - Sexually: through sexual intercourse (vaginal, penile, oral, and anal), T - Transmitted: spread from one person to another I - Infections: germs (that are not normally present in the body) Transmission of STIs STIs may be transmitted through the following:  Unprotected sexual intercourse o Penis-vagina sex o Penis-rectal sex o Sharing of sex toys (vibrator, dildos, strokers, sex dolls, prostate massagers) o Oral sex (mouth-penis, mouth-vagina, mouth-anus) o Infected mother to baby (unborn, during birth)

Table 2: Common STIs

Presentation Type of STI Main signs and symptoms Treatment of STIs Genital Gonorrheae  In men: discharge burning sensation when Can be treated urethral Chlamydia urinating, irritation inside the penis and discharge Trichomoniasis frequent urination. Vaginalis  In women: lower abdominal pain, abnormal smelly discharge, pain during sexual intercourse

Genital ulcer Syphilis  Genital sores, Syphillis and syndrome Herpes  Blisters (small water-filled spots) - some Chancroid can Chancroid blisters may burst and leave painful sores be treated;  Painful sores in the genital and anal area Herpes can be  Pain on contact with urine managed

Genital warts Warts  Cauliflower-like lumps Can be managed  May be itchy and unlikely to cause pain

Viral Hepatitis  Headache and fatigue Can be managed infection  Dark urine, abdominal pain, jaundice  Often no visible symptoms

Complications of STIs Complications in women  Prolonged lower abdominal pain  Miscarriages  Pregnancy that takes place outside the womb (ectopic pregnancy)  Giving birth before the due date (premature delivery)  Inability to have children (infertility)  Cancer of the cervix  Mental health disorders  Death Complications in babies  Death of the baby during the pregnancy (still-born)  Eye infection with excess yellowish discharge, when untreated it results in blindness  Flat nose (resulting from untreated syphilis)

 Pneumonia  Death Complications in men  Swollen and painful testicles  Swollen and painful scrotum  Blockage of the urinary tract  Mental health disorders  Infertility (inability to have children)  Death The link between STIs and HIV There is a strong correlation between untreated STIs and HIV transmission. STIs disrupt the normal lining of the genital area and make it easier for HIV to enter the body. Sexual acts that tear or break the skin carry a higher risk of HIV and STI transmission. Rectal sex poses a high risk because tissues in the rectum tear easily. It is worth noting that HIV is not only an STI but is also transmitted in other ways. Treatment of STIs Some STIs can be treated by antibiotics given orally or by injection at a health facility. Medication should be taken as prescribed, even when there are no longer signs of infection. Other STIs can be managed to decrease the symptoms (viral STIs – herpes and genital warts). Prevention of STIs  Abstinence  Use of condoms (and lubricants) correctly and consistently  Reduction of multiple, concurrent sexual partners  Avoid sharing needles and syringes (for PWID)  Screening of pregnant women for STIs  Early detection of STI signs and symptoms and timely treatment will reduce the spread of STIs  Partner notification (once diagnosed with an STI, notify your partner and encourage him/her to seek treatment immediately)  Avoid risky sex practices—e.g., dry sex, douching, group sex (orgy), sharing of sex toys

STIs Facts:  Most STIs can be prevented and treated.  Treatment of STIs is available in all health facilities in the country.  The earlier STIs are detected and treated, the better.  Untreated STIs may result in complications which may even lead to death.  People of all ages, including babies, may be infected (affected) by STIs.  Consistent and correct use of condoms (and lubricants) prevents the transmission of STIs.  It is important to complete treatment even when there are no more signs and symptoms.

Misconceptions and facts about STIs

Misconceptions Fact STIs are not transmitted through rectal STIs are transmitted through any type of sex/oral sex. unprotected sexual intercourse (vaginal, penile, oral, and rectal) Eating chilly foods will result in STIs. Food does not cause STIs. But STIs are transmitted from person to person. Having sex with a virgin will cure HIV. A person cannot be cured of HIV by having sex with a virgin. He will still have the virus in his body after sex, and he potentially could infect the virgin. STIs are diseases for women only. STI affects women, babies, and men. One cannot get an STI if their partner(s) does Even when there are no visible signs one can not have any signs. still be infected with an STI and can transmit it to their partner(s).

Unit 3: Tuberculosis Introduction The unit covers the basic facts about tuberculosis (TB) including symptoms, transmission, effects on the body and a person’s livelihood, preventive measures, and treatment.

Objectives By the end of this unit, participants will:  Understand basic information about TB  Understand and recognize signs and symptoms of TB  Understand how TB is transmitted  Understand how TB is prevented and treated

Basic facts on TB Tuberculosis remains the leading cause of death among people living with HIV, accounting for around one in three AIDS-related deaths. A person with a compromised immune system is at highest risk for TB. For PLHIV, the risk is 20 to 37 times greater. However, TB can be treated and cured by adhering to prescribed medicines from a health facility. If improperly treated, TB can advance to the drug resistance stage, i.e., multidrug resistant (MDR). It must be noted that the MDR-TB can be passed from one person to another.

Transmission of TB TB is spread through inhaling tiny droplets from the coughs or sneezes of an infected person. It can attack any part of the body but pulmonary TB (mainly affecting the lungs) is the most common. Pulmonary TB is the most infectious type spread from person t o person. However, the infection can spread via blood from the lungs to all organs in the body. A person can develop TB in the pleura (the covering of the lungs), the bones, urinary tract and sexual organs, intestines, kidney, spine, brain, and even the skin.

People at risk of TB infection  People with weakened immune systems  People in overcrowded or poorly ventilated areas  People exposed to silica; those whose jobs compromise their respiratory system, e.g., mineworkers; and chain smokers  People who are underweight; malnourished children  Alcoholics and people who inject drugs  People who have spent time with someone recently diagnosed with TB Signs and symptoms of TB  Coughing that lasts more than two weeks, usually worse in the morning  Tiredness 27

 Coughing up blood  Unintentional and noticeable weight loss  Prolonged fever  Chest pain, or pain with breathing or coughing  Night sweats  No appetite  Chills

Prevention of TB  Good ventilation: TB bacteria remain suspended in the air for several hours with no ventilation  Natural light: UV lights kills TB bacteria  Good hygiene: covering the mouth and nose when coughing and sneezing (with your elbow or cloth) reduces the spread of TB. Everyone should wash their hands before eating.  Avoid spitting on open ground  Vaccination: All newborns and infants should be given a vaccine to protect them against TB. The vaccine enables the child to develop antibodies against TB germs.  Provide TB prophylaxis for individuals who are HIV positive  Maintain a healthy immune system and lifestyle: People with lowered immunity are at higher risk of infection. A healthy lifestyle is important in preventing TB. This may include proper eating habits, quitting smoking and drinking alcohol, exercising regularly, and staying fit.

Management of TB  TB screening and early diagnosis and treatment: Lowering the number of deaths due to TB requires early diagnosis and treatment. If any of the symptoms of TB—such as a persistent cough—are noticed, go to a health facility immediately.

 TB is usually treated with a combination of drugs taken for six months or more. TB treatment is available in most health facilities. One can only stop treatment at the instruction of a health professional. It is recommended that people on TB treatment have a treatment supporter for DOT. It is important that PLHIV who have TB start ART, if they have not already, as soon as possible.

 Adherence to medication: When people do not adhere to treatment, this gives an opportunity for the TB bacteria to develop resistance to the drugs. When this resistant TB bacterium is expelled into the air, it can be taken in by healthy individuals. A person being treated for TB should complete the prescribed course of medication. One of the major reasons for the increase in the number of deaths from TB is the development of the drug-resistant form.

Module 1: Communicable Diseases: HIV and AIDS, STIs and TB Review  While there is no cure for HIV, ART is available for everyone infected with HIV to help them have healthier lives.  HTS is a critical entry point to HIV prevention, care and treatment services.  PLHIV should begin ART as soon as possible.  Effective ART depends on adherence—taking ARVs every day and exactly as prescribed.  Most STIs can be prevented and treated.  Untreated STIs may result in complications which may even lead to death.  Consistent and correct use of condoms (and lubricants) prevents the transmission of STIs.  TB is curable, preventable, and can be deadly if not attended to on time.  PLHIV are at a higher risk of getting TB.  Not adhering to TB treatment results in the development of other strains such as multidrug- resistant tuberculosis (MDR-TB).  HIV, TB, STIs screening and treatment are available at all health facilities at no cost

Module 2: Non-communicable Diseases

Introduction The module covers noncommunicable diseases (NCDs). These includes cancer, diabetes, and hypertension. It discusses prevention, diagnosis, effects, and management. Globally, NCDs are the leading cause of death. A NCD is a chronic medical condition that is not caused by infectious agents. The main types are cardiovascular diseases (e.g., heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructive pulmonary disease and asthma), hypertension, and diabetes. In the Kingdom of Eswatini, the most common NCDs are cancers, diabetes, and hypertension.

Objectives By the end of this module, participants will be able to:  Understand different types of cancer, diabetes, and hypertension  Identify signs and symptoms of these diseases  Discuss prevention and management of these conditions

Unit 1: Cancer Introduction The unit discusses the main types of cancers. It oulines risk factors as it relates to cancer and provides guidanace on prevention and treatment.

Objectives By the end of this unit, participants will be able to:  Understand what is cancer and the common types of cancer  Understand risk factors associated with cancer  Identify ways to prevent cancer  Understand treatment options for cancer

Basic facts on Cancer Cancer is an abnormal growth of cells that tend to multiply in an uncontrolled way and can spread to the rest of the body. Any part of the body can be affected. The different types are usually named after the part of the body where the abnormal cell growth begins, e.g., when the abnormal cells grow in the breast area, it is called breast cancer. There are more than 100 types, including skin cancer, lung cancer, liver cancer, colon cancer, and prostate cancer. Most cancers are diagnosed by a biopsy. Depending on the location of the tumor, the biopsy may be a simple procedure or an operation.

Risk factors Some factors that increase the risk of cancer:  Age  Family history of cancer  Having children late, not having children, and not breastfeeding (breast cancer)  Beginning menstruation before age 12 or completing menopause after age 55 (breast cancer)  Drinking alcohol and smoking  Lack of regular exercise and being overweight  Exposure to radiation therapy and prolonged use of hormone replacement therapy  Young age at first time of having sexual intercourse  Multiple sexual partners  Presence of STIs  Immune suppression  Low intake of fresh fruits and vegetables

Types of cancers Types are usually named according to the organs or tissues where the cancers form, but they also may be described by the type of cell that formed them. The most common types are described below:

Type Signs and symptoms Misconception Breast Cancer  Growth of lump in or near the breast or under  An injury to the breast the arm can cause cancer  Thickening or swelling of part of the breast  Using deodorants causes  Irritation or lumpiness of breast skin breast cancer  Pain in the armpits or breast that does not  Underwire bras cause seem to be related to the menstrual period cancer  Redness or flaky skin in the nipple area or the  Men can’t get breast breast cancer because they  A rash around or on one of the nipples don’t have breasts  Nipples change in appearance; may become  Drinking warm water sunken or inverted from a plastic bottle  The size or the shape of the breast changes causes cancer Prostate Cancer  Need to urinate often, due to incomplete  Having too much sex emptying of bladder cause cancer  Difficulty in starting or stopping the urine flow  A vasectomy (sterilization  Weak, decreased, or interrupted urine stream for family planning)  Burning or pain during urination causes cancer  Blood in urine or semen  Masturbation causes  Inability to urinate cancer  Painful ejaculation  Having an erection and not having sex causes cancer Cervical Cancer  Caused by HPV  Only promiscuous women  Blood spots or light bleeding between or get HPV following periods  There is nothing I can do  Menstrual bleeding that is longer and heavier to prevent cervical cancer than usual  Bleeding after intercourse, douching, or a pelvic examination  Pain during sexual intercourse  Bleeding after menopause  Increased vaginal discharge Anal Cancer  Rectal bleeding  Anal cancer is a man’s  Rectal itching disease  A lump or mass at the anal opening  Anal cancer cannot be  Pain or a feeling of fullness in the anal area prevented  Narrowing of stool or other changes in bowel movements  Abnormal discharge from the anus  Swollen lymph nodes in the anal or groin areas

Treatment of cancer Treatment options vary depending on the type of cancer and how far it has grown and spread. The four most common treatments are described below; some cancers may require a combination of two or more. A range of other treatments may also be used to ease cancer-related symptoms such as pain.  Cryotherapy: A treatment using localized freezing temperatures to destroy the abnormal and irritated nerve; used to treat localized areas of some cancers.  Surgery: Removal of a cancerous (malignant) tumor.  Chemotherapy: Use of anticancer medicines to kill cancer cells or to stop them from multiplying. Various types of medicines are used for chemotherapy; selection depends on the type of cancer.  Radiotherapy: High-energy beams of radiation focused on cancerous tissue to kill cancer cells or stop them from multiplying.

Prevention of cancer Each cancer type is different in origin, composition, and responsiveness to treatment; reliable prevention techniques are very difficult to identify. Cancer prevention cannot usually be accomplished by a single event, preventive measures must be taken for many years to give results that can be examined. Even if food or activity is shown to help prevent a certain type of cancer, there is no guarantee that eating or behaving in a certain way will absolutely assure freedom from cancer development. Research suggests that a combination of different essential nutrients is better than consuming a large amount of a single item.

Some ways to reduce the risk of cancer:  Limit alcohol consumption  Avoid direct high sun exposure  Early diagnosis and treatment of STIs earlier, including a HPV vaccination  Consistent and correct use of condoms (and lubricants) prevents the transmission of STIs.  Exercise regularly and maintain a healthy weight  Avoid using postmenopausal hormone therapy (PHT)  Eat a low-calorie diet containing fiber, fruits, and vegetables, and avoid a sedentary lifestyle, animal fats, and grilled meats.  Regular checkups including screening (visual inspection of cervix with acetic acid (VIA) pap smear, and rectal examination once in two years for HIV-negative individuals and yearly for HIV-positive ones) and breast self-examination.  Practice safe sex by: o Reducing the number of sexual partners, o Using condoms correctly and consistently during sex, o Avoiding receptive anal sex, o Getting tested regularly for sexually transmitted infections-HPV.

Figure 3: Example of self examination

Unit 2: Diabetes Introduction The unit discusses diabetes outling the three types of diabetes, and warning signs and symptoms. It also provides guidance on the management of diabetes.

Objectives By the end of this unit, participants will be able to:  Understand what is diabetes and discuss the three types of diabetes  Understand risk factors associated with diabestes  Identify ways to prevent and manage diabetes

Basic facts on Diabetes Diabetes is a chronic, metabolic disease characterized by elevated levels of blood sugar which, over time, may lead to serious damage to the heart, blood vessels, eyes, kidneys, and nerves. There are three main types of diabetes: type 1, type 2, and gestational diabetes (diabetes while pregnant). Type 1 diabetes is caused by an autoimmune reaction (the body attacks itself by mistake) that stops your body from making insulin. About 5 percent of the people who have diabetes have type 1. It is usually diagnosed in children, teens, and young adults, but it can develop at any age. In type 1 diabetes, the pancreas is not making insulin or is making very little. Insulin is a hormone that enables blood sugar to enter the cells in the body where it can be used for energy. Without insulin, blood sugar cannot get into cells and builds up in the bloodstream. Type 2 diabetes results when the body does not use insulin well and is unable to keep blood sugar at normal levels, called insulin resistance. Most people with diabetes—nine in 10—have type 2. The pancreas makes more insulin to try to get cells to respond. Eventually the pancreas cannot keep up, and blood sugar rises, setting the stage for prediabetes and then type 2 diabetes. High blood sugar is damaging to the body and can cause other serious health problems. Gestational diabetes develops in pregnant women who have never had diabetes. During pregnancy, the body makes more hormones and goes through other changes, such as weight gain. These changes cause the body’s cells to use insulin less effectively, a condition called insulin resistance. Insulin resistance increases the body’s need for insulin. In gestational diabetes, the baby could be at higher risk for health complications. Gestational diabetes usually goes away after the baby is born but increases your risk for type 2 diabetes later in life. The baby is more likely to become obese as a child or teen, and more likely to develop type 2 diabetes later in life, too. Type 1 diabetes risk factors  Family history: Have a parent, brother, or sister with type 1 diabetes  Age: Type 1 diabetes can develop at any age, but it’s more likely in a child, teen, or young adult

Type 2 diabetes risk factors  Overweight  Age: 45 years or older  Family history and genetics: Have a family member with type 2 diabetes

 Sedentary lifestyle or less physical activities  Have had gestational diabetes or given birth to a baby who weighed more than 4 kg

Early diabetes warning signs and symptoms:  Excessive thirst and hunger  Frequent urination (from urinary tract infections or kidney problems)  Weight loss or gain  Fatigue  Irritability  Blurred vision  Slow-healing wounds  Nausea

Management of diabetes Keeping blood sugar levels within the range recommended by your doctor can be challenging. Many things can make blood sugar levels change, sometimes unexpectedly. Some factors are listed below.

Food Healthy eating is a cornerstone of healthy living—with or without diabetes. But those who have diabetes need to know how foods affect blood sugar levels. They need to monitor the type of food, how much, and the combinations of food types.

What to do:  Have the right amount of carbohydrate portion sizes. A key to many diabetes management plans is having proper carbohydrates portion sizes of at each meal. Carbohydrates often have the biggest impact on blood sugar levels.  Make every meal well-balanced. Plan for every meal to have a good mix of starch, fruits and vegetables, proteins, and fats.  Coordinate your meals and medications. Too little food in proportion to diabetes medications—especially insulin—may result in dangerously low blood sugar (hypoglycemia). Too much food may cause the blood sugar level to climb too high (hyperglycemia). A diabetes health care team can advise how to coordinate meal and medication schedules.  Avoid sugar-sweetened beverages. These beverages tend to be high in calories and offer little in the way of nutrition.

Exercise 3.1 Physical activity is another important part of a diabetes management plan. During exercise, muscles use sugar (glucose) for energy. Regular physical activity also helps the body use insulin more efficiently. These factors work together to lower the blood sugar level. The more strenuous the workout, the longer the effect lasts. But even light activities—such as housework, gardening, or standing for extended periods—can improve blood sugar.

Unit 3: Hypertension Introduction The unit discusses hypertension outling what it is, symptoms and risk factors. It also provides different management options.

Objectives By the end of this unit, participants will be able to:  Understand what is hypertension  Understand risk factors associated with hypertension  Identify was to prevent and mangae hypertension

Basic facts on Hypertension Globally close to one-third of adults have hypertension or high blood pressure (BP). As we age, the likelihood that we will develop hypertension increases by 29 percent and it should be checked more regularly. In most cases, a person will be asymptomatic (having no noticeable symptoms), which is why this disease is so dangerous. If hypertension is not detected, it can wreak havoc on your cardiovascular system by putting excess strain on your blood vessel walls and heart. In some very rare cases, a person may develop a sudden onset of hypertension, which causes noticeable symptoms, otherwise most people will not have any symptoms.

Symptoms of hypertension  Severe headache  Nosebleeds  Nausea  Confusion  Blurred vision  Dizziness  Headaches  Shortness of breath  Facial flushing  Chest pain

These symptoms require immediate medical attention. They do not occur in everyone with hypertension but waiting for a symptom of this condition to appear could be fatal.

29 37

Risk factors  Family history and genetics: Some people are genetically predisposed to hypertension. This may be from genetic abnormalities inherited from parents.  Being overweight or obese: The more you weigh the more blood flow is needed to supply oxygen and nutrients to tissues. As the volume of blood circulated through vessels increases, so does the pressure inside arteries.  Too much salt in diet: Too much salt can cause the body to retain fluid, and also cause the arteries to constrict. Both factors increase blood pressure.  Lack of physical activity: Exercise increases blood flow through all the arteries. Lack of physical activity increases the risk of becoming overweight.  Drinking too much alcohol: Having more than two drinks per day can cause hypertension by causing constriction of blood vessels and simultaneous increase in blood flow and heart rate.  Stress: High levels of stress can lead to a temporary increase in blood pressure. Trying to relax by eating more, using tobacco, or drinking alcohol may only aggravate problems with high blood pressure.  Certain chronic conditions: Conditions such as diabetes and kidney disease may increase the risk of high blood pressure.

Management of Hypertensive Patients

Lifestyle modification All hypertensive patients should be encouraged to attempt lifestyle modification. Lifestyle modifications that have been shown to reduce BP include:

 Smoking cessation (stop smoking)  Low salt diet: less than 2.4 g/day and reduce red meat in diet  Exercise: more than 30 minutes of aerobic exercise daily, for example, brisk walking  Alcohol management: men, two drinks per day; women, one drink per day o A drink equivalent is: Beer: 660 ml (two cans) Wine: 150 ml per day (one glass) Spirits/whiskey: 50 ml per day (one small glass)  Weight: Maintain Body Mass Index (BMI) 18.5-24.9

Medications  Many patients will require drugs to treat hypertension.

 The choice of drugs depends on the individual and other conditions they may have.

Module 2: Non-communicable Diseases Review  Majority (90%) of people with diabetes have Type 2 diabetes while 10 to 15% have Type 1 diabetes.  Type 2 diabetes runs in families but a sedentary lifestyle and being overweight or obese are also causes,  Diabetes affects the way the body metabolizes, or uses, digested food to make glucose, the main source of fuel for the body.  Diabetes of all types can lead to complications such as blindness, heart disease, amputation, end- stage kidney disease, liver problems and increase the risk of dying prematurely.  Diabetes can be managed and its complications can be prevented by a healthy diet, regular physical activity, maintaining a normal body weight and avoiding tobacco use.  Some cancers are more aggressive and grow more quickly than others.  Some cancers are more likely to spread to other parts of the body.  Some cancers respond to treatment better than others.  Cancer prevention is an essential component of all cancer control plans.  Underdiagnosed and undertreated hypertension is an independent, reversible risk factor for heart disease and renal disease.  HIV-infected patients have a high prevalence of hypertension and other heart disease risk factors.  In most cases, the management of hypertension should start with lifestyle modification and treatment.  Hypertensive patients are encouraged to have a BP machine at home for self-monitoring.

Module 3: Human Sexuality, Stigma, Discrimination,

and Violence

Introduction The module discusses huan sexuality, stigma, discrimination, and violence. These topics will help the reader understand the concept of human sexuality and the connection between violence, stigma, discrimination, and HIV.

Objectives By the end of this module, participants will be able to:  Define concepts related to human sexuality, stigma, and discrimination.  Help police understand key terms and issues around gender, sexuality, sex work, and drug use.

Unit 1: Human sexuality Introduction The module discusses human sexuality looking at conepts of gender and sexuality looking at them through both a biological and social lens. It also discusses how it is experienced and influenced at both an individual and society level.

Objectives By the end of this unit, participants will be able to:  Define concepts related to human sexuality.  Help police understand key terms and issues around gender and sexuality

According to the World Health Organization (WHO),30 sexuality is a central aspect of being human and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, characters, practices, roles, and relationships. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, ethical, legal, historical, religious, and spiritual factors. Human sexuality can be broadly broken down into five concepts:

30 World Health Organisation 2014. 40

 biological sex  gender identity  sexual orientation  sexual identity  sexual practices

The image below provides a visual summary of these different concepts.

Source: Duby Z. (2017). Sexuality training. Cape Town

Figure 4: Concepts of Sexuality

Biological sex Biological sex refers to the biological difference between females and males present at birth. This includes anatomical differences, such as a vagina or penis; genetic differences as in chromosomal makeup; and physiological differences, such as menstruation or sperm production. Until recently, sex was considered to be unchangeable. Now individuals can go through a transition that includes both social (changes to clothes, mannerisms or names) and medical (sex reassignment surgery) transitions.

 Intersex Intersex, a subset of biological sex, refers to people who is both with sexual anatomy, reproductive organs or chromosome patters that do not fit the typical definition of male or female. Historically, intersex individuals were surgically altered soon after birth to cosmetically appear more definitely male or female. These surgeries were often riddled with complications that affected the individuals for the remainder of their lives. Intersexuality shows that biological human sex is actually a spectrum with male at one end, a variety of intersexualities in the middle, and female at the other end.

Gender A person’s gender refers to attitudes, feelings, and behaviors that society associates with the biological sexes. It is common to confuse “sex” and “gender” but they do not refer to the same thing. Sex is a biological concept while gender is a social construct. Gender is an idea that is built, or “constructed,” by society rather than nature.

Gender describes a common set of traits and social expectations attached to a person’s biological sex. People are born with their biological sex but they are taught their gender through society and culture.

 Gender expression Gender is often expressed either in relation with biological sex or not. The external display of one’s gender, through a combination of appearance, disposition, social behavior, and other factors, generally measured on a scale of masculinity and femininity.

 Gender identity Gender identity refers to a person’s deeply felt internal and individual experience of gender, which may or may not correspond with the sex assigned at birth. People may identify either as a man or a woman in relation with their biological sex. However, some people may not identify with their biological sex, this is known as transgender.

 Transgender Transgender refers to individuals whose gender, or self-identification as a man or woman, does not match their biological sex assigned at birth. Consider the example of a baby who is born with a vagina and is assumed to be a girl. Growing up, the person is raised to follow the gender roles associated with women, but they identify as a man often conflicting the societal

norms and/or expectations. This experience may lead to issues of stigma and discrimination and constant frustration. Sexual orientation Sexual orientation is part of identity and refers to the way in which a person feels attraction to other people of a specific sex or gender. Essentially, sexual orientation encompasses all of a person’s intimate psychological and physical feelings toward others. The three different sexual orientations are heterosexuality, homosexuality, and bisexuality. Sexual identity Sexual identity refers to the way in which individuals identify themselves sexually. This may be linked to their sexual orientation, but also refers to the lifestyle and labels with which they associate. Examples of sexual identities are gay, lesbian, heterosexual, bisexual, and queer. Sexual behavior Sexual behavior is the way in which individuals express their sexuality. All people, no matter their sexual orientation, use various body parts to express sexual pleasure, on their own or with others. Sexual behavior and roles are independent from but may be influenced by an individual’s biological sex, sexual orientation, sexual identity, or gender. For example, a man who has sex with men who is married to a woman can have sex with another man but not identify as being a gay man. A heterosexual man may enjoy being penetrated anally by a woman with a sex toy but this does not make him gay. A female sex worker may have sex with a female client, but does not identify as lesbian.

Unit 2: Stigma and Discrimination Introduction Heightened experiences of stigma, prejudice, and discrimination toward key populations have been documented globally. Members of KPs experience stigma due to a number of characteristics, rather than any one particular attribute. These layers of stigma create an additional burden on their lives and well-being. Stigma often leads to discrimination, which occurs when a person or group of individuals are treated unjustly or unfairly because of a specific trait they possess.

Objectives By the end of this unit, participants will be able to:  Define concepts related to stigma and discrimination  Describe different types of stigma and their impacts on individuals and society  Discuss different experiences of stigma and discrimination experienced

What is stigma? Stigma refers to the strong negative feelings or significant disapproval that is linked to a specific person, group, or trait. For example, stigma has developed toward individuals with mental illness, physical disabilities, or diseases such as HIV. Stigma can be experienced both externally and internally. There are different types of stigma and in this unti we will discuss external and internal stigma. Types of stigma External stigma Also referred to as enacted stigma, external stigma is experienced from the actions of others. Most signs of external stigma are centered on the way people interact with one another. These may include:  Avoidance: When individuals spend less time with or do not want to be associated with a person or group of people because of a particular characteristic or practice. For example, a person avoids his/her close friend because of his/her sexual orientation, being HIV positive, or due to their economic or social status.

 Rejection: When individuals are no longer willing to associate with or welcome people or individuals who are perceived to belong to a particular group. This might include a family member rejecting or disowning a relative because of HIV status or sexual orientation.

 Moral judgment: When individuals begin to perceive a person as good or bad as measured against some standard of “good.” For example, a young woman in a community might be labelled immoral because of being perceived as a sex worker, which is in conflict with the religious beliefs and values acceptable within that community.

 Stigma by association: When those who associate or support a person or group of people who are stigmatized are also perceived to belong to that group. For example, a person working with KPs may be labelled as being a key population member because of being associated with the group.

 Gossip: When individuals speak negatively about other people behind their back with regard to perceived or sexual behavior. For example, colleagues in an office can be saying negative things about another colleague behind his/her back because he or she is HIV positive, is a man who has sex with men, or a sex worker.

 Unwillingness to employ: When a person is refused employment because of HIV status, gender, religion, or sexual behavior.

 Abuse: When a person is emotionally, economically, verbally, or physically mistreated because they belong to, or are perceived to belong to, a particular group. For example, a woman may not disclose her HIV status to her spouse because of fear of being beaten blamed or even divorced.

 Victimization: When someone is singularly blamed or punished for a problem that is unrelated to him or her. For example, a sex worker might be blamed for being responsible for spreading HIV in a community.

Internal stigma An individual experiences internal stigma due to a perception other people have about him or her. Unlike external stigma, the signs of internal stigma may be much harder to identify because most of them occur within the individual and are focused on the way the person feels about themselves. The result can be low self-esteem, shame, and low moral worth when the person begins to believe and relate to the stigma they are experiencing. Some signs of internal stigma include:  Self-exclusion from services: Self-exclusion may occur when an individual avoids opportunities due to fear of being further ostracized, or the individual feels unworthy of those opportunities. For example, a sex worker may not want to go to the health facility to seek care because of fear of being labelled or denied services.

 Low self-esteem: A person who is experiencing internal stigma may have low self-esteem, low sense of self-worth, or other self-confidence issues.

 Social withdrawal: When a person experiencing internal stigma disengages or withdraws from social networks of friends, family, or colleagues.

 Overcompensation: When a person who is feeling internal stigma feels the need to overly contribute to a situation to make up for their perceived stigmatization. For example, this

happens when a stigmatized individual is overly grateful when someone is kind to them.

 Mental health issues: Internal stigma may cause a person to become depressed or develop mental health issues. For example, a stigmatized person may develop generalized anxiety disorder because of continual stress and anxiety from his or her perceived Positive Cases from Police stigma. Sebentile is an 18-year-old young woman who is

exchanging sex for money and food. She lives in Big Bend  Substance abuse: A person affected or and started engaging in sex work when she was 15. This experiencing internal stigma may was after she lost her brother who was a breadwinner in resort to substance abuse as a means their family after they lost both parents in 2004. of coping with the stressful situation. Sebentile normally provides sex for food and money to the men working in the Big Bend sugar mill especially at  Suicide or attempted suicide: Sadly, the end of the month. Today she was raped and some individuals may not be able to assaulted by one of the men and she goes to the police cope with internal stigma and may station to report the case. She is being received politely turn to suicide in order to escape the by the desk officer who listens to her story and then pain of stigma. In some circumstances, refers her to a DCS officer. The DCS officer on duty sex workers may resort to trying to kill records her story, gives her proper counselling. The themselves to escape the pain of police help her to bring justice to her case and she is stigma. happy.

Stigma and discrimination among KPs in the Kingdom of Eswatini Key populations in Eswatini face challenges linked to the structural economic context. Criminalizing certain behaviors results in experiences related to stigma and discrimination against certain KPs. A study conducted in 2011 by the Ministry of Health showed that FSWs face a wide range of discrimination31. For instance, 50 percent reported experienceing legal discrimination, 52.3 percent were refused police protection, and 36.3 percent were blackmailed while 64.1 percent experienced verbal and physical harassment, and about 40 percent reported having been raped.

31 Swaziland Biobehavioural Surveillence Survey, 2011. 46

Unit 3: Violence Introduction Violence is the intentional use of force or power, threatened and actual, against a person by another person, or against a group of community, which either results in, or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation (WHO). While gender-based violence refers to any form of violence that is directed at an individual based on biological sex, gender identity (e.g., transgender), or behaviors that are [perceived as] not in line with social expectations. Objectives By the end of this unit, participants will be able to:  Understanding types of violence  Understand the prevalence of gender-based violence (GBV) in the country  Understanding violence among key populations in the Kingdom of Eswatini  Understanding the links between stigma, discrimination, and violence

Types of Violence: o Physical: hitting, pushing, kicking, choking, spitting, pinching, punching, poking, slapping, biting, shaking, pulling hair, throwing objects, being dragged, beaten up, deliberately burned, use of weapon, kidnapping, holding against will, physically restraining, being deprived of sleep by force, being forced to consume drugs or alcohol, subjected to invasive body searches/forced to strip, poisoning, killing o Sexual: Rape; gang rape; being physically forced, coerced, psychologically intimidated or socially or economically pressured to engage in any sexual activity against one's will; undesired touching, oral, anal, or vaginal penetration with penis or with an object; refusal to wear a condom; genital cutting/mutilation (e.g., Femal genital mutilation) o Emotional: Psychological and verbal abuse; humiliation; threats of physical or sexual violence or any other harm to an individual or those they care about, including threatening to take custody of an individual’s children; coercion; controlling behaviors; calling names; verbal insults; being confined to or isolated from friends/family; repeated shouting; intimidating words/gestures; destroying possessions; blaming; isolating; bullying o Economic: Use of money or resources to control an individual; blackmailing; refusing right to work; taking earnings; refusing to pay money that is earned/due, including clients refusing to pay; withholding resources as punishment

Data on violence in the Kingdom of Eswatini The key drivers of violence in the Kingdom of Eswatini are: inequality between men and women; acceptance of violent conflict-resolving mechanisms; male authority and control of decision-making; restrictions on women’s ability to leave the home; and cultural notions of women as the weaker sex or as property (gender roles and stereotyping). Figure 1 shows the prevalence of violence in the Kingdom of Eswatini from 2014 to 2016. The main types of violence experienced in 2017 can be seen in Figure 2. Figure 1. Prevelance of Violence in the Kingdom of Eswatini from 2014-2016 Violence among KPs at a globl level 12000 10504 70.6% 10000 Figure 2. Types of Violence 7729 increase 8000 Experienced in 2017 6154 from 6000 4000 15% 2000 35% 0 19% 2014 2015 2016 31%

Violence is common against KPs in the global context. The reasons include culture, social norms, and Emotional Physical Sexual Other criminalization of KPs. GBV is rooted in power differences, both social and economic. High rates of violence among KPs needs to be addressed as we know that violence:  Is a human rights violation  Increases HIV risk32,33, 34  Decreases testing uptake and disclosure 35, 36, 37  Decreases adherence to ART 38, 39  Causes a host of other health issues 40

32 UNAIDS, 2010a 33 Decker, et al. 2013 34 Beattie, et al., 2015 35 Gari, et al. 2013 36 UNIFEM, 2011 37 UNAIDS, 2010b 38 Schafer, et al. 2012 39 Mugavero, et al. 2006 40 WHO, 2013 48

The link between stigma, discrimination, and violence The vulnerability of KPs to HIV and violence are rooted in structural inequalities, including unequal power relationships based on biological sex, gender identity, sexual orientation, occupation (in the case of sex work), and other behaviors perceived as unacceptable by society, such as injecting drugs. These structural inequalities are entrenched in cultural beliefs and societal norms and are reinforced by political and economic systems. In addition, the criminalization of sex work and homosexuality, as well as stigma, discrimination, and violence, pose significant barriers for KPs in seeking and receiving HIV services. Many factors increase the risk of HIV, including:  Mobility and migration that may introduce new partners and make seeking health care harder  Legal obstacles when behaviors or identities are criminalized that make it difficult for individuals to access services and to engage in behaviors in a safe way (for example, sex workers having sufficient time to talk to and assess a client before going somewhere with him)  Cultural and social practices resulting in stigma and discrimination that drive specific behaviors underground and make it difficult for people to disclose their behaviors or seek support

Certain laws that criminalize same-sex relationships, “gender impersonation,” drug use, and sex work create an environment where violence targeting KPs is accepted by powerholders, clients of sex workers and communities. There is an added layer of complexity when gender norms are rigidly viewed within the community. This subects KPs to abuse and violence by family, community members, and strangers alike. 41

Besides rigid gender norms, stigma, and power inequalities, other factors contribute to, or fuel, violence and abuse against KPs: o Lack of training for providers and key stakeholders o Religious beliefs

41 LINKAGES Newsletter Issue 7, July 2016 49

Module 3: Human Sexuality, Stigma, Discrimination and Violence review  Sexuality is a central aspect of being human and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction. Human sexuality can be broadly broken down into four distinct concepts: sex, gender, sexual orientation and sexual behavior.  We are all sexual beings, and human sexuality is very fluid.  Stigma refers to the strong negative feelings or significant disapproval that is linked to a specific person, group, or trait.  KPs face stigma and discrimination.  Violence is the intentional use of force or power, threatened and actual, against a person by another person, or against a group of community, which either results in, or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.  KPs experience a great deal of violence.  There is a link between stigma, discrimination, violence, and HIV.

Module 4: Human Rights, KPs, and HIV

Introduction The module discusses human rights, KPs, and HIV. Police officers are custodians of the protection and enforcement of human rights. The mandate of the REPS found in section 189 of the constitution Act 001 of 2005 along with section 7 of the Police Act (Police service act of 1957)42 establishes the Royal Eswatini Police Services. The mandate of the REPS is pirmaily the preservation of peace and order. This means that in the scope of their duties Police officers act in accordance with the provisions of the constitution, especially in ensuring that fundamental rights and freedoms are upheld. Therefore, Police officers are critical stakeholders in the criminal justice system. In the scope of their duties they will be exposed to vulnerable people and must exercise their skills and knowledge in dealing with such groups, especially ensuring that they have access to their rights as per the constitution.

Objectives By the end of this module, participants will be able to:  Define law and human rights  Discuss the significance of human rights  Discuss why human rights are important to the Police and the role of Police in protecting human rights  Explore international and national laws and policies that support the rights of all people  Establish the nexus between human rights, health, and HIV infection  Understand stigma, discrimination, and human rights violations

Unit 1: Law and Human rights Introduction Law is a social control mechanism. It is a binding custom or practice of a community, a rule of conduct or action prescribed or recognized as binding or enforced by a control authority. In Eswatini, law is inacted by parliament which is the legislative arm of governmet

42 Act No. 29 of 1957. 51

Objectives By the end of this unit, participants will be able to:  List the characteristics of human rights  Explore and understand human rights in the context of Eswatini  Analyze the bill of rights in the Constitution of Eswatini and the country’s international obligations

Definition of human rights Human rights are commonly understood as those rights which are inherent in the mere fact of being human. The concept of human rights is based on the belief that every human being is entitled to enjoy her/his rights without discrimination. Human rights differ from other rights in two respects.

First, they are characterized by being:  Inherent in all human beings by virtue of their humanity alone (they do not have, e.g., to be purchased or granted)  Inalienable (within qualified legal boundaries)  Equally applicable to all  They are interdependent and inter-related  They derive from the dignity and worth of the human person  Their enjoyment is based on the principle of non-discrimination

Second, the main duties deriving from human rights fall on states and their authorities or agents, not on individuals.

One important implication of these characteristics is that human rights must themselves be protected by law (the rule of law). Furthermore, any disputes about these rights should be submitted for adjudication to a competent, impartial, and independent tribunal, applying procedures which ensure full equality and fairness to all the parties, and determining the question in accordance with clear, specific and pre-existing laws, known to the public and openly declared. The idea of basic rights originated from the need to protect the individual against the (arbitrary) use of state power. Attention was therefore initially focused on those rights which oblige governments to refrain from certain actions. Human rights in this category are generally referred to as fundamental freedoms. As human rights are viewed as a precondition for leading a dignified human existence, they serve as a guide and touchstone for legislation.

Human rights in Eswatini In line with the trend in modern democratic states in adopting written constitutions in the context of Eswatini has put forth its own. The constitution was adopted in 2005.43 It is the supreme law of the land.44 The legislature, executive, and judiciary and all organs and agencies of government are enjoined to respect the rights and freedoms, without regard to gender, race, religion, etc. There is also recognition and protection of the rights of what is commonly referred to as marginalized groups, such as women, children, and persons with disabilities. Not only does the constitution declare and guarantee human rights and freedoms, it further provides mechanisms for redress in the event of violations.45 Fundamental rights and freedoms Chapter III of the constitution is what is commonly referred to as the Bill of Rights. Fundamental human rights and freedoms of the individual are declared and guaranteed. It should be noted that these rights and freedoms are not absolute. Consequently, certain limitations are imposed in the exercise and enjoyment of these rights and freedoms. These rights and freedoms are enumerated as follows: 1. Respect for life, liberty, security of person, and equality before the law and equal protection of the law. 2. Freedom of conscience, expression, and peaceful assembly and association 3. Protection of the privacy of the home and other property of the individual 4. Protection from the deprivation of property without compensation except as provided by law

Notwithstanding the fact that these rights and freedoms have been declared and guaranteed, certain derogations are permitted in situations of an emergency. A clear procedure for declaring state emergency and circumstances that warrant a declaration of a state of emergency are set out. Further, to ensure that there is never a perpetual state of emergency and thus a perpetual violation of rights and freedoms, time limits for a state of emergency, if declared, are prescribed. As indicated that a declaration of a state of emergency constitutes derogation to the protection of rights and freedoms, it is noteworthy that the constitution provides that notwithstanding such

43 July 26, 2005. 44 Section 2, Constitution of the Kingdom of Swaziland. 45 35. (1) Where a person alleges that any of the foregoing provisions of this Chapter has been, is being, or is likely to be, contravened in relation to that person or a group of which that person is a member (or, in the case of a person who is detained, where any other person alleges such a contravention in relation to the detained person) then, without prejudice to any other action with respect to the same matter which is lawfully available, that person (or that other person) may apply to the High Court for redress. (2) The High Court shall have original jurisdiction — (a) to hear and determine any application made in pursuance of subsection (1); (b) to determine any question which is referred to it in pursuance of subsection (3); and may make such orders, issue such writs and make such directions as it may consider appropriate for the purpose of enforcing or securing the enforcement of any of the provisions of this Chapter.

declaration there are certain rights and freedoms that cannot be compromised. These are the rights and freedoms to:  Life, equality, and severity of person  Right to fair hearing  Freedom from slavery or servitude  Freedom fro  torture, cruel, inhuman, or degrading treatment or punishment

The sections below the key concepts from the constitution that are relevant to the understanding of fundamental rights and freedoms for Emaswati.

Section 16: Protection of right to personal liberty.

16. (1) A person shall not be deprived of personal liberty save as may be authorised by law in any of the following cases — (a) in execution of the sentence or order of a court, whether established for Swaziland or another country, or of an international court or tribunal in respect of a conviction of a criminal offence; (b) in execution of the order of a court punishing that person for contempt of that court or of another court or tribunal; (c) in execution of the order of a court made to secure the fulfilment of any obligation imposed on that person by law; (d) for the purpose of bringing that person before a court in execution of the order of a court; (e) upon reasonable suspicion of that person having committed, or being about to commit, a criminal offence under the laws of Swaziland; (f) in the case of a person who has not attained the age of eighteen years, for the purpose of the education, care or welfare of that person; (g) for the purpose of preventing the spread of an infectious or contagious disease; …

Section 18: Protection from inhumane or degrading treatment 18. (1) The dignity of every person is inviolable. (2) A person shall not be subjected to torture or to inhuman or degrading treatment or punishment

Section 20: Equality clause

Equality before the law. 20. (1) All persons are equal before and under the law in all spheres of political, economic, social and cultural life and in every other respect and shall enjoy equal protection of the law. (2) For the avoidance of any doubt, a person shall not be discriminated against on the grounds of gender, race, colour, ethnic origin, tribe, birth, creed or religion, or social or economic standing, political opinion, age or disability. (3) For the purposes of this section, “discriminate” means to give different treatment to different persons attributable only or mainly to their respective descriptions by gender, race, colour, ethnic origin, birth, tribe, creed or religion, or social or economic standing, political opinion, age or disability. (4) Subject to the provisions of subsection (5) Parliament shall not be competent to enact a law that is discriminatory either of itself or in its effect. (5) Nothing in this section shall prevent Parliament from enacting laws that are necessary for implementing policies and programmes aimed at redressing social, economic or educational or other imbalances in society.

Section 21: The right to a fair hearing

21. (1) In the determination of civil rights and obligations or any criminal charge a person shall be given a fair and speedy public hearing within a reasonable time by an independent and impartial court or adjudicating authority established by law. (2) A person who is charged with a criminal offence shall be — (a) presumed to be innocent until that person is proved or has pleaded guilty; (b) informed as soon as reasonably practicable, in a language which that person understands and in sufficient detail, of the nature of the offence or charge; (c) entitled to legal representation at the expense of the Goverrnment in the case of any offence which carries a sentence of death or imprisonment for life; (d) given adequate time and facilities for the preparation of the defence; (e) permitted to present a defence before the court either directly or through a legal representative chosen by that person; (f) afforded facilities to examine in person or by a legal representative the witnesses called by the prosecution and to obtain the attendance of witnesses to testify on behalf of that person on the same conditions as those applying to witnesses called by the prosecution; and (g) permitted to have, without payment, the assistance of an interpreter if that person cannot understand the language used at the trial. …

Section 23: Protection of the freedom of conscience 23(1) A person has a right to freedom of thought, conscience or religion.

Section 24: Freedom of expression 24. (1) A person has a right of freedom of expression and opinion. (2) A person shall not except with the free consent of that person be hindered in the enjoyment of the freedom of expression, which includes the freedom of the press and other media, that is to say — (a) freedom to hold opinions without interference; (b) freedom to receive ideas and information without interference; (c) freedom to communicate ideas and information without interference (whether the communication be to the public generally or to any person or class of persons); and (d) freedom from interference with the correspondence of that person. …

Section 26: Protection to the right to movement 26. (1) A person shall not be deprived of the freedom of movement, that is to say, the right to move freely throughout Swaziland, the right to reside in any part of Swaziland, the right to enter Swaziland, the right to leave Swaziland and immunity from expulsion from Swaziland.

Section 28: The rights and freedoms of women 28. (1) Women have the right to equal treatment with men and that right shall include equal opportunities in political, economic and social activities. (2) Subject to the availability of resources, the Goverrnment shall provide facilities and opportunities necessary to enhance the welfare of women to enable them to realise their full potential and advancement. (3) A woman shall not be compelled to undergo or uphold any custom to which she is in conscience opposed.

Sexual Offences and Domestic Violence Act on sex work in Eswatini Eswatini has recently promulgated the Sexual Offences and Domestic Violence Act (SODV).46 Part III of the Act prohibits commercial sexual activities. The act classifies sex work as prostitution. Section 15 provides that a person who procures another to engage in prostitution shall on conviction be liable to a fine not exceeding E50 000.00 or imprisonment not exceeding 15 years or both. The provisons of Section 16(1) of the act are similar as they impose a fine of up to E50 000.00 or imprisonment of 15 years or both for receiving a financial, or other, favor or compensation from the commission of sexual act or sexual violations. In terms of this act, therefore, sex workers (both male and female) faces a risk of being arrested and/or imprisonment

International law obligations

Eswatini is enjoined by section 236 of the constitution to pursue international relations with other states, thus Eswatini has signed and ratified a number of international and regional instruments on human rights. Although the country is quick to ratify implementation is slow, understandably so, as drafting and tabling any bill to parliament is a long process. Eswatini belongs to the dualist tradition, thus views international law and domestic law as two separate legal systems. Hence, domestication of international law by an Act of Parliament is necessary before international law can be applied. This, of course, excludes customary international law, which is binding on all states. Section 238 of the constitution provides that unless an international agreement is self-executing, it will not become law in Eswatini unless enacted into law by Parliament. The Attorney General is mandated by section 77(5) (b) to draft and peruse treaties and agreements the Government of Eswatini is party to. The international and regional Human Rights instruments in which Eswatini has signed and ratified include: . UDHR Universal Declaration of Human Rights . ICSER International Covenant for Socioeconomic Rights . ICCPR International Covenant for Civil and Political Rights . CEDAW Convention of Elimination of all Forms of Discrimination Against Women . UNCAT Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment . CRC Convention of the Rights of the Child . ACHPR African Charter on Human and People’s Rights The Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa (Maputo Protocol).

46 Act No. 15 of 2018. 57

Unit 2: Importance of human rights to police Introduction The principle of human rights is an important aspect of policing and vice versa.47 Protection of human rights is a central domain of Police work.48 There can hardly be human rights in the absence of effective policing.49 Among their functions, Police are responsible for the realization of human rights as stated in various human rights instruments, including the twin principles of individual freedom and human dignity.50

Objectives By the end of this unit, participants will be able to:  Understand the role of the Police Services in generalUnderstand the role police play in protecting human rights.Understand Police’s safeguards in protection of human rights in the maintenance of law and order.

Police are an important building block of the criminal justice system, which is supposed to work in accordance with the rule of law. The credibility of the criminal justice system depends on the relative strength or weakness of the laws and procedures established for the police, the prosecution, and the court system. The police are an arm of the State vested with the primary responsibilities of law enforcement and prevention of crimes against the State and private citizens. On the other hand, respect for human rights by law enforcement officials not only ensures that they act in a manner that is lawful and ethical, but it also enhances their effectiveness. Police As Protectors Of Human Rights Police have to play a vital role as the protector of Human Rights. As stated above the role of the Police is to maintain the law and order in the Kingdom of Eswatini. Police work encompasses preventive and protective roles in the course of maintaining law and order.Police should give priority in protecting the rights of the vulnerable section of the society.

Effects of violations of human rights by the Effects of respect of human rights by police police

 Erode public confidence  Builds public confidence in them and  Exacerbate civil unrest fosters community cooperation

47 SARPCCO Code of Conduct, Human Rights and Policing; towards ethical Policing Resource Book 2003. 48 SARPCCO Code of Conduct, Human Rights and Policing; towards ethical Policing Resource Book 2003.. 49 SARPCCO Code of Conduct, Human Rights and Policing; towards ethical Policing Resource Book 2003.. 50 SARPCCO Code of Conduct, Human Rights and Policing; towards ethical Policing Resource Book 2003. 58

 Hamper effective prosecutions in  Contributes to the peaceful resolution of court conflict and complaints  Isolate the police from the community  Makes prosecutions in court successful  Result in the guilty going free and the  Makes police be seen as part of the innocent being punished community  Leaves the victim of crime without  Contributes to the fair administration of justice for his/her suffering justice and the enhancement of  Forces the public to be reactive rather confidence in the system than preventive or proactive in their  An example is set for respect for the law approach by others in the society  Results in criticism of the police and  Are able to be closer to the community the government at the national and and in a position to prevent and solve international levels crimes through proactive policing  Will generally enjoy the support of the community, the media, civil society, the government, and the international community  The Southern African Regional Police Chiefs Cooperation Organisation (SARPCCO) of the protection of human rights Eswatini is a member of SARPCCO.51 The organization subscribes to the concept of human rights in policing. Article 1 of SARPCCO code of conduct52 enjoins the police to respect human rights. This means that in the performance of their duties, police officials shall respect and protect human dignity, maintain and uphold the human rights of all persons.53 Article 4 of the code prohibits torture and cruel, inhuman, and degrading treatment or punishment. This means that no police official shall,

51 The Southern African Regional Police Chiefs Cooperation Organisation (SARPCCO) is the primary force in Southern Africa for the prevention and fighting of cross-border crime. The Organisation was formed in 1995 in Zimbabwe and has firmly established itself as a benchmark for international police cooperation. This regional organisation is supported by the Sub-Regional Bureau of INTERPOL in Harare, which coordinates its activities and programs. Available at https://www.sadc.int/themes/politics-defence-security/police-sarpcco/ (accessed August 2, 2018).

52 The Code of Conduct for Police Officials is based on SARPCCO’s principles on cooperation which promote the observation of human rights in policing. The Code is aimed at strengthening and integrating human rights into police training and best practices and is based on the following principles:

 Respect for all human life

 Reverence for the law

 Integrity service excellence

 Respect for property rights

Priority crime areas

53 As above n 52. 59

under any circumstances, inflict, instigate, or tolerate any act of torture or other cruel, inhuman, or degrading treatment or punishment of any person. It is, therefore, expected that the REPS adhere to the standards set forth in the code in dealing with all citizens including key populations.

Summary: (a) Appreciate the different schools of thought on classification of rights. (b) Appreciate the duties and obligations that flow from particular rights. (c) Comprehend the indivisibility, interrelatedness and universality of human rights.

Unit 3: Human rights, Health, and HIV Introduction The Constitution of Eswatini does not explicitly provide for the right to health or its access. The Kingdom however does have the Public Health Act as well as policies that address issues of public health.

Objectives By the end of this unit, participants will be able to:  Link health issues and human rights  Learn about best practices in dealing with KPs from other jurisdictions.

Since public health has increasingly become a global issue, most of these policies are derived from international law. The human right to health is recognized in several UN instruments. Article 25(1) of the Universal Declaration of Human Rights affirms that: “everyone has the right to a standard of living adequate for the health of himself and of his family, including food, clothing, housing, medical care and necessary social services.” Article 12(1) of the International Covenant on Economic, Social and Cultural Rights further recognizes “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.” The right to health is also recognized in Article 5(e) (iv) of the International Convention on the Elimination of All Forms of Racial Discrimination of 1965, in Articles 11(1) (f) and 12 of the Convention on the Elimination of All Forms of Discrimination against Women of 1979, and in Article 24 of the Convention on the Rights of the Child of 1989 (among others). The Constitution of Eswatini guarantees the right to inherent dignity54 of the people and the right to have their dignity respected and protected. The constitution further prohibits any form of discrimination. This means that no actions should be taken against any individuals solely on the basis of their HIV status, gender, sexual status, or job, as this will constitute stigma and discrimination.55

Role of police in protecting human rights “The exercise of power by a police official is one significant manifestation of an interaction between the world of the powerful and the powerless ... a police official. ... exemplifies, probably more than any other person, the blurring of the division between the worlds of the powerful and the powerless.”56

54 18.(1) the dignity of every person is inviolable. 55 20 (2) For the avoidance of any doubt, a person shall not be discriminated against on the grounds of gender, race, colour, ethnic origin, tribe, birth, creed or religion, or social or economic standing, political opinion, age or disability. (3) For the purposes of this section, “discriminate” means to give different treatment to different persons attributable only or mainly to their respective descriptions by gender, race, colour, ethnic origin, birth, tribe, creed or religion, or social or economic standing, political opinion, age or disability. 56 Ralph Crawshaw. 61

The obligation of the police leadership to protect human rights will be fulfilled when it is emphasized that power for the police is not an end in itself but is a means to serve the people. Police officers are highly trained personnel, therefore it is expected that they be humane, ethical, and possess high qualities of human excellence. Professionalism is a proper balance of knowledge and skills on the one hand and proper response to the needs of the people on the other. Globally, police relations with KPs have been largely negative, with these groups highly susceptible to police violence and harassment. Using condoms as evidence of sex work and harassment are just a few examples of police behavior that is driving KP individuals away from health care and increasing their risk for HIV infection. Therefore, police partnerships such as this training will surely reverse these trends and reduce KPs vulnerability to HIV. Concentrating on human rights and public health, this training is changing police practices, helping police officers acknowledge the vital role they play in the HIV epidemic and ultimately reducing HIV transmission among KPs. Human rights approach in daily practice and work among KPs and the general public The goal of reduction of new HIV infections in Eswatini requires a comprehensive approach with a good understanding of the epidemic among certain target populations. This goal can only be realized if universal access to all population groups is ensured, including KPs. Therefore, to scale down HIV transmissions to zero tailormade interventions for KPs need to be developed and implemented. In the scope of their work, police officials are exposed to KPs and therefore have to ensure that they provide help to them. The police can influence the course and development of the epidemic, either in a negative or positive way. This influence is connected to a number of problems, some of which are related to the implementation of the law and some to the practices of some members of the police service. The spread of HIV/TB is prevalent among KPs, and the spread might happen during arrest, coercion, or removal from hot spots. Thus, police must pay careful attention and exercise caution, professionalism, and sensitiveness when executing their duties. Every human rights violation has multiple consequences on health issues and programs; the police have to be conscious of the health implications of their actions. The REPS core values clearly state that in the performance of their duties, police officers shall respect and protect human dignity, and maintain and uphold the rights for all persons. In environments where there is no tolerance for violations of human rights, inhuman and degrading police practices, the police can contribute greatly to the success of prevention programs and to establishing collaborative relationships with those sectors of society that implement these programs.

HIV and the police: Best practices of police, HIV, and KP programs globally–a comparative analysis Interventions targeting police to reduce human rights violations and violence toward KPs are being implemented worldwide with efforts to improve public health, reduce HIV-related risks, and improve the general well-being of KPs. Positive experiences observed in other countries may need to be considered for adoption in the context of as Eswatini. The Pink in Blue task force of the Dutch Police has established police network that champions the safety of KPs by providing contact service points. Police training in Kyrgyzstan is expected to reduce cases of extortion key populations rights. In Kenya, the districts of Nyanza and

Kisumu have managed to build and improve relationships between, and police, reducing violence and improving access to police services. African Men for Sexual Health and Rights has also held workshops with the intent of sensitizing law enforcement officials on sexual diversity and the legal framework as it pertains to Key populations.

Module 4: Human Rights, KPs and HIV review  The right to adequate health is essential  Dignity of every human being is inviolable  Police are the main stake holders in the criminal justice for the preservation of law and order  On the issue of Key Populations the Police must embark on a balancing act.

References, Resources and Further Reading

1. ABC Radio Australia. “Thai Police Spread Safe Sex Message.” Available from: http://www.radioaustralia.net.au/international/radio/onairhighlights/thai-police-cadets- spread-safe-sex-message. 2. Government of the Kingdom of Eswatini (GKE). Constitution of the Kingdom of Eswatini. Act 001 of 2005. Mbabane (Swaziland): 2005. 3. GKE. Crimes Act of 1899. 4. GKE. Sexual Offences and Domestic Violence Act 15 of 2008. 5. Joint United Nations Programme on HIV/AIDS (UNAIDS). “Key Populations. Geneva: UNAIDS, 2018. Available from: http://www.unaids.org/en/topic/key-populations. 6. Keeping Alive Societies Hope (KASH). Kisumu (Kenya). Available from: www.kash.or.ke. 7. Kharsany, B.M. “HIV Infection and AIDS in Sub-Saharan Africa: Current Status, Challenges and Opportunities.” Open AIDS Journal 10 (2016): 34–49. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893541/. 8. Nossal Institute for Global Health, Brigitte Tenni, Nick Crofts, Nicole Turner, Melissa Jardie, Natalie Stephens, Nick Thomson. Sex Work and Law Enforcement—Collaborations that Work and Why. Melbourne (Australia): The University of Melbourne, 2013. Available from: http://66.147.244.77/~leahnorg/wp-content/uploads/2013/08/Sex-work-and-Law- Enforcement-Collaborations-that-Work-3.pdf. 9. Keeping Alive Societies Hope: http://www.kash.or.ke/ 10. Southern African Regional Police Chiefs Cooperation Organisation (SARPCCO). The primary force in Southern Africa for the prevntion and fighting of cross-border crime. Formed in 1995 in Zimbabwe, this regional organization is firmly established as a benchmark for international police cooperation and is supported by the Sub-Regional Bureau of INTERPOL in Harare, which coordinates its activities. Available from: https://www.sadc.int/themes/politics-defence-security/police-sarpcco/. 11. SARPCCO, Philliat Matsheza, Human Rights Trust of Southern Africa (SAHRIT). SARPCCO Code of Conduct: Human Rights and Policing: Towards Ethical Policing Resource Book. Harare: SARPCCO & SAHRIT, 2003. 12. World Health Organization (WHO). “HIV/AIDS: Key Facts.” Geneva: WHO, 2018. Available from: http://www.who.int/news-room/fact-sheets/detail/hiv-aids. 64

Module 4: Human Rights, KPs, and HIV

Introduction….NB: to Always write (section, constitution, police service) in caps. The module discusses human rights, KPs, and HIV. Police officers are custodians of the protection and enforcement of human rights. The mandate of the REPS found in section 189 of the constitution along with section 7 of the Police service act of 201857 establishes the Royal Eswatini Police Services. The mandate of the REPS is pirmaily the preservation of peace and order. This means that in the scope of their duties police officers act in accordance with the provisions of the constitution, especially in ensuring that fundamental rights and freedoms are upheld. Therefore, police officers are critical stakeholders in the criminal justice system. In the scope of their duties they will be exposed to vulnerable people and must exercise their skills and knowledge in dealing with such groups, especially ensuring that they have access to their rights as per the constitution of Eswatini no. 001 of 2005.

Objectives By the end of this module, participants will be able to:  Define law and human rights  Discuss the significance of human rights  Discuss why human rights are important to the police and the role of police in protecting human rights  Explore international and national laws and policies that support the rights of all people  Establish the nexus between human rights, health, and HIV infection  Understand stigma, discrimination, and human rights violations

57 Act No. 29 of 1957. 65