Effective HIV & SRH Responses among Key Populations in Myanmar Module 5: Creating Enabling Environments for Key Populations

Session 1 Creating Enabling Environments for KPs CRITICAL ENABLERS

Overview  A rights-based approach to HIV and SRH programming for key populations  Legal and policy conflicts  Stigma and discrimination  Preventing and addressing violence  Advocacy

Typical barriers to implementation of a comprehensive package for KPs include:  Unsupportive national policy  Lack of adequate funding  Restrictive criteria for eligibility for services  Stigma and discrimination  Law enforcement harassment  Cost of services to users  Poor geographic distribution of services  Limited hours of operation  Limited technical capacity including comprehensive sexual history assessment and STI management Critical Enablers

Rights-Based Approach  A rights-based approach to HIV and SHR programming for KPs means approaches based on international human rights law  Key human rights documents include:  Universal Declaration of Human Rights (1948)  International Covenant on Economic, Social and Cultural Rights (1966)  International Covenant on Civil and Political Rights (1966)

Rights-Based Approach Group Discussion: Human Rights KPs are entitled to fundamental human rights including: Right to non-discrimination Right to equal treatment before the law Right to the highest attainable standard of health People don’t lose their human rights if they are involved in illegal activity or in activity that is perceived as being morally wrong

Rights-Based Approach Core principles of human rights-based programming that all activities should be assessed against:  Community Participation  Equity and non-discrimination  Grounded in international human rights law  Sustainability

Rights-Based Approach  HIV and SRH programmes that are rights-based have been shown to be more effective  HIV and SRH programmes for KPs must be strategic and effective, this is not possible without also respecting human rights  Effective and appropriate programmes should involve KPs in all stages of planning, implementing and monitoring and evaluation  Human rights violations of KPs hinder their ability to openly participate in programming, therefore restricting reach and impact

Rights-Based Approach  If a programme is violating the human rights of KPs that programme should be stopped and new methods for reaching and meeting the needs of KPs must be explored  Rights abuses and violations should be recorded and reported  Donors are committed to meeting their obligations under international human rights treaties and global, regional and organisational commitments. Donors do not want to be seen as supporting human rights violations in programming or research

Rights-Based Approach  Human rights abuses may include:  Forced testing  Police abuse  Denial of access to health care and life-saving medicines

Rights-Based Approach Group Discussion: Conflicting public health and law enforcement policies and laws severely impede effective SRH and HIV responses

 Laws and policies that impede effective SRH and HIV responses include:  Criminalisation of behaviours risky for HIV  Punitive law enforcement practices  Confiscation of condoms  Criminalisation of clients  Licensing or registration  Mandatory, compulsory or coerced testing  Lack of labour rights and social security rights  Denial of identification documents and citizenship rights  Compulsory detention centres  Anti-trafficking laws, policies and practices  100% Condom Use Policies Supportive Legal and Policy Environment

 Criminalising behavior risky for HIV increases vulnerability to HIV:  Fuels stigma & discrimination  Undermines access to health services  Legitimises violence, harassment and extortion  Limits carrying of condoms for fear of arrest  Police ‘crackdowns’ including raids, harassment and violence against KPs at the hands of law enforcement disperse KPs and undermines access to services Supportive Legal and Policy Environment

 Global Guidance present consistent findings that criminalisation of sex work hinders HIV response and call to decriminalise behaviour risky for HIV. Key documents include:  Sex Work and the Law in Asia and Pacific, October 2012  Global Commission on HIV and the Law, July 2012  Commission on AIDS in Asia, 2008  National Reviews and Commitments provide evidence for review and reform of national laws and policies. ESCAP Member States committed to review laws and policies that hinder an effective HIV response in Resolution 67/10 Supportive Legal and Policy Environment

Sex Work and the Law in Asia and Pacific (October 2012)  Analysis of laws and human rights environment and their impact on effective HIV responses among KPs in 48 countries  Evidence based tool to support governments, UN agencies and KAP communities to prioritize and implement strategies to address legal and human rights challenges  Defines an agenda for country action

Laws and policies that support effective SRH and HIV responses include:  Court judgments that recognise the human rights of KPs  Policy development including national HIV strategies which commit to addressing stigma and discrimination and police violence against KPs  Legislation including the decriminalisation of sex work  Initiatives of KPs and their organisations to improve the legal environment through advocacy and direct services such as crisis support Supportive Legal and Policy Environment

Access to Legal Services  ‘Know your Rights’- having a rights-based legal framework to support the response to HIV among KPs will be of little use unless people know their legal rights and are able to access the legal system to enforce them  Making legal services accessible and affordable is therefore a key practical component of human rights programming Supportive Legal and Policy Environment

Access to Legal Services  HIV-related legal services:  protect and promote the human rights of people living with HIV, people affected by HIV and key populations  are essential to ensure good public health and development outcomes  HIV-related legal services contribute directly to building an enabling environment for effective HIV programmes  Legal services enable people to claim and enforce their rights to access HIV services and thereby create demand for access to HIV services Supportive Legal and Policy Environment

A significant barrier to access of services by KPs remains stigma and discrimination. This may be perceived or real, from health workers and the greater community. As a result, or fear of stigma and discrimination, KPs may be reluctant to disclose sexual activity and request STI screens or physical examinations even when they do present to services. Stigma and Discrimination

 Stigma and discrimination is complex and operates at many levels across multiple sectors  Stigma and discrimination in health care settings remains a significant impediment to ensuring KAP’s access to HIV prevention, testing, treatment and care  Stigma in the form of devaluing, discounting and discrediting KPs results in marginalisation and the inability to fully participate in community life or access health services.

Stigma and Discrimination Stigma and discrimination are barriers to scaling up effective interventions for KPs:  Lack of KAP friendly services, poor status of health care services and limited access discourages KPs from seeking healthcare including uptake of treatment  Stigma and discrimination, including self inflicted or imposed, affect health seeking behaviors  Law and policy enforcement.

Preventing and Responding to Violence Violence against key populations  Violence against female, male and transgender sex workers, other MSM and transgender people and PWID is pervasive and takes many forms: economic, emotional, physical and sexual  Violence against KPs often happens in the course of sex work, in communities and families  Violence within sex work is commonly perpetuated by police, clients, client brokers, local gangs/thugs, particularly in street sex work settings.

Preventing and Responding to Violence Violence against key populations  Violence, particularly physical and sexual violence, increase risk of STIs and HIV  Violence before, during or after sexual intercourse could lead to increased HIV risk in several ways:  Through compromising condom use  By injuries caused by physical or sexual violence leading to open wounds, tears and lesions in the vagina or anus.

Advocacy Domains

Critical Enablers Small Group Activity  Break into small groups  Draw the Critical Enabler Circles → What services exist now?  Refer back to map of the Element  What programmes and services exist? What services need to exist?  What services need to exist? Where should services be located? Who should provide? Critical Enablers Circle:  What critical enablers must be addressed to achieve development, implementation and scale-up of the services that need to exist?