Memorandum submitted by the International
Planned Parenthood Federation (IPPF)
SUMMARY OF
RECOMMENDATIONS
1. IPPF recommends that a focus is placed
on increasing access to integrated SRH and HIV services for marginalised
populations and recognising that treating poor SRH is integral
to HIV prevention, treatment, care and support.
2. IPPF recommends that policy and programme
efforts, within a human rights framework, should include a focus
on eradicating stigma and discrimination to prevent the marginalisation
of people within society. This should include specific efforts
to remove laws that criminalise men who have sex with men and
sex workers, as well as supporting harm reduction programmes for
injecting drug users.
3. IPPF recommends the limits to categorising
individuals as part of a specific group must be recognised in
order to ensure services and messages reflect the real need. The
language used to communicate issues around HIV and the link to
marginalised populations must be used sensitively to prevent stigmatisation
of these populations and to ensure wider populations also recognise
their vulnerability to HIV.
4. IPPF recommends that efforts to alleviate
the HIV epidemic must take into account the diversity of those
infected and affected and have targeted programmes to address
specific needs.
5. IPPF recommends that the principle of
involving people should be extended to include all those excluded
from existing decision making models and processes.
6. IPPF recommends that legislation and
policies that restrict access to services for marginalised populations,
and the collection of information on their experiences, should
be reformed.
7. IPPF recommends that the existing SRH
infrastructure is used to provide HIV prevention, treatment, care
and support services.
8. IPPF recommends that the donor governments
should provide financial and policy support to ensure the full
provision of male and female condoms.
9. IPPF recommends the repeal of restrictive
policies, at both domestic and international level, that impede
harm reduction services.
10. IPPF recommends that the UK government
should advocate for increased political commitment to support
the needs of marginalised populations.
BACKGROUND ON
THE INTERNATIONAL
PLANNED PARENTHOOD
FEDERATION
1.1 The International Planned Parenthood
Federation (IPPF) is a global network of 151 Member Associations
working in 180 countries and is the world's foremost voluntary,
non-governmental provider and advocate of sexual and reproductive
health and rights.
1.2 IPPF aims to improve the quality of
life of individuals by campaigning for sexual and reproductive
health (SRH) and rights through advocacy and services, especially
for poor and vulnerable people. We defend the right of all young
people to enjoy their sexual lives free from ill-health, unwanted
pregnancy, violence and discrimination. We support a woman's right
to choose to terminate her pregnancy legally and safely. We strive
to eliminate sexually transmitted infections and reduce the spread
and impact of HIV/AIDS.
1.3 IPPF's strategy on HIV/AIDS aims to
reduce the global incidence of HIV/AIDS and to protect the rights
of those infected and affected. The four specific objectives towards
delivering this strategy are 1) to reduce social, religious, cultural,
economic, legal and political barriers that make people vulnerable
to HIV/AIDS, 2) to increase access to interventions for prevention
of HIV/AIDS/STIs through integrated, gender-sensitive and rights-based
SRH programmes, 3) to increase access to care, support and treatment
for people infected and support for those affected by HIV/AIDS,
and 4) to strengthen the programmatic and policy linkages between
SRH and HIV/AIDS.
We therefore submit this Memorandum to highlight
issues and recommendations gained through our experience.
IPPF'S RESPONSE
TO THE
CALL FOR
EVIDENCE
— Evidence on the provision of
HIV prevention, treatment, care and support to populations marginalized
in society, including but not restricted to, commercial sex workers,
intravenous drug users and men who have sex with men.
— Evidence on the extent to which
HIV and AIDS policy and programming is effectively addressing
emerging epidemics, including those in Eastern Europe and Asia.
1. Poor Sexual and Reproductive Health (SRH)
amongst marginalised populations increases vulnerability to HIV
1.1 High incidence of Sexually Transmitted
Infections (STIs) can occur in marginalised populations, thus
increasing vulnerability to HIV.
1.2 Sexually Transmitted Infections increase
the risk of HIV transmission. [28]Marginalised
populations, such as sex workers, can experience high STI prevalence,
[29]thus
increasing their vulnerability to HIV. This situation is, in part,
created by low access to services, compounded by stigma and discrimination
(see point 2 ) which increase vulnerability to STIs, leading to
poor SRH and consequently increasing vulnerability to HIV.
Treating poor SRH is a key aspect of successful
HIV prevention, treatment, care and support. The links between
poor SRH and HIV are strong, with action in one area necessitating
action in the other—these links must be recognised at all
levels. Equally, the synergies between prevention and treatment
can lead to a more efficient use of resources and greater levels
of both prevention and treatment. For example, treatment of STIs
acts to reduce vulnerability to HIV and therefore acts as a mode
of HIV prevention. There is a continuum of care between prevention,
treatment and care with HIV and SRH integral.
Ensuring especially marginalised populations
(Men who have sex with men (MSM), Injecting drug users (IDUs)
and Sex Workers) can access necessary prevention and treatment
services for STIs and HIV requires a recognition of their sexual
and reproductive health and rights (SRHR). All too frequently,
these populations are simply seen as recipients of treatment,
with little regard to their individual rights. A programme in
Nagaland, Northern India, delivered by the Family Planning Association
of India[30]
is providing SRH and HIV services to injecting drug users and
their sexual partners, to not only address wider SRH and HIV goals,
but also to meet the individual SRHR of these people.
1.3 IPPF recommends that a focus is placed
on increasing access to integrated SRH and HIV services for marginalised
populations and recognising that treating poor SRH is integral
to HIV prevention, treatment, care and support.
2. Stigma and discrimination
2.1 The stigma and discrimination associated
with HIV and AIDS frequently overlap with the pre-existing stigma
attached to some marginalised populations. This leaves marginalised
populations more vulnerable to HIV by reducing their access to
necessary services.
2.2 Populations can be marginalised because
of what is perceived as involvement in "deviant behaviour"
(for example, injecting drug use). This pre-existing stigma can
then overlap with HIV and AIDS related stigma and discrimination.
[31]For
example, in many societies sex between men is heavily stigmatised
and consequently prevents people from trying to access relevant
HIV services. [32]These
views by wider society act to reduce the availability and provision
of appropriate health services (including sexual and reproductive
health services) that cater to the specific needs of these marginalised
populations.
Stigma and discrimination are human rights violations.
The recognition that people seen as "belonging" to marginalized
populations have equal human rights is often lacking in formal
policy. Equally lacking in many respects, is the recognition of
the sexuality of people living with HIV, who experience stigma
and discrimination which inhibits them accessing necessary services.
The centrality of human rights to any response is identified in
many policy documents. [33]This
recognition should be linked to a concrete plan of action, on
how to overcome stigma and discrimination. A core component of
this, should be efforts to address societal attitudes about HIV
and AIDS, in order to create a supportive environment in which
people are able to access HIV (and SRH) services.
2.3 IPPF recommends that policy and programme
efforts, within a human rights framework, should include a focus
on eradicating stigma and discrimination to prevent the marginalisation
of people within society. This should include specific efforts
to remove laws that criminalise men who have sex with men and
sex workers, as well as supporting harm reduction programmes for
injecting drug users.
3. Marginalised populations are not homogenous
or discrete
3.1 The labelling of individuals as belonging
to a specific marginalised group ignores the diversity and overlapping
nature of identity and behaviour, and consequently needs, in relation
to SRH and HIV.
3.2 The institutional imperative to categorise
in order to measure and apportion resources and effort, although
necessary, can undermine recognition of the true complexity and
diversity of a situation. This applies equally to the identification
of marginalised populations in the context of the HIV epidemic.
The categorising of men who have sex with men can prevent the
recognition of the variety of self-identities—gay, bisexual,
heterosexual—and corresponding SRH and HIV needs. Diversity
also cuts across "categories"—for example, the
overlaps between injecting drug use and sex work. [34]Marginalised
groups are not discrete or homogenous, which has implications
for how services and information are designed, in that they need
to reflect this complexity.
Categorising of individuals has outcomes for
stigma and discrimination—where "groups" become
identified as "vectors for transmission" rather than
as individuals, and holders of human rights. Equally, an emphasis
on marginalised "groups" can create a sense that if
people don't identify with these groups then they are not vulnerable
to HIV.
3.3 IPPF recommends the limits to categorising
individuals as part of a specific group must be recognised in
order to ensure services and messages reflect the real need. The
language used to communicate issues around HIV and the link to
marginalised populations must be used sensitively to prevent stigmatisation
of these populations and to ensure wider populations also recognise
their vulnerability to HIV.
4. Targeted programmes
4.1 Programmes and policies aimed at a general
audience will not always address the needs of a specific marginalised
population. As a result, in many emerging epidemics, HIV is concentrated
in certain key vulnerable populations yet the resources are not
targeted to match this need.
4.2 In many settings HIV is concentrated
within specific populations (for example, sex workers, injecting
drug users, men who have sex with men) and is not generalised
across the population. Despite this, resources to combat the HIV
epidemic are frequently used in programmes aimed at the general
population. For example, many prevention activities have focussed
on broad messages that do not account for the specific needs of
certain marginalized and vulnerable populations. Inappropriate
prevention programmes can mean those who most require services
do not receive them. These could, in different regional and national
settings, be MSM, IDUs and their partners, or sex workers and
their partners. IPPF recognises the UK government is promoting
the need to support vulnerable populations and rightfully raises
the issues of affordability, stigma and discrimination—all
barriers to effective action, [35]yet
prevention and treatment programmes also need to be designed to
cater for the needs of marginalized and vulnerable populations.
Targeting of programmes and policies to reach
those marginalised in society must take account of the specific
conditions and factors which affect people's lives. For example,
PROFAMILIA in Colombia, an IPPF Member Association, has designed
specific campaigns and messages to encourage men who have sex
with men to access their integrated HIV and SRH services. [36]This
programme highlights how resources can be used more effectively
in targeted messages as well as in efforts to educate health providers.
4.3 IPPF recommends that efforts to alleviate
the HIV epidemic must take into account the diversity of those
infected and affected and have targeted programmes to address
specific needs.
5. Meaningful involvement of affected communities
5.1 The involvement of affected communities
in designing policies and programmes is key to appropriate and
sensitively implemented services and information.
5.2 The principle of the Greater involvement
of people living with HIV/AIDS (GIPA) [37]acts
to encourage the involvement of PLHIV in all areas of the HIV
response. This is intended to ensure not only that there are supportive
environments for PLHIV, but that services are appropriate for
a response. This same principle is now being applied in other
contexts. A recent initiative seeks to include drug users in policies,
programmes and services to respond to HIV. [38]The
recent Delhi Declaration (which IPPF was involved in developing)
discussed the sexual health of men who have sex with men and underlined
the need to involve MSM in decision making, policy development
and programme planning. [39]
5.3 IPPF recommends that the principle of
involving people should be extended to include all those excluded
from existing decision making models and processes.
6. Criminalisation of behaviour
6.1 Legislation and policies that make certain
behaviours illegal: sex work, men having sex with men, injecting
drug use, impede access to HIV and SRH services.
6.2 Policies and legislation that criminalise
certain behaviours inhibit access to services. For example, criminalization
of behaviours like injecting drug use complicates harm-reduction
efforts and drives illegal drug use underground by making it harder
for individuals to access services, eg needle exchange. [40]This
criminalisation also acts to further the stigma and discrimination
attached to these marginalised populations. A second issue is
that criminalisation prevents the collection of information on
the specific HIV prevalences and experiences of marginalised populations.
This inhibits the development of effective policy and the efficient
targeting of resources.
6.3 IPPF recommends that legislation and
policies that restrict access to services for marginalised populations,
and the collection of information on their experiences, should
be reformed.
7. Existing SRH infrastructure and services
7.1 In many emerging epidemics there is
a lack of infrastructure able to provide HIV prevention, treatment,
care and support services.
7.2 Sexual and Reproductive Health clinics
and other services (eg mobile clinics, outreach services, community
based distribution) offer an existing infrastructure that can
integrate HIV services in order to provide services in emerging
epidemics. This provides synergies by: reducing resource use (eg
costly physical infrastructure—new clinics etc), providing
service-delivery points not directly associated with HIV and so
mitigating the effects of stigma and discrimination surrounding
HIV, as well as acting on the overlaps between SRH and HIV by
providing common entry points for prevention, treatment and care.
Linking these services provides opportunities to provide services
for marginalised populations, for example in Kenya, the SRH infrastructure
provided by Family Health Options Kenya (an IPPF Member Association)
is being used to provide antiretrovial treatment. [41]Utilising
this infrastructure, increases overall access to services. When
combined with appropriate messaging and targeting of resources
this can also increase access for marginalised populations (see
point 4).
7.3 IPPF recommends that the existing SRH
infrastructure is used to provide HIV prevention, treatment, care
and support services.
8. Condom availability
8.1 There is a global shortage of the male
condom, despite its proven ability to prevent the transmission
of HIV.
8.2 According to UNFPA figures for 2000,
to meet the total global condom need would have cost £314.8
million US dollars, in that same year only $45.9 million US dollars
were given by donors. [42]A
report by Interact highlights that in 2004 donors provided the
equivalent of just four condoms per man in the developing world.
[43]This
condom gap has implications for both HIV and SRH prevention.
8.3 IPPF recommends that the donor governments
should provide financial and policy support to ensure the full
provision of male and female condoms.
9. Low coverage of Harm Reduction programmes
9.1 Many emerging epidemics are driven by
injecting drug use, despite this there is low coverage of harm
reduction programmes.
9.2 Harm reduction programmes aim to reduce
the health and social consequences of injecting drug use. [44]There
is substantial evidence to support their efficacy as a means of
HIV prevention. [45]As
the recent Government paper on harm reduction acknowledges, access
to AIDS treatment for IDUs is an essential part of a harm reduction
package, as well as a wider package of SRH services. Despite this
support, there are barriers to scale up. These include restrictive
policy environments, such as those in Russia that inhibit the
scale-up of harm reduction programmes. [46]
9.3 IPPF recommends the repeal of restrictive
policies, at both domestic and international level, that impede
harm reduction services.
10. Political commitment
10.1 Political commitment is essential to
ensuring the necessary policy environment in which action can
be taken to prevent emerging epidemics from becoming large-scale.
10.2 The UK Government has acknowledged
the importance of strengthening political leadership on HIV, particularly
through its role in the G8 and EU and in supporting NEPAD and
the African Union. However, political commitment is required beyond
international policy discussions, it must also reach, and influence,
grassroots policy and programmes. Political and community leaders
should be supported in efforts to meet the needs of marginalised
populations within their countries, as addressing these publicly
can meet opposition. These nuances of political leadership must
be recognised and supported.
10.3 IPPF recommends that the UK government
should advocate for increased political commitment to support
the needs of marginalised populations.
October 2006
28 For example, see UNAIDS Sexually Transmitted
Infections, http://www.unaids.org/en/Issues/Prevention_treatment/sexually_transmitted_infections.asp Back
29
HIV and Sexually Transmitted Infection Prevention Among Sex
Workers in Eastern Europe and Central Asia, (UNAIDS Best Practice
Collection, 2006) available from www.unaids.org Back
30
FPA India is a Member Association of IPPF. The programme is delivered
using funds from the Japan Trust Fund for HIV/AIDS. Back
31
HIV and AIDS related stigma and discrimination: a conceptual
framework and implications for action (Parker, R and Aggleton,
P, 2002) Thomas Coram Research Institute. Back
32
UNAIDS Policy brief, -HIV and sex between men, http://data.unaids.org/pub/BriefingNote/2006/20060801_Policy_
Brief_MSM_en.pdf Back
33
For example, Sexual and Reproductive Health and HIV/AIDS: a
framework for priority linkages (UNFPA, UNAIDS, WHO, IPPF,
2005). Back
34
For example, see HIV and Sexually Transmitted Infection Prevention
Among Sex Workers in Eastern Europe and Central Asia, (UNAIDS
Best Practice Collection, 2006) available from www.unaids.org Back
35
UK Government, Taking Action, The UK's strategy for tackling
HIV and AIDS in the developing world, p 48. Back
36
Models of Care project, linking HIV/AIDS treatment, care and
support in sexual and reproductive health settings: examples in
action (IPPF, 2005). Back
37
See http://www.unaids.org/en/GetStarted/LivingWithHIV.asp Back
38
Nothing about us without us, Greater, meaningful involvement
of people who use illegal drugs: a public health, ethical and
human rights imperative (Canadian HIV/AIDS legal network:
2005). Back
39
The Delhi Declaration of Collaboration, 26 September, 2006, statement
from Risks and Responsibilities, Male Sexual Health and HIV
in Asia and Pacific, International Consultation. Back
40
"Illicit drug policies and their impact on the HIV epidemic
in Europe," Godinho, J and Veen, J in Europe, moving from
death sentence to chronic disease management, Matic, S, Lazarus,
JV and Donoghoe, MC (eds) (WHO, 2006). Back
41
Models of Care project, linking HIV/AIDS treatment, care and
support in sexual and reproductive health settings: examples in
action (IPPF, 2005). Back
42
Protection that only condoms provide, from a 2002 report
Global Estimates of Contraceptive Commodities and Condoms for
STI/H\HIV Prevention 2000-2015, UNFPA, see www.unfpa,org http://www.unfpa.org/supplies/condoms.htm Back
43
Condom shortage, counting the cost in lives (Interact Worldwide,
2006) available from www.interactworldwide.org Back
44
Harm reduction, tackling drug use and HIV in the developing
world, HM Government, December 2005. Back
45
"Injecting drug use, harm reduction and HIV/AIDS,"
Martin C Donoghoe in HIV/AIDS in Europe, moving from death
sentence to chronic disease management, Matic, S, Lazarus,
JV and Donoghoe, MC (eds) (WHO, 2006) and Harm reduction, tackling
drug use and HIV in the developing world, HM Government, December
2005. Back
46
HIV/AIDS and drug misuse in Russia, harm reduction programmes
and the Russian legal system (Butler, 2005). Back
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