An Assessment of Policy Toward Most-At-Risk Populations for HIV/AIDS in West Africa
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ACTION FOR WEST AFRICA REGION II (AWARE II) An Assessment of Policy toward Most-at-Risk Populations for HIV/AIDS in West Africa Submitted to: USAID/West Africa Regional Mission Office of Health, Population and Nutrition American Embassy—No. 24 Fourth Circular Rd. Cantonments Accra, Ghana P. O. Box 1630 Accra, Ghana CONTRACT GHS-I-05-07-00006-00 i Suggested citation: Dutta, A., and M. Maiga. (June 2011). An Assessment of Policy toward Most-at-Risk Populations for HIV/AIDS in West Africa. Accra, Ghana: Action for West Africa (AWARE-II) Project. ii This report is made possible by the support of the American People through the United States Agency for International Development (USAID.) The contents of this report are the sole responsibility of AWARE II and do not necessarily reflect the views of USAID or the United States Government. iii Table of Contents Acknowledgments ........................................................................................................................................ v Executive Summary ......................................................................................................................................vi Abbreviations .............................................................................................................................................. xiii 1. Overview of the Report ............................................................................................................................. 1 1.1 Background of the AWARE II Project .......................................................................................................... 1 1.2 What Is Included under ―Policy‖? ................................................................................................................. 3 1.3 Organization of the Report ............................................................................................................................ 4 2. MARPs Matter and What Matters for MARPs in the AWARE II Region ..................................................... 6 2.1 Epidemiological Determinants of Policy ....................................................................................................... 7 2.2 HIV Risk and Vulnerability among Population Groups .............................................................................. 13 2.3 Heterogeneity within the Core MARPs ....................................................................................................... 16 2.4 HIV Prevention Policy and MARPs ............................................................................................................ 18 2.5 Some HIV Service Delivery Considerations among MARPs ...................................................................... 24 2.6 Conclusions .................................................................................................................................................. 29 3. A Framework for Formal Policies and Policy Implementation Related to MARPs ............................... 31 3.1 The Structural and Individual Levels of Interventions for HIV/AIDS ........................................................ 31 3.2 A Framework for Key Inputs into the MARPs Policy Space ...................................................................... 33 3.3 Laws and Regulations in the Context of MARPs ........................................................................................ 37 3.4 Data Collection Process ............................................................................................................................... 40 3.5 Conclusions .................................................................................................................................................. 41 4. Assessment of Formal Policies and Policy Implementation for MARPs in the AWARE II Region ........ 43 4.1 Individual/Direct Policy Inputs .................................................................................................................... 43 4.2 Individual/Indirect Policy Inputs ................................................................................................................. 56 4.3 Structural/Direct Policy Inputs .................................................................................................................... 64 4.4 Structural/Indirect Policy Inputs .................................................................................................................. 72 5. Discussion and Recommendations ........................................................................................................ 76 5.1 Key Questions .............................................................................................................................................. 76 5.2 Next Steps .................................................................................................................................................... 84 Notes ............................................................................................................................................................ 86 References ................................................................................................................................................... 89 iv Acknowledgments The authors want to thank Laura McPherson for her encouragement, high-level advice, and recommendations, as well as moral support through the writing of this report and the associated data collection. Harrison Holcomb, Britt Herstad, Danielle Goetter, and Nathan Wallace provided invaluable research assistance. Colleagues at AWARE II who provided valuable support and encouragement include Issakha Diallo, Sani Aliou, Scott Kellerman, Sara Holtz, and Stephen Redding. The assistance of Marie-Paule Gbedjrou, Martine Laney, Freda Obeng-Ampofo, and Kouamé Marcellin in administration is gratefully acknowledged. The following data collectors and headquarters staff provided assistance in collecting and synthesizing data on laws, regulations, and programs in the AWARE II countries related to most at-risk populations: Benin – Zounon Kokou Burkina Faso – Bakionou Cameroon – Emmanuel Francis Metogo Cape Verde – Mendonca João Gomes Chad – Dokblama Kadah Côte d‘Ivoire – Koffi Hortense Gabon – Elizabeth McDavid The Gambia – Bai Cham Ghana – Maj-Britt Dohlie Guinea – Diallo Kadiatou Thierno Guinea Bissau – Sadna Na Mali – Diarra Aissé Mauritania – Fatimetou Maham Niger – Soumana Hamma Senegal – Dr. Athie Cheick Togo – Aquereburu Ahoye Ahlonkopba v Executive Summary Context The region of West and Central Africa is the most populous on the continent, totaling 340 million people. Countries in the region suffer significant HIV epidemics, which require a continued and comprehensive response. However, a current plateau in funding for HIV is juxtaposed with increasing needs for coverage and imperatives due to the shifting nature of the epidemic. These pose great challenges for policymakers in the region. In this context, the importance of most at-risk populations (MARPs) for HIV has been mentioned repeatedly. For mixed and concentrated epidemics, a prevention focus on MARPs is requisite and cost-effective, and the focus involves enhanced surveillance as well as targeted interventions. These are essential from the ―know your epidemic—know your response‖ perspective, as well as for ―smart investments.‖ However, much is uncertain about how HIV policy in the West and Central African region responds to the epidemiological and programmatic evidence on MARPs. These questions remain. Are countries aware of what is needed? Are they doing it? What is working? This report is concerned with the first two issues, i.e., sharing a policy perspective on what is needed for MARPs in the region and producing an inventory of what is being done. One of our main concerns is providing evidence on the situation of a ―continuum of response‖ for MARP that also includes treatment, care, and structural change to fully capture all potential benefits. This report represents the second volume of the overall situation assessment of MARPs in West and Central Africa by the Action for West Africa Region II (AWARE II) Project. This volume focuses on the subject of policy, which involves, among other elements, laws, regulations, and programs. The broadening of a definition of policy beyond these familiar elements in the context of MARPs is an outcome of this report. Overall, this report has two objectives. The primary objective is to create a framework for policy related to MARPs and to use this framework to assess the situation in the AWARE II region. The assessment involves taking an inventory of existing laws, regulations, and programs in the region. The secondary objective is to interpret the inventory and data in order to identify barriers to effective prevention and treatment/care programming for MARPs in the region. A Framework for MARP Policy We frame the idea of a policy space for HIV/AIDS, building on prior work. We see three conceptual areas within the space: the Determinants of the Policy Environment, i.e., ideas and agreements among stakeholders; the Formal Policies; and Policy Implementation, i.e., the programmatic response. We highlight several policy ―inputs‖ that affect one or more of the conceptual areas. These inputs can be considered ―building blocks‖ for the policy areas. Within the broad concept of MARPs, we focus on female sex workers (FSWs), men who have sex with men (MSM), clients of sex work (clients) and, where they