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Extrait

An Assessment of Policy toward
Most-at-Risk Populations for
HIV/AIDS in West Africa

ACTION FOR WEST AFRICA REGION II (AWARE II)









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. 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


Table of Contents

Acknowledgments.......................................................................................................................................... iv
Executive Summary ......................................................................................................................................... v
Abbreviations ................................................................................................................................................. xii
1. Overview of the Report.............................................................................................................................. 13
1.1   Background of the AWARE II Project ........................................................................................................13 
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 ..............................................................................14 
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 Space33 
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 Inputs72 
5. Discussion and Recommendations............ 76
5.1  Key Questions..............................................................................................................................................76 
5.2   Next Steps....................................................................................................................................................84 
Notes................................................................................................................................................................ 86
References................................. 89
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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

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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 are present, injecting drug users (IDUs). We defend our
sel