How policies can fuel stigma

Assessment of policy and access to HIV prevention, care, and treatment services for men who have sex with men and for sex workers in Burkina Faso and Togo.

Duvall S, Irani L, Compaore C, Sanon P, Bassonon D, Anato S, Agounke J, Hodo A, Kugbe Y, Chaold G, Nigobora B, MacInnis R. J Acquir Immune Defic Syndr. 2015 Mar 1;68 Suppl 2:S189-97. doi: 10.1097/QAI.0000000000000450.

Background: In Burkina Faso and Togo, key populations of men who have sex with men (MSM) and sex workers (SW) have a disproportionately higher HIV prevalence. This study analyzed the 2 countries' policies impacting MSM and SW; to what extent the policies and programs have been implemented; and the role of the enabling environment, country leadership, and donor support.

Methods: The Health Policy Project's Policy Assessment and Advocacy Decision Model methodology was used to analyze policy and program documents related to key populations, conduct key informant interviews, and hold stakeholder meetings to validate the findings.

Results: Several policy barriers restrict MSM/SW from accessing services. Laws criminalizing MSM/SW, particularly anti-solicitation laws, result in harassment and arrests of even nonsoliciting MSM/SW. Policy gaps exist, including few MSM/SW-supportive policies and HIV prevention measures, e.g., lubricant not included in the essential medicines list. The needs of key populations are generally not met due to policy gaps around MSM/SW participation in decision-making and funding allocation for MSM/SW-specific programming. Misaligned policies, e.g., contradictory informed consent laws and protocols, and uneven policy implementation, such as stockouts of sexually transmitted infection kits, HIV testing materials, and antiretrovirals, undermine evidence-based policies. Even in the presence of a supportive donor and political community, public stigma and discrimination (S&D) create a hostile enabling environment.

Conclusions: Policies are needed to address S&D, particularly health care provider and law enforcement training, and to authorize, fund, guide, and monitor services for key populations. MSM/SW participation and development of operational guidelines can improve policy implementation and service uptake.

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Editor’s notes: This paper summarizes an interesting policy analysis of approaches to the provision of HIV services for gay men and other men who have sex with men and sex workers in Togo and Burkina Faso. Both countries are experiencing similar HIV epidemics, categorised as ‘mixed’ with high HIV prevalence among key populations nested within a generalised HIV epidemic. The policy analyses focus on assessing the ‘enabling’ environment defined as policies and programmes for gay men and other men who have sex with men and sex workers that support or hinder HIV prevention and treatment programming. The analysis clearly illustrates the importance of an enabling environment to facilitate use of programmes as well as shaping attitudes towards gay men and other men who have sex with men and sex workers.  Findings illustrate similar policy environments across both countries. While there are no specific laws preventing gay men and other men who have sex with men and sex workers using services, laws that criminalise sex between men or the exchange of sex result in people being harassed. Or laws are wrongly applied by police and discourage people from using services for fear of harassment and negative attitudes of health workers. Community-based organisations led by gay men and other men who have sex with men are not allowed to participate in developing national HIV strategies, which results in programmes not being tailored to specific population needs. The study clearly illustrates the gap between policy and practice. Even when a policy exists supporting a focussed activity for gay men and other men who have sex with men or sex workers, this is not implemented because of lack of appropriate implementation mechanisms. The paper provides important insights into what are the priorities for advocacy and policy development for gay men and other men who have sex with men and sex workers and calls for more research to illuminate the full range of barriers to services. Any advocacy efforts need to be accompanied by education campaigns to reduce stigma and discrimination against gay men and other men who have sex with men and sex workers. 

Burkina Faso, Togo
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